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LIST  OF  AUTHOES. 


N.  E.  BRILL,  M.D. 
CHARLES  W.  BURR,  M.D. 
JOSEPH  COLLINS,  M.D. 
CHARLES  L.  DANA,  M.D. 

F.  X.  DERCUM,  M.D. 
E.  D.  FISHER,  M.D. 
LANDON  CARTER  GRAY,  M.D. 
C.  A.  HERTER,  M.D. 
GEORGE  W.  JACOBY,  M.D. 

W.  W.  KEEN,  M.D.,  LL.D. 
PHILIP  COOMBS  KNAPP,  M.D. 
JAMES  HENDRIE  LLOYD,  M.D. 
CHARLES  K.  MILLS,  M.D. 
S.  WEIR  MITCHELL,  M.D.,  LL.D. 
CHARLES  A.  OLIVER,  M.D. 
WILLIAM  OSLER,  M.D. 
FREDERICK  PETERSON,  M.D. 
MORTON  PRINCE,  M.D. 

G.  E.  DE  SCHWEINITZ,  M.D. 
WHARTON  SINKLER,  M.D. 
M.  ALLEN  STARR,  M.D. 
JAMES  C.  WILSON,  M.D. 


A    TEXT-BOOK 


ON 


NEKYOUS  DISEASES 


BY   AMERICAN  AUTHORS. 


EDITED  BY 

FRA:^0IS   X.  DERCUM,  A.M.,  M.D.,  Ph.D., 

CLINICAL   PROFESSOR    OF    NERVOUS    DISEASES    IN    THE    JEFFERSON    MEDICAL    COLLEGE    OF    PHILADELPHIA  ; 
PRESIDENT    OF    THE    AMERICAN    NEUROLOGICAL    ASSOCIATION. 


With  341   Engravings  and  7  Colored   Plates. 


PHILADELPHIA: 
LEA   BROTHERS   &   CO. 

1895. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1895,  by 

LEA  BROTHERS  &  CO., 

In  the  OfBce  of  the  Librarian  of  Congress.     All  rights  reserved. 


PHILADELPHIA  : 
no  EN  AN,    PRINTER. 


PREFACE. 


The  prevailing  impression  that  the  subject  of  Nervous  Diseases  pre- 
sents peculiar  difficulties  has  but  slight  foundation  in  fact.  No  branch  of 
medicine  can  be  grasped  without  serious  study,  and,  granting  this,  the 
student  and  practitioner  can  approach  neurology  with  confidence.  Pos- 
sibly the  difficulty  is  not  inherent  so  much  in  the  subject  as  in  the  manner 
of  its  presentation,  a  belief  which  has  led,  after  careful  study,  to  the 
somewhat  novel  arrangement  of  this  work. 

In  brief,  the  general  affections  are  considered  first,  and  attention  is 
then  progressively  directed  to  those  which  are  more  and  more  special. 
The  advantages  of  this  arrangement  are  universally  recognized  in  the 
other  sciences,  and  its  applicability  to  medicine  seems  hardly  to  need 
demonstration.  Further,  diseases  clinically  allied  have  been  considered 
in  close  connection,  and  by  this  means  it  has  been  sought  to  accentuate 
the  practical  features  of  the  subject.  In  building  upon  this  basis  atten- 
tion has  also  been  devoted  to  the  anatomy  and  physiology  of  the  nervous 
system,  these  subjects  being  incorporated  with  the  consideration  of  the 
various  diseases.  The  choice  of  subjects  and  the  space  devoted  to  each 
have  been  arranged  with  special  reference  to  practical  needs,  and  it  is 
believed  that  the  mode  of  handling  details  is  conducive  to  clearness, 
utility,  and  completeness. 

A  glance  at  the  List  of  Contributors,  opposite  the  title-page,  will  show 
that  this  volume  represents  the  views  of  writers  widely  recognized  as 
authorities  in  neurological  science,  and  especially  known  in  connection 
with  the  subjects  assigned  to  them.  The  work  is  likewise  representative 
of  our  great  medical  schools,  and  hence  it  embodies  not  only  high 
authority,  but  is  likewise  illustrative  of  the  best  methods  of  instruction. 

Free  use  has  been  made  of  illustrations  in  l^lack  and  colors.  The 
series  of  pictures  is  largely  original,  and  where  authenticity  is  requisite 


VI  PREFACE. 

it  has  been  attained  by  photographic  methods.  It  is  confidently  hoped 
that  the  other  engravings,  and  especially  those  which  are  diagrammatic, 
will  be  found  full  of  assistance. 

In  conclusion,  the  editor  desires  to  extend  his  sincere  thanks  to  his 
colleagues  for  their  recognition  of  the  importance  of  the  work  and  their 
earnest  support  in  its  production. 

F.  X.  DERCUM. 

Philadelphia,  September,  1895. 


CONTENTS. 


CHAPTER   I. 

PAGE 

■GENERAL  CONSIDERATIONS 17 

By  S.  Weir  Mitchell,  M.D.,  LL.D.  (Harvard,  Edinburgli),  Member 
of  the  National  Academy  of  Sciences;  and  F.  X.  Deecum,  A.M.,  M.D., 
Clinical  Professor  of  Nervous  Diseases,  Jefferson  Medical  College ; 
Neurologist  to  the  Philadelphia  Hospital ;  Visiting  Physician  to  the 
Pennsylvania  Institution  for  Feeble-minded  Children,  at  Elwyn  ;  Con- 
sulting Physician  to  the  Asylum  for  the  Chronic  Insane  at  Werners- 
ville ;  Assistant  Physician  to  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases,  Philadelphia;  Consulting  Neurologist  to  St. 
Agnes's  Hospital. 

The  Examination  of  the  Eye  from  the  Standpoint  of  the  Neurol- 
ogist     39 

By  C.  A.  Oliver,  A.M.,  M.D.,  Attending  Surgeon  to  Wills'  Eye  Hospital ; 
Ophthalmic  Surgeon  to  the  Philadelphia  Hospital,  etc. 

CHAPTER  II. 
GENERAL  MORBID  STATES  OF  THE  NERVOUS  SYSTEM ...    51 

NEURASTHENIA. 

By  F.  X.  Deroum,  A.M.,  M.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jefferson  Medical  College  ;  Neurologist  to  the  Philadelphia  Hospital ; 
Visiting  Physician  to  the  Pennsylvania  Institution  for  Feeble-minded 
Children,  at  Elwyn ;  Consulting  Physician  to  the  Asylum  for  the  Chronic 
Insane  at  Wernersville  ;  Assistant  Physician  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Philadelphia ;  Consulting  Neurolo- 
gist to  St.  Agnes's  Hospital. 

CHAPTER   III. 

GENERAL  MORBID  STATES  OF  THE  NERVOUS  SYSTEM  (Continued)     87 

HYSTERIA. 

By  James  Hendrie  Lloyd,  A.M.,  M.D. ,  Neurologist  to  the  Philadelphia 
Hospital;  Physician  to  the  Methodist  Episcopal  Hospital;  Physician 
to  the  Home  for  Crippled  Children;  Consulting  Neurologist  to  the 
Elwyn  Institute  for  Feeble-minded  Children. 


viii  CONTENTS. 

CHAPTER   ly. 

PAGE 

GENEEAL  MORBID  STATES  OF  THE  NERVOUS  SYSTEM  (Continued)  135 

NERVOUS  AFFECTIONS  FOLLOWING  RAILWAY  AND  ALLIED  INJURIES. 

By  Philip  Coombs  Knapp,  A.M.,  M.D  ,  Clinical  Instructor  in  Diseases 
of  the  Nervous  System,  Harvard  Medical  School ;  Physician  for  Diseases 
of  the  Nervous  System,  Boston  City  Hospital. 

CHAPTER   V. 

DIATHETIC  AND  TOXIC  AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  183 

By  E.  D.  Fisher,  M.D.,  Professor  of  Mental  and  Nervous  Diseases  in 
the  Medical  Department  of  the  University  of  the  City  of  New  York ; 
Assistant  Visiting  Physician  to  Bellevue  Hospital ;  Neurologist  to  the 
Hospital  for  Incurables;  President  of  the  New  York  Neurological 
Society,  etc. 

CHAPTER  YI. 

DISEASES  THE  DIRECT  OR  INDIRECT  RESULT  OF  INFECTION     .  20S 

By  William  Oslek,  M.D  ,  Fellow  of  the  Royal  College  of  Physicians, 
London ;  Professor  of  Medicine  in  the  Johns  Hopkins  University,  and 
Physician-in-chief  to  the  Johns  Hopkins  Hospital,  Baltimore ;  formerly 
Professor  of  the  Institutes  of  Medicine,  McGill  University,  Montreal, 
and  Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania, 
Philadelphia. 

CHAPTER  VII. 

CHOREIFORM  AFFECTIONS 227 

By  Wharton  Sinkler,  M.D.,  Physician  to  the  Philadelphia  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Neurologist  to  the  Phila- 
delphia Hospital ;  Consulting  Neurologist  to  the  State  Hospital  for  the 
Chronic  Insane ;  Professor  of  Nervous  Diseases,  Philadelphia  Poly- 
clinic ;  Neurologist  to  the  Bryn  Mawr  Hospital. 

CHAPTER   VIII. 

LOCAL  SPASMS.    OCCUPATION-SPASM    .        .        .        .        .        .        .270 

By  C.  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous  Diseases  in  the 
Medico-Chirurgical  College  of  Philadelphia. 

CHAPTER   IX. 

FUNCTIONAL  TREMORS 280 

By  Landon  Carter  Gray,  A.M.,  M.D.,  Professor  of  Nervous  and 
Mental  Diseases  in  the  New  York  Polyclinic. 


CONTENTS.  ix 

CHAPTER   X. 

PAGE 

PAEALYSIS  AGITANS 288 

Bv  Landon  Carter  Gray,  A.M.,  M  D.,  Professor  of  Nervous  and 
Mental  Diseases  in  the  New  York  Polyclinic. 

CHAPTER   XI. 

EPILEPSY 296 

By  Landox  Carter  Gray,  A.M.,  M.D.,  Professor  of  Nervous  and 
Mental  Diseases  in  the  New  York  Polyclinic. 

CHAPTER   XII. 
GENERAL  DISEASES  OF  THE  BRAIN 315 

ARRESTED  DEVELOPMENT,  MALFORMATIONS. 

By  N.  E.  Briix,  A.M.,  M.D.,  Visiting  Physician  to  Mt.  Sinai  Hospital, 
New  York ;  Ex-President  of  the  Society  of  Medical  Jurisprudence, 
New  York ;  Fellow  of  the  Academy  of  Medicine,  etc 

CHAPTER  XIII. 

GENERAL  DISEASES  OF  THE  BRAIN  (Continued)        .        .        .        .348 

DISEASES  OF  THE  MEMBRANES,  SINUSES,  AND  BRAIN  TISSUE. 

By  F.  X.  Dercum,  A.M.,  M.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jefferson  Medical  College ;  Neurologist  to  the  Philadelphia  Hospital ; 
Visiting  Physician  to  the  Pennsylvania  Institution  for  Feeble-minded 
Children,  at  Elwyn ;  Consulting  Physician  to  the  Asylum  for  the  Chronic 
Insane  at  Wernersville ;  Assistant  Physician  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Philadelphia  ;  Consulting  Neurolo- 
gist to  St.  Agnes' s  Hospital. 

C  H  A  P  T  E  R    X  I V. 

THE  ANATOMY  OF  THE  CEREBRAL  CORTEX  AND  THE  LOCALI- 
ZATION OF  ITS  FUNCTIONS 381 

By  Charles  K.  Mills,  A.M.,  M.D.,  Professor  of  Mental  Diseases  and  of 
Medical  Jurisprudence  in  the  University  of  Pennsylvania ;  Clinical  Pro- 
fessor of  Nervous  Diseases  in  the  Woman's  Medical  College  of  Pennsyl- 
vania ;  Neurologist  to  the  Philadelphia  Hospital,  etc. 

CHAPTER   XV. 

FOCAL  DISEASES  OF  THE  BRAIN 444 

HEMORRHAGE,  EMBOLISM,  AND  THROMBOSIS. 

By  Charles  L.  Dana,  A.M.,  M.D.,  Professor  of  Nervous  and  Mental 
Diseases  in  the  New  York  Post-Graduate  Medical  School;  Visiting 
Physician  to  Bellevue  Hospital. 


X  CONTENTS. 

CHAPTER    XVI. 

PAGE 

FOCAL  DISEASES  OF  THE  BRAIN  (Continued) 470 

TUMORS. 

By  M.  Ali,en  Starb,  M.D.,  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  College  of  Physicians  and  Surgeons,  Medical  Depart- 
ment of  Columbia  College,  New  York ;  Consulting  Neurologist  to  the 
Presbyterian  and  Orthopedic  Hospitals,  and  to  the  New  York  Eye  and 
Ear  Infirmary. 

CHAPTER  XVII. 

FOCAL  DISEASES  OF  THE  BRAIN  (Continued)      .        .        .        .        .  506 

CEREBRAL  PALSIES  OF  CHILDHOOD. 

By  F.  X.  Deecum,  A.M.,  M.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jefferson  Medical  College ;  Neurologist  to  the  Philadelphia  Hospital ; 
Visiting  Physician  to  the  Pennsylvania  Institution  for  Feeble-minded 
Children,  at  Elwyn ;  Consulting  Physician  to  the  Asylum  for  the  Chronic 
Insane  at  Wernei'sville ;  Assistant  Physician  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Philadelphia;  Consulting  Neurolo- 
gist to  St.  Agnes's  Hospital. 


CHAPTER   XVIII. 

DISEASES  OF  THE  SPINAL  COED 521 

GENERAL  AFFECTIONS. 

By  James  Hendrie  Lt.oyd,  A.M  ,  M.D.,  Neurologist  to  the  Philadelphia 
Hospital ;  Physician  to  the  Methodist  Episcopal  Hospital;  Physician 
to  the  Home  for  Crippled  Children;  Consulting  Neurologist  to  the 
Elwyn  Institute  for  Feeble-minded  Children. 


CHAPTER   XIX. 

DISEASES  OF  THE  SPINAL  CORD  (Continued) 556 

GENERAL  AFFECTIONS. 

By  Morton  Prince,  M.D.,  Physician  to  the  Boston  City  Hospital  for 
Diseases  of  the  Nervous  System;  Clinical  Instructor  in  Nervous  Diseases, 
Harvard  Medical  School. 


CHAPTER   XX. 

DISEASES  OF  THE  SPINAL  CORD  (Continued) 612 

SYSTEMIC  AFFECTIONS. 

By  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  Ncm"^  York;  Pathologist  to  the 
New  York  City  Hospital ;  Neurologist  to  Randall's  Island  Hospital ; 
Attending  Physician,  New  York  Hospital  for  Nervous  Diseases. 


CONTENTS. 


CHAPTER   XXI. 

PAGE 

BULBAR  PALSY 657 

By  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York ;  Pathologist  to  the 
New  York  City  Hospital ;  Neurologist  to  Eandall's  Island  Hospital ; 
Attending  Physician,  New  York  Hospital  for  Nervous  Diseases. 


CHAPTER   XXII. 

MULTIPLE  CEREBEO-SPINAL  SCLEROSIS 661 

By  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York ;  Pathologist  to  the 
New  York  City  Hospital ;  Neurologist  to  Eandall's  Island  Hospital ; 
Attending  Physician,  New  York  Hospital  for  Nervous  Diseases. 

CHAPTER   XXIII. 

PARETIC  DEMENTIA 667 

By  F.  X.  Dercum,  A.M.,  M.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jeiferson  Medical  College ;  Neurologist  to  the  Philadelphia  Hospital : 
Visiting  Physician  to  the  Pennsylvania  Institution  for  Feeble-minded 
Children,  at  Elwyn  ;  Consulting  Physician  to  the  Asylum  for  the  Chronic 
Insane  at  Wernersville ;  Assistant  Physician  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Philadelphia ;  Consulting  Neurolo- 
gist to  St.  Agnes' s  Hospital. 

CHAPTER  XXIV. 

SYPHILIS  OF  THE  NERVOUS  SYSTEM 699 

By  F.  X.  Derctjm,  A.M.,  M.D.,  Clinical  Professor  of  Nervous  Diseases, 
Jefferson  Medical  College  ;  Neurologist  to  the  Philadelphia  Hospital ; 
Visiting  Physician  to  the  Pennsylvania  Institution  for  Feeble-minded 
Children  at  Elwyn  ;  Consulting  Physician  to  the  Asj  lum  for  the  Chronic 
Insane  at  Wernersville ;  Assistant  Physician  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  Philadelphia;  Consulting  Neurolo- 
gist to  St.  Agnes's  Hospital. 

CHAPTER   XXV. 

DISEASES  OF  THE  NERVES 720 

GENERAL  AFFECTIONS. 

By  Wharton  Sinkler,  M.D.,  Physician  to  the  Philadelphia  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Neurologist  to  the  Phila- 
delphia Hospital ;  Consulting  Neurologist  to  the  State  Hospital  for  the 
Chronic  Insane ;  Professor  of  Nervous  Diseases,  Philadelphia  Poly- 
clinic; Neurologist  to  the  Bryn  Mawr  Hospital. 


xii  CONTENTS. 

CHAPTER  XXYI. 

PAGE 

DISEASES  OF  THE  CEAXIAL  ^'ERVES    ...  ...  752 

By  Geobge  E.  de  Schweikitz,  A.M.,  M.D.,  Clinical  Professor  of  Oph- 
thalmology, Jefferson  Medical  College ;  Professor  of  Ophthalmology, 
Philadelphia  Polyclinic  and  School  for  Graduates ;  Ophthalmic  Surgeon 
to  the  Philadelphia  Hospital. 

CHAPTER   XXYII. 

DISEASES  OF  THE  CEAXIAL  XEEYES  (Coxtixued)       .        .        .        .804 

By  Christian  A.  Hertee,  M.D.,  Visiting  Physician  to  the  City  (Charity) 
Hospital ;  Consulting  Physician  to  the  Babies'  Hospital ;  Professor  of 
the  Anatomy  and  Pathology  of  the  Xervous  System,  Xew  York  Poly- 
clinic. 

CHAPTER   XXYIII. 

DISEASES  OF  THE  SPIRAL  XEEVES  AXD  THEIE  PLEXUSES         .  835 

By  Christian  A.  Herter,  M.D.,  Visiting  Physician  to  the  City  (Charity) 
Hospital ;  Consulting  Physician  to  the  Babies'  Hospital ;  Professor  of 
the  Anatomy  and  Pathology  of  the  Xervous  System,  Xew  York  Poly- 
clinic. 

CHAPTER  XXIX. 
DISEASES  OF  THE  MUSCLES 857 


By  George  W.  Jacobt,  M.D.,  Attending  Xeurologist  to  the  German 
Dispensary ;  Consulting  Neurologist  to  the  German  Hospital ;  Consult- 
ing Neurologist  to  the  Infirmary  for  "Women  and  Children,  etc. 


CHAPTER   XXX. 
THE  TEOPHO-NEUEOSES 


By  Joseph  Collixs,  M.D.,  Visiting  Physician  to  the  Hospital  for  Nerv- 
ous Diseases,  New  York  ;  Attending  Physician  to  St.  Mark's  Hospital, 
New  Y^'ork ;  Instructor  of  Nervous  and  Mental  Diseases  in  the  New 
York  Post-Graduate  Medical  School. 


CHAPTER   XXXI. 

TEOPHIC  DISEASES  ASSOCIATED  WITH  PATHOLOGICAL  CHANGES 

IN  THE  THYEOID  GLAND 913 

By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous  Diseases  in 
the  Medico-Chirurgical  College  of  Philadelphia. 


CONTENTS  xiii 

CHAPTER   XXXII. 

PAGE 

SYMPTOMATIC  DISORDERS 927 

By  James  C  Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and 
of  Clinical  Medicine  in  the  Jefferson  Medical  College ;  Physician  to  the 
Hospital  of  the  Jefferson  College  and  to  the  German  Hospital,  Phila- 
delphia. 

CHAPTER   XXXIII. 

SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES         .        .  957 

By  William  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of 
Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia ;  Surgeon  to  the  .Jefferson  Medical  College  Hospital  and  to  the 
Philadelphia  Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases ; 
Consulting  Surgeon  to  St.  Agnes's  Hospital,  to  the  Woman's  Hospital, 
to  St.  Clement's  Hospital  for  Epileptics,  to  the  Asylum  for  the  Insane 
at  Wernersville,  Pa.,  and  the  Pennsylvania  School  for  Feeble-minded 
Children,  Elwyn,  Pa. ;  Membre  correspondant  etrangere  de  la  Societe  de 
Chirurgie  de  Paris. 

CHAPTER   XXXIV. 

NEURO-ELECTROTHERAPEUTICS 1007 

By  George  W.  .Jacoby,  M.D.,  Attending  Neurologist  to  the  German  Dis- 
pensary ;  Consulting  Neurologist  to  the  German  Hospital ;  Consulting 
Neurologist  to  the  Infirmary  for  Women  and  Children. 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


CHAPTER  I. 
GENERAL  CONSIDERATIONS. 

By  S.  weir  MITCHELL,  M.D.,  and   F.  X.  DERCUM,  M.D. 

For  a  generation  past  diseases  of  the  nervous  system  have  attracted  an 
ever-increasing  amount  of  attention.  Little  by  little  they  have  become 
better  understood  and  have  gradually  assumed  the  importance  of  a  well- 
defined  department  of  medical  knowledge.  However,  unlike  such  special- 
ties as  diseases  of  the  eye  and  ear,  no  line  of  demarcation  exists  between  this 
department  and  general  medicine.  Indeed,  the  two  touch  at  almost  every 
point  and  can  never  be  entirely  separated.  At  the  same  time  the  field  of 
nervous  diseases  has  become  so  vast  and  the  details  so  intricate  that  special 
study  is  absolutely  demanded. 

Before  disease  can  be  intelligently  considered,  a  knowledge  of  normal 
structure  must  first  be  acquired.  Especially  is  this  true  of  diseases  of  the 
nervous  system.  Here  a  knowledge  of  morphology  is  of  supreme  importance. 
Not  only  must  the  student  be  familiar  with  gross  relations  and  minute  details, 
but  also  with  general  principles.  To  this  end  his  studies  should  not  be  con- 
fined to  man,  but  should,  if  possible,  include  general  biology.  An  under- 
standing of  nervous  structure  is  hardly  possible  without  a  knowledge  of 
embryology  and  comparative  anatomy.  The  lessons  taught  by  these  sciences 
m^ke  clear  much  that  is  otherwise  inexplicable  and  give  to  the  student  a 
foundation  for  a  broad  and  philosophical  grasp  of  the  subject. 

The  study  of  the  diseases  of  the  nervous  system  embraces  of  necessity  a 
study  of  its  pathology.  The  pathological  processes  at  work  are  many  of 
them  common  to  the  body  as  a  whole.  Svich,  for  instance,  are  the  various 
forms  of  inflammation,  some  forms  of  sclerosis,  and  several  forms  of  tumor. 
Again,  as  in  diseases  of  other  organs,  morbid  processes  may  affect  pri- 
marily either  the  parenchyma  or  the  supporting  and  protective  structures ; 
that  is,  they  may  affect  primarily  the  nervous  elements,  the  nerve  cells  and 
fibres,  or  the  neuroglia,  the  connective  tissue,  and  the  enveloping  membranes. 
The  bloodvessels,  also,  are  subject  to  changes  similar  to  those  which  they 
undergo  elsewhere.  In  general  terms,  with  the  exception  of  certain  new 
formations,  such  as  gliomata,  and  with  the  further  exception  of  a  special 
form  of  parenchymatous  degeneration  known  as  tract  or  Wallerian  degene- 
ration, the  morbid  changes  in  the  nervous  system  resemble  the  changes  found 
in  other  tissues. 

On  the  other  hand,  in  their  clinical  aspects  nervous  diseases  present  numer- 
ous special  features.  This  is  true  not  only  of  symptoms,  but  also  of  the 
family  and  personal  histories.     Thus  it  is  noteworthy  that  in  the  production 

2 


18  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  nervous  diseases  heredity  frequently  plays  an  important  part.  This  fact 
lends  a  peculiar  value  to  the  family  history.  As  far  as  possible,  facts  bearing 
upon  any  diseases  from  which  the  parents  or  other  relatives  may  have  suf- 
fered should  be  brought  to  light.  Special  attention  should,  of  course,  be 
paid  to  those  which  bear  directly  upon  the  nervous  system.  In  this  connec- 
tion it  is  not  sufficient  merely  to  inquire  whether  a  grandparent,  father  or 
mother,  uncle  or  aunt,  brother  or  sister  has  been  insane,  has  had  epilepsy  or 
other  nervous  affection,  but  also  to  determine  whether  there  be  a  history  of 
alcoholic  excess,  of  dissipation,  of  gout,  of  rheumatism,  of  syphilis,  and  even 
of  tuberculosis  in  the  ancestry. 

The  nervous  features  presented  by  family  histories  are  of  three  kinds. 
The  first  is  illustrated  by  a  class  of  patients  in  whom  we  obtain  merely  a 
history  of  general  nervousness,  of  irritability,  of  invalidism,  or  of  chronic 
headaches  as  existing  in  this  or  that  member  of  the  family.  In  other  words, 
we  obtain  a  history  which  is  suggestive,  other  things  equal,  of  a  neurasthenic 
strain  in  the  ancestry.  The  second  is  illustrated  by  a  class  from  which  we 
learn  that  one  or  more  relatives  have  suffered  from  insanity,  epilepsy,  or 
organic  nervous  disease;  or  there  may  be  a  history  of  suicide,  of  an 
occasional  feeble-minded  or  idiotic  child,  or  of  strange  personal  eccen- 
tricities. A  patient  with  such  a  history  is  more  or  less  liable  to  serious 
nervous  or  mental  disease  ;  he  is  apt  to  have  what  is  known  as  "  the  neuro- 
pathic constitution  "  or  the  "  insane  neurosis,"  as  it  is  also  called.  There 
is  in  such  a  patient  an  inherent  tendency  to  certain  forms  of  nervous  degene- 
ration. The  third  is  illustrated  by  a  class  of  jDatients  in  whose  family  his- 
tories nervous  features  are  apparently  lacking,  but  in  their  stead  various  ele- 
ments are  present  also  potent  for  ill ;  among  them  are  alcoholism,  the  various 
diathetic  diseases,  such  as  gout  and  rheumatism,  and  infectious  diseases,  such 
as  syphilis  and  tuberculosis.  That  alcoholism  in  the  ancestors  is  of  grave 
significance  is  shown  by  two  facts :  first,  the  admitted  physical  inferiority  of 
the  children  of  alcoholic  parents,  and,  secondly,  the  transmission  of  the  alco- 
holic habit  from  one  generation  to  another.  Diathetic  affections,  in  their 
turn,  are  not  infrequently  related  to  neurasthenia,  migraine,  and  other  func- 
tional nervous  troubles  in  the  offspring.  The  importance  of  syphilis  in  the 
ancestry  is  shown  either  by  the  direct  transmission  of  the  disease  to  the 
foitus,  causing,  among  other  things,  an  arrest  of  development,  or  by  the  pro- 
duction of  a  markedly  neurasthenic  and  feeble  stock. 

As  in  all  other  classes  of  aflections,  the  personal  history  is  also  of  great 
importance.  The  method  of  eliciting  it  differs  in  no  respect  from  that  used 
in  studying  other  diseases.  Our  inquiries  should  be  especially  directed  to 
determine  whether  the  nervous  system  of  the  patient  has  been  normal  in  its 
development,  whether  it  has  shown  itself  prone  to  disturbances,  and,  finally, 
whether  it  has  been  exposed  to  certain  deleterious  influences.  Thus  we 
inquire  in  certain  cases,  as  to  the  time  when  the  child  began  to  talk,  what 
progress  it  made  at  school,  whether  or  not  at  the  age  of  puberty  nervous 
symptoms  were  present,  and  whether  or  not  during  adolescence  the  mental 
and  emotional  life  of  the  individual  was  normal.  Further,  we  should  inquire 
as  to  the  history  of  convulsions  in  early  childhood,  of  frequently  recurring 
headaches,  of  neuralgia,  or  of  excessive  irritability  and  nervousness.  Finally, 
we  must  question  our  patient  as  to  a  history  of  grave  illnesses,  of  exposure, 
of  injuries,  of  alcoholic  and  other  excesses.  In  this  connection,  too,  it  is  of 
the  greatest  importance  to  determine  the  existence  of  syphilitic  infection,  or, 
if  this  be  denied,  a  history  of  promiscuous  exposure.  In  no  other  class  of 
diseases  does  syphilis  play  so  gi^eat  a  role.  Questions  directed  to  determine 
the  presence  or  absence  of  this  malady  are,  in  organic  nervous  affections, 
absolutely  essential. 


I 


GENERAL  CONSIDERATIONS.  19 

The  part  played  by  alcohol  is  second  in  importance  only  to  the  part  played 
by  syphilis.  The  abuse  of  tobacco,  tea,  coffee,  and  of  the  various  narcotics 
should  also  be  carefully  inquired  into.  Further,  in  addition  to  the  toxic  agents 
which  the  patient  voluntarily  ingests,  there  are  others  which,  by  being  acciden- 
tal ingredients  of  food  or  drink,  may  profoundly  affect  the  nervous  apparatus. 
This  is  especially  true  of  the  various  metallic  poisons — e.  g.,  lead  and  arsenic. 

The  history  of  the  sexual  life  of  the  patient  is  also  of  great  importance. 
Sexual  excess,  and  especially  abnormalities  in  the  performance  of  the  sexual 
act  (see  Chapter  II.),  are  definitely  related  to  various  functional  and  organic 
nervous  diseases.  Further,  disease  of  the  sexual  apparatus,  such  as  strictures 
of  the  urethra  in  men  or  organic  disease  of  the  ovaries  and  tubes  in  women, 
react  profoundly  upon  the  nervous  system. 

Various  other  facts  in  the  personal  history  relating  to  deleterious  influ- 
ences acting  on  the  nervous  system  could  be  here  enumerated ;  they  are, 
however,  considered  in  detail  in  the  following  chapters. 

Next  in  order  is  the  direct  examination  of  the  jDatient.  First,  in  a  general 
way,  we  notice  peculiarities  of  posture,  of  gait,  and  of  general  movements ; 
the  presence  of  any  gross  deformity,  of  marked  paralysis,  or  the  wasting 
of  a  limb.  We  note  also  the  patient's  method  of  talking,  his  manner 
of  explaining  his  case,  his  gestures,  and  his  facial  expression.  By  this 
means  we  are  often  enabled  roughly  to  classify  the  case  Avith  this  or  that 
group  of  nervous  affections.  Of  course,  a  detailed  examination  is  invariably 
necessary,  and  must  be  made  in  a  systematic  manner.  Inasmuch  as  the 
nervous  system  is  extremely  complex,  the  symptoms  produced  by  its  derange- 
ment are  manifold.  They  may  present  themselves  as  anomalies  of  motion,  of 
sensation,  of  reflex  action,  of  nutrition,  of  intellectual  and  emotional  activity, 
or  as  disturbances  of  various  visceral  functions. 

Fig.  1. 

Forward. 


Right.    ^     ^       ^<>  L    //  Left. 


Backward. 
Tracing  of  the  sway  in  a  healthy  man     (Hinsdale.)    In  taking  the  above  tracing  a  piece  of  black- 
ened cardboard  was  fixed  in  a  horizontal  position  above  the  head  of  a  normal  man  standing  in  the 
position  described  in  the  text.    The  subject  wore  a  cap,  upon  the  centre  of  which  was  mounted  a 
small  stylus. 

In  our  detailed  examination,  we  note  first  whether  the  patient  is  able  to 
maintain  an  upright  position  without  swaying  to  either  side  or  forward  or 
backward  more  than  normally.  In  other  words,  we  determine  his  station — 
i.  e.,  his  power  of  maintaining  his  equilibrium.  As  is  well  known,  a  healthy 
man  standing  erect  sways  a  little  to  and  fro.  No  one  can  stand  absolutely 
still.  The  sway  taking  place  in  health  has  been  studied  by  S.  Weir  Mitchell 
and  Guy  Hinsdale.^  They  found  that  a  man  standing  Avith  his  feet  close 
together,  heels  and  toes  apposed,  sways  forward,  backward,  and  laterally, 
but  that  this  sway  is  usually  more  pronounced  in  certain  directions.     "  The 

1  American  Journal  of  the  Medical  Sciences,  April,  1887. 


20 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


first  moyement  is  almost  invariably  forward,  then  there  is  a  counterbalancing 
effort,  bringing  the  body  backward  and  usually  to  the  right."  The  more 
j)ronounced  swaying  is  in  the  antero-posterior  line.    Normal  men  and  women 


Fig. 


Tracing  of  the  sway  in  a  case  of  locomotor  ataxia.    (Hinsdale.) 

have  an  average  sway  of  one  inch  in  the  forward  and  backward  direction,  and 
about  three-quarters  of  an  inch  laterally.     As  is  shown  in  the  accompanying 

tracing  (Fig.  1),  the  forward  sway  is  largely  in 
excess  of  the  backward  sway,  and,  iiirther,  that 
movement  to  the  right  is  largely  in  excess  of 
movement  to  the  left ;  in  other  words,  the  nor- 
mal sway  is  distinctly  antero-dextral.  As  Hins- 
dale has  shown,  in  left-handed  persons  the  sway 
is  often  antero-sinistral.  Closing  the  eyes  in- 
creases the  amount  of  sway  about  50  per  cent. 

If  the  power  of  maintaining  the  equilibrium 
be  impaired,  swaying  becomes  exaggerated  (see 
Fig.  2  '.  Further,  if  the  eyes  be  closed,  so  that 
the  patient  is  denied  their  guidance,  this  symp- 
tom becomes  still  more  marked.  In  excessive 
swaying,  such  as  occurs  in  locomotor  ataxia,  the 
patient  may  even  fall  while  this  test  is  being 
made.  This  symptom — i.  e.,  the  increased  sway 
upon  closure  of  the  eyes — is  technically  known 
as  the  Romberg  symjjtom. 

We  next  direct  our  attention  to  the  other 
motor  symptoms.  We  begin  by  studying  the 
gait.  We  note  whether  the  limbs  are  used  as 
readily  and  as  freely  as  in  health,  whether  they 
are  weak,  whether  they  are  held  rigidly  and 
weir  Mitcheirs  apparatus  for  Clin-  ^crfped  along  the  ground,  or  whether  they  are 
icai  observations  of  station.        awkAvardly  thrown  from  place  to  place.      The 


GENERAL  CONSIDERATIONS. 


21 


typical  abnormal  gaits  naturally  group  themselves  into  the  ataxic  gait,  in 
which  the  movements  are  not  properly  co-ordinated ;  the  sjxistie  gait,  in 
which  the  legs  are  held  very  rigidly  ;  and,  lastly,  the  various  gaits  of  simple 
weakness,  in  which  one  or  both  legs  are  partially  paralyzed.  It  will  be  best 
to  study  briefly  the  elements  of  the  normal  walk,  so  that  the  differences  be- 
tween it  and  the  various  abnormal  gaits  will  be  more  readily  comprehended. 
In  walking  a  series  of  oscillations  are  performed  by  the  trunk,  and  these 
oscillations  take  place  in  three  different  directions :  First,  an  oscillation  in 
the  horizontal  direction,  the  trunk  swaying  from  side  to  side ;  secondly,  an 
oscillation  in  the  vertical  direction,  the  trunk  rising  and  falling ;  and, 
thirdly,  an  oscillation  in  the  forward  direction,  the  trunk  being  propelled 
forward  by  a  series  of  regularly  recurring  impulses.  The  curves  described 
have  been  studied  in  detail  by  Dercum.'  In  Fig.  4  is  traced  the  oscilla- 
tion of  a  point  upon  the  head  in  a  vertical  direction.     In  Fig.  5  is  traced 

Fig.  4. 


1 

— 

, 

■^ 

' 

'^ 

-~ 

^ 

Fig.  5. 

— 





— ■ 

1 — 

■ 

1 

1 

Fig.  6. 

1 

^ 

^ 

-' 

■^ 

-^ 

V, 

' 

--• 

'- 



1 

-^ 

Fig.  7 

1 





















__ 

^ 

— 

' — 

— 

— 

— ' 

— 

— 

— 

— 

— 

— 

— 

— 

— 

Illustrating  the  vertical  and  lateral  oscillations  of  the  head  and  pelvis  in  the  normal  walk.  Fig. 
4  represents  the  vertical  oscillation  of  the  point  upon  the  head.  Fig.  5  represents  the  lateral  oscil- 
lation of  the  same  point.  Fig.  6  represents  the  vertical  oscillation  of  the  superior  spinous  process 
of  the  iUum.    Fig.  7  represents  its  lateral  oscillation. 

the  oscillation  of  the  same  point  in  a  lateral  direction.  Fig.  6  represents 
the  rise  and  fall  of  the  superior  spinous  process  of  the  ilium,  while  Fig.  7 
represents  the  lateral  oscillation  of  the  same  point.  These  curves  are  inter- 
esting as  demonstrating  slight  differences  in  the  character  of  the  movement 
in  various  portions  of  the  body  ;  thus  it  will  be  seen  at  once  that  the  ampli- 
tude of  the  vertical  movement  of  the  hip  is  decidedly  greater  than  that  of 
the  head.  At  the  same  time  it  is  noted  that  the  lateral  sway  of  the  hip  is 
much  less  than  that  of  the  head.  These  facts  are  in  keeping  with  what  we 
would  expect  on  a  priori  grounds.     The  pelvis  is  relatively  fixed  and  not 


1  Dercum,  F.  X.:    Transactions  of  the  College  of  Physicians,  Philadelphia,  1887 


22 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


nearly  so  free  to  move  in  a  lateral  direction  as  the  head  or  upper  portions  of 
the  trunk  ;  and,  again,  the  tilting  of  a  column  is  naturally  exaggerated  at  its 
upper  and  free  end.  As  a  matter  of  fact,  also,  the  lateral  sway  is  slightly 
more  pronounced  toward  the  right  than  toward  the  left.  This  is  in  har- 
mony with  the  more  pronounced  sway  to  the  right  seen  in  normal  station. 

It  is,  however,  the  movement  of  the  leg  and  foot  that  is  most  interesting. 
In  Fig.  8  are  represented  the  curves  described  by  the  external  malleolus  in 

Fig.  8. 


Representing  the  vertical  and  lateral  oscillations  of  the  foot  in  the  normal  walk, 
the  external  malUeous  being  taken  as  a  fixed  point. 

the  course  of  a  single  step.  The  upper  line  represents  the  rise  and  fall  of  the 
malleolus.  It  is  seen  at  a  glance  that  this  curve  is  made  up  of  a  number  of 
elements.  The  curve  begins  by  the  malleolus  SAveeping  upward  on  an  arc, 
the  radius  of  which  centres  in  the  ball  of  the  great  toe.  At  the  next  instant, 
the  centre  of  rotation  is  transferred  to  the  tip  of  the  great  toe.  The  remainder 
of  the  curve  up  to  its  highest  point  is  the  result  of  the  flexion  of  the  leg  and 
of  the  forward  movement  of  the  pelvis ;  thence  to  the  final  impact  of  the 
heel  upon  the  ground  the  curve  is  the  resultant  of  a  complex  movement,  in 
which  three  principal  elements  are  distinguishable :  first,  a  pendulum  move- 
ment; second,  Si  fall;  and,  third,  a,  forward  movement,  the  latter  being  due  to 
the  movement  forward  of  the  body  as  a  whole.  The  first  two  elements  are 
those  of  a  cycloid,  and  the  foot  therefore  falls  to  the  ground,  other  things 
equal,  along  the  line  of  sidfted  descent.  A  fourth  element  is  observed  in  the 
slight  secondary  rise  occurring  in  the  curve  just  previous  to  its  termination. 
The  significance  of  this  secondary  rise  is  as  follows  :  We  notice  that  the  heel  of 
the  passive  leg  in  swinging  forward  in  its  cycloid-like  descent  does  not  imme- 
diately strike  the  ground,  but  that  just  previous  to  the  impact  it  again  makes 
a  slight  ascent.  It  is  relatively  slow  in  the  beginning,  but  steadily  increases 
in  velocity  until  the  step  is  almost  completed,  when  a  slowing  of  movement 
again  takes  place.  This  slowing  of  movement  is  coincident  with  the  sec- 
ondary rise  (see  Fig.  10).  The  impact  of  the  heel  upon  the  ground  is  then 
made  without  any  waste  of  force  and  with  a  minimum  amount  of  jar. 
When,  in  addition,  we  reflect  that  the  heel  is  but  a  part  of  a  moving 
lever,  and  that  the  muscles  attached  to  this  lever  are  elastic,  we  realize  that 
the  jar  of  impact  is  indeed  reduced  to  a  minimum. 

It  is  further  of  interest  to  note  that  the  weight  is  rapidly  transferred  to 
the  outer  edge  of  the  fi)ot,  and  thence  again  to  the  ball  of  the  great  toe, 
preparatory  to  the  next  propulsive  eflbrt.  A  complex  rotatory  movement  of 
the  foot  therefore  takes  place. 

As  seen  in  Fig.  9  and  Fig.  10,  the  rate  of  motion  is  not  by  any  means 
uniform. 

AVith  a  clear  conception  of  the  normal  walk  before  us,  the  gaits  of  loco- 
motor ataxia  and  of  lateral  sclerosis,  which  can  be  taken  as  typical  of  the 
various  ataxic  and  spastic  gaits,  become  easily  understood.    In  ataxia,  which 


GENERA  L  CONS  ID  ERA  TIONS. 


23 


we  will  consider  first,  the  lateral  sway  of  the  trunk  and  head  is  much  in-_ 
creased.  It  is  also  very  irregular  and  is  enormously  exaggerated  by  closure  of 
the  eyes.  When  we  come  "to  study  the  movements  of  the  legs  Ave  find  that 
they  also  are  very  irregular.  When,  however,  they  are  closely  studied,  either 
in  the  living  subject  or,  better  still,  in  serial  photographs  (see  Chapter  XX.), 


Fig.  9. 


Fig.  10. 


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Fig.  9  illustrates  the  variations  in  the  position  of  the  leg  and  foot,  as  also  the  varying  rate  of 
movements,  the  time  Interval  between  any  two  tracings  being  always  the  same. 
Fig.  10  illustrates  a  slight  secondary  rise  and  the  impact  of  the  heel  on  the  ground. 

Ave  note  that  tAvo  factors  are  constant,  namely,  an  increase  in  the  outAvard  sway 
of  the  foot,  and,  secondly,  an  increase  in  the  height  to  Avhich  the  foot  is  raised 
from  the  ground.  The  curves  or  trajectories  of  the  movement  of  the  foot 
differ  therefore  strikingly  from  the  corresponding  trajectories  of  the  normal 
walk.     This  is  readily  seen  by  a  comparison  of  the  curves  of  Fig.  11  with 

Fig.  11. 


Represents  the  vertical  and  lateral  oscillations  of  the  foot  in  the  case  of  locomotor  ataxia,  the 
external  malleolus  being  taken  as  a  fixed  point.  The  direction  of  the  movement  is  from  left  to 
right. 

those  of  Fig.  8.  The  altitude  of  the  vertical  trajectory  is  seen  to  be  very 
much  greater,  Avhile  the  outward  sway  is  also  much  exaggerated.  The 
vertical  trajectory  is  made  up  of  the  same  elements  as  the  corresponding  line 
of  the  normal  gait,  namely  :  first,  a  short  curve  depending  upon  the  upward 
rotation  of  the  malleolus  upon  a  radius  centring  in  the  ball  of  the  great  toe ; 
secondly,  a  curve  depending  upon  the  centre  of  rotation  being  transferred  to 
the  tip  of  the  great  toe.  This  curve  again  passes  insensibly  into  one  caused 
by  the  flexion  of  the  leg  on  the  thigh  and  the  ouAvard  movement  of  the  hip. 
A  reference  to  Fig.  12  Avill  shoAV  that  the  flexion  of  the  leg  is  much  more 
marked  than  in  the  normal  walk,  and,  consequently,  tlie  corresponding  per- 


24 


NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 


tion  of  the  curve  is  higher.  Not  only  is  the  ahitude  of  the  curve  greater, 
but  the  fall  of  the  foot  is  irregular.  Especially  do  we  notice  that  the  heel 
fails  to  make  the  slight  secondary  rise  which  occurs  in  the  normal  walk  just 
before  the  impact  on  the  ground  is  made ;  in  fact,  the  curve  suddenly  drops 


Fig.  12. 


Illustrates  the  movement  and  the  varying  positions  of  the  leg  and  foot  in  the  case  of 
locomotor  ataxia,  and  also  the  impact  of  the  heel  upon  the  ground. 

as  though  the  impact  were  made  by  a  sudden  descent.  Further,  while  we 
note  that  the  outward  swav  is  also  increased,  we  note  again  that  it  is  very 
irregular. 

A\  hen  we  come  to  the  spastic  gait,  such  as  is  typified  in  lateral  sclerosis, 
we  find  that  the  amplitudes  of  the  curves  described  by  the  foot  are  lessened. 
This  is  readily  seen  by  reference  to  Fig.  14,  as  well  as  the  curves  of  Fig.  13. 

Fig.  13. 


In  Fig.  13  are  represented  the  lateral  and  vertical  oscillations  of  the  foot  in  the  case  of  lateral 
sclerosis,  the  external  malleolus  being  again  taken  as  a  fixed  point.  The  direction  of  the  step  is 
from  left  to  right. 

When  we  compare  the  vertical  trajectory  in  this  instance  with  that  of  the 
normal  walk,  Fig.  8,  we  note  at  once  'that  the  altitude  of  the  curve  is 
much  diminished,  and  we  also  find  that  the  outward  sway  is  reduced 
to  a  minimum.  In  other  words,  in  this  gait  the  leg  is  held  very  stiffly. 
There  is  but  little  action  at  the  knee,  and  the  foot  is  barelv,  if  at  all,  raised 
from  the  ground.  At  the  same  time,  instead  of  being  well  abducted,  it  is 
really  adducted.  Indeed,  the  advancing  foot  at  the  completion  of  its  move- 
ment may  be  brought  so  far  within  the  median  line  as  to  get  in  the  Avay  of 
its  fellow.     This  crossing  of  the  feet  is  every  now  and  then  seen  in  the  spastic 


GENERAL  CONSIDERATIONS. 


25 


gaits  of  hysteria.  As  regards  the  lateral  sway  of  the  trunk  in  the  spastic 
gait,  it  is  grossly  exaggerated,  and  it  always  takes  place  toward  the  side 
opposite  the  advancing  leg.  It  is  only  by  means  of  this  grossly  exaggerated 
sway  that  the  leg  can  be  advanced  at  all  in  many  cases.  The  sway  tilts  the 
pelvis,  and  thus  assists  in  raising  the  foot  from  the  ground.  This  exaggerated 
lateral  sway  seen  in  the  spastic  gait  differs,  however,  radically  from  the 
excessive  sway  of  ataxia  in  that  it  is  neither  irregular  nor  spontaneous,  but 
distinctly  associated  with  the  effort  of  moving  the  limbs.  The  spastic  gait 
is,  further,  relatively  slow — certainly  much  slower  than  the  normal  walk,  and 
decidedly  slower  than  the  gait  in  ataxia.  When  spastic  paralysis  is  confined 
to  one  side  of  the  body,  the  peculiarities  in  the  movements  of  foot  and  leg, 
just  described,  are  limited,  of  course,  to  the  paralyzed  side.  Occasionallv 
in  such  ca.ses  the  foot,  instead  of  being  closely  approximated  to  the  median 
line,  is  well  thrown  out  by  the  tilting  of  the  trunk  toward  the  sound  side. 

Fig.  14. 


!   I 

■""1 

1 

-t 

--  ■        1  ■       \      ^      \     \ 

-t    -i^ 

-        -1         \     A    \  'l 

-t    1-t 

-       '    -  -         ^           ^,         \       ^    !         - 

1 

-    ^^ 

^          \        \      \ !       7 

1 

X-        M    V- 

,     )       i)        )     v\ 

//     1 

/               ^     /             1                        )] 

//\  •  J 

//\  \  //  \  / 

11                           11/  ^// 

V\  \  //  \  i/l/ 

/                         /  1             /        //^  ' 

//  \  '//  \  \ /\  ^l 

/  i            ;          1   \        1     :       1  /A 

'   \///  1  / 1  1  / 

i      /I         '    1   7  '  \  ■    t       /// ' 

1/1    / i  '  / 

■  /'  '       '  r\  \  '  ///'  ' 

M  /'/■■     f  i  1  1  / 

/  M            1       1    i    1    ■# 

//  yUi  !  'vi  '  /i 

!   i       /   i  I  '   1   1   ;|      1 

A  '  i  (\  \  X 1  i  \     ( 

!    Ki     i    i    !     1     1     i\    i     •     .'iiS^         ! 

Vj^    X'.  \<  v^  \    i--- 

^  i   \i  ^  iV^'   i    \      :  X 

,N^^>,|   H^i    1 

i  >J_M5 1  i  1  v-i-j^  i  '  i  t;? 

In  Fig.  14  are  seen  the  relative  positions  of  the  foot  and  leg,  as  also  the  varying  rates  of 
movement  in  the  case  of  lateral  sclerosis. 


In  the  gait  of  simple  weakness,  such  as  that  seen  in  partial  loss  of  power 
in  both  legs,  it  will  be  noticed  that  the  feet  are  thrown  forward  in  a  passive 
or  pendulum-like  manner,  and  that  the  weight  is  not  trusted  to  the  leg  rest- 
ing upon  the  ground  until  the  knee  ha.s  been  thro\^^l  far  back — i.  e.,  has 
become  slightly  retroflexed  or  locked.  This  expedient  the  patient  uncon- 
sciously adopts  in  order  to  make  a  collapse  fi-om  sudden  flexion  impossible. 
This  is  in  marked  contrast  with  what  is  seen  in  the  normal  leg.  When  a 
simple  weakness  is  limited  to  one  leg  the  latter  is  carried  forward  in  a  help- 
less or  pendulum-like  manner,  and  the  weight  of  the  body  is  not  thrown  upon 
it  until,  as  in  the  previous  instance,  it  has  become  Avell  locked  at  the  knee. 
Special  gaits  due  to  the  paralysis  or  contractures  of  special  muscles  or  groups 
of  muscles  are  described  whenever  necessary  in  the  text. 

At  times  it  is  important  to  study  the  movements  of  the  legs  not  only  in  the 
erect  position,  but  also  when  the  patient  is  lying  flat  upon  his  back,  upon  his 
side,  or  even  prone. 

It  is  evident  that  the  various  tests  for  muscular  co-ordination  are  directly 
related  to  the  tests  for  station.  It  follows  that  a  patient  whose  station  is 
below  normal  is  apt  to  reveal  lack  of  co-ordination  or  ataxia  in  his  gait. 

Next  we  examine  the  arms.  Here  again  we  determine  whether  movement 
is  modified,  whether  it  is  impaired  so  as  to  indicate  either  weakness  or  rigid- 
ity, or  whether  there  is  lack  of  jDroper  co-ordination.  We  test  the  strength 
of  the  arm  in  various  wavs.     A  fair  idea  can  be  obtained  bv  askiuir  the 


26 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


patient  to  grasp  the  hand  of  the  physician  as  firmly  as  possible.  For  pur- 
poses of  more  accurate  information,  however,  special  forms  of  apparatus  have 
been  devised.  Thus  we  have  an  instrument  known  as  the  hand  dynamometer 
(Fig.  15),  which  consists  of  an  elliptical  steel  spring  bearing  a  scale  and 


Fig.  15. 


Fig.  16. 


Hand  dynamometer. 

index.  When  the  ellipse  is  grasped  by  the  hands  and  its  sides  approximated 
the  index  registers  the  exact  amount  of  pressure  exerted.  We  should 
remember  in  this  connection  that  in  right-handed  persons  the  right  side 
should  be  a  little  stronger  than  the  left.  The  reverse  obtains  in  left-handed 
persons. 

For  testing  the  strength  of  the  foot  and  leg  various  forms  of  apparatus 
have  been  devised.  For  practical  purposes,  hoAV- 
ever,  they  are  not  required.  If  the  suspected 
weakness  be  not  revealed  by  the  gait,  it  may  be  at 
once  brought  to  light  by  asking  the  patient  to 
stand  on  one  leg  alone.  However,  the  hand  dyna- 
mometer can,  if  necessary,  be  converted  into  a 
foot-dynamometer  by  the  use  of  a  belt  and  stirrup, 
as  has  been  done  by  Dr.  Krauss,'  of  Buffalo.  The 
dynamometer  is  inserted  lengthwise  between  the 
stirrup  and  the  stirruj)-strap,  the  latter  being  in 
turn  attached  to  the  belt  at  the  side.  The  belt 
being  adjusted,  the  patient  inserts  the  foot  into  the 
stirrup  and  makes  an  effort  to  extend  the  leg. 
The  amount  of  force  exerted  is,  as  before,  regis- 
tered on  the  dynamometer.     (Fig.  16.) 

Having  studied  the  strength  of  the  j)atient,  we 
next  determine  whether  the  movements  of  the  arms 
are  properly  co-ordinated.  The  legs,  as  we  have 
seen,  are  readily  tested  in  this  respect  by  means  of 
the  gait.  In  the  case  of  the  arms  we  adopt  the  ex- 
pedient of  asking  the  patient  to  perform  certain 
movements ;  thus,  we  ask  him  to  button  and  un- 
button his  coat,  noting  whether  the  act  is  j^er- 
formed  with  the  ease  and  skill  of  a  person  in 
health ;  or,  the  arms  having  been  previously  extended,  we  ask  him  to  approx- 
imate slowly  the  tips  of  the  forefingers.     Next  we  note  Avhether  these  move- 


Krauss'  foot  and  leg  dynamometer. 


1  Krauss,  Wm.  C.  :  Journal  of  Nervous  and  Mental  Disease,  October,  1893. 


GENERAL  CONSIDERATIONS.  27 

ments  are  possible  Avith  the  eyes  closed.  A  great  many  similar  tests  can  be 
devised,  such,  for  instance,  as  asking  the  patient  to  place  the  forefinger  of 
either  hand  upon  the  tip  of  the  nose,  upon  the  chin,  or  upon  the  tip  or 
the  base  of  the  ear.  Marked  inco-ordination  is  made  manifest  by  gross  irreg- 
ularities of  movement. 

In  speaking  of  motor  symptoms  Ave  use  the  following  terminology:  The 
words  paralysis  and  palsy  are  used  interchangeably  to  indicate  a  complete  or 
marked  loss  of  voluntary  power.  The  Avord  paresii  is  used  to  indicate  a  par- 
tial or  a  mild  degree  of  loss  of  poAver,  If  the  patient  present  a  paralysis  of 
one  limb  only,  Ave  speak  of  a  monoplegia.  If  it  be  the  arm  that  is  affected,  Ave 
speak  of  a  brachial  monoplegia ;  if  it  be  the  leg,  of  a  crural  monoplegia.  Some- 
times it  happens  that  only  a  single  muscle  or  a  group  of  muscles  is  affected. 
In  such  an  instance  Ave  have  a  local  palsy.  Frequently  it  happens  that  the  leg 
and  arm,  and  sometimes  the  face,  of  the  same  side  are  paralyzed.  This  con- 
dition is  termed  a  hemiplegia.  Occasionally  a  hemiiDlegia  upon  one  side  is 
followed  by  hemiplegia  on  the  other.  Such  a  condition  is  termed  double 
hemij)legia.  It  is  noAV  and  then  met  Avith  in  the  cerebral  palsies  of  childhood 
and,  not  infrequently,  in  hysteria.  If  both  legs  be  paralyzed,  Ave  haA'e  a 
jxvraplegia.  If  numerous  separate  groups  of  muscles  are  paralyzed,  Ave  speak 
of  a  multiple  jicdsy.  If  almost  all  of  the  muscles  of  the  body  are  affected,  Ave 
speak  of  a  general  palsy. 

Instead  of  the  muscles  of  a  part  being  paralyzed  Ave  may  find  them  in  a 
condition  of  iuA'oluntary  contraction.  This  inA'oluntary  contraction,  or  spasm, 
as  it  is  called,  may  be  continuous  or  interrupted  and  recurring.  If  continu- 
ous, it  is  knoAvn  as  a  tonic  spasm.  If  interrupted  and  recurring,  it  is  known 
as  a  clonic  spasm.  If  the  muscles  of  the  limb  be  in  a  condition  of  clonic 
spasm,  it  folloAvs  of  necessity  that  the  part  affected  is  moA^ed  more  or  less 
rapidly  to  and  fro.  If,  on  the  other  hand,  tonic  spasm  be  present  the  limb 
is  firmly  fixed  and  rigid.  On  attempting  to  flex  such  a  limb  Ave  find,  first, 
that  the  joints  yield  only  after  a  certain  amount  of  force  has  been  exerted ; 
and,  secondly,  that  the  muscles  feel  hard  and  firm.  This  condition,  in  Avhich 
loss  of  j)0Aver  is  associated  Avith  rigidity,  is  termed  spastic  paralysis. 

In  place  of  these  phenomena  the  limbs  may  be  throAA'n  about  iuA'oluntarily 
and  in  an  irregular  manner.  In  such  an  instance  Ave  haA^e  present  choreiform 
movements,  or  a  chorea.  These  moA^ements  are  very  frequently  seen  when 
the  patient  is  quietly  seated  in  a  chair  or  lying  in  bed,  and  in  such  an  instance 
are  termed  a  jxissive  chorea.  Less  frequently  the  chorea  is  only  obserA^ed  Avhen 
the  patient  attempts  to  move.  In  the  latter  instance  it  is  termed  an  intention 
chorea.  It  may  be  that,  in  place  of  these  phenomena,  a  small  A^bratory 
movement  is  present  in  the  hands  or  feet  or  in  other  portions  of  the  body. 
In  such  a  case  our  patient  is  said  to  have  tremor.  This  symptom  is  sometimes 
absent,  especially  if  the  patient  be  lying  doAvn  or  quietly  seated  in  a  chair ; 
consequently,  if  tremor  be  suspected,  the  patient  should  not  be  examined 
Avhile  at  rest,  but  should  be  asked  to  perform  some  simple  A^oluntary 
movement.  If  brought  on  by  A^oluntary  movement,  it  is  termed  intention 
tremor.  Tremor  present  in  a  state  of  rest  is  ahvays  obvious,  and  is  termed 
passive  tremor. 

Having  satisfied  our  minds  Avith  regard  to  the  presence  or  absence  of  the 
various  symptoms  thus  far  described,  Ave  turn  our  attention  to  the  A^arious 
tendon  phenomena.  These  are  Avell  represented  by  the  reaction  Avhich  takes 
place  in  a  healthy  person  Avhen,  the  leg  being  semi-flexed  and  so  suspended 
as  to  be  free  to  moA^e,  the  patellar  tendon  is  struck  a  moderate  bloAV.  Under 
these  circumstances  the  leg  is  throAvn  involuntarily  fbrAvard — that  is,  is  par- 
tially extended  by  a  contraction  of  the  quadriceps  femoris  muscle.  In  other 
words,  Ave  have  a  response  to  the  blow  upon  the  tendon  by  a  contraction  of 


28  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  muscle,  with  a  consequent  movement  of  the  limb.  Much  time  and  study 
have  been  spent  upon  this  phenomenon.  By  some  observers  it  has  been,  and 
still  is,  regarded  as  a  reflex,  the  theory  being  that  an  impulse  travels  from  the 
nerve-endings  in  the  tendon  to  the  spinal  cord,  and  thence  is  reflected  back 
to  the  muscle.  However,  the  time  elapsing  between  the  blow  upon  the  ten- 
don and  the  contraction  of  the  muscle  has  been  repeatedly  and  carefully 
measured,  and  is  less  than  would  be  required  for  the  passage  of  the  impulse 
along  the  course  just  described.  Therefore  it  is  held  by  others  that  the  phe- 
nomenon is  really  due  to  muscle  irritability,  and  that  the  muscle  responds 
because  of  the  sudden  pull  upon  its  belly  which  the  blow  upon  the  tendon 
produces.  Whatever  may  be  the  correct  explanation,  the  study  of  this  reac- 
tion in  diseases  of  the  nervous  system  is  of  the  utmost  importance. 

As  might  be  expected,  the  quadriceps  is  not  the  only  muscle  that  responds 
when  its  tendon  has  received  a  blow.  As  a  matter  of  fact,  all  of  the  muscles 
of  the  body  whose  tendons  are  mechanically  accessible  respond  in  a  similar 
manner ;  but  certain  tendons,  because  of  their  anatomical  relations,  are  more 
favorably  situated  for  the  study  of  these  reactions  than  others.  The  most 
important  of  them  all  is  the  tendon  of  the  quadriceps,  the  ligamentum 
patellae.  The  reaction  which  is  obtained  by  striking  this  tendon  is  known 
as  the  patellar  reflex,  or  the  knee-jerk.  The  term  patellar  reflex  is  objec- 
tionable because  it  implies  a  special  theory.  The  term  knee-jerk  simply 
expresses  a  fact,  and  is  much  to  be  preferred.  The  other  tendon  reactions, 
such  as  the  elbow-jerk,  obtained  by  striking  the  tendon  of  the  biceps,  the 
wrist-jerks,  and  the  tendo-Achillis  jerk  are  of  minor  importance,  though  all 
valuable  in  certain  cases.  To  this  category  should  also  be  added  the  jaw- 
jerk,  described  by  Morris  J.  Lewis. 

The  amount  of  response  to  a  blow  upon  a  tendon  depends,  other  things 
being  equal,  upon  the  degree  of  the  muscle  tonus.  It  follows  that  any 
increase  in  the  muscle  tonus  is  accompanied  by  an  increase  in  the  tendon 
reactions.  Advantage  is  taken  of  this  fact  in  cases  in  which  the  reactions 
are  feeble,  or  apparently  absent,  by  asking  the  patient  to  make  a  strong 
voluntary  effort  with  the  hands,  or  with  the  jaws,  at  the  moment  when  the 
tendon  is  struck.  The  voluntary  muscular  effort  causes  a  rise  in  the  tonus  of 
all  the  muscles  of  the  body,  and  thus  the  patient  is  placed  under  more  favor- 
able conditions  for  the  detection  of  the  tendon  response.  This  test  is  called 
the  test  by  motor  re-enforcement,  while  the  method  by  which  the  reaction 
is  elicited  bears  the  name  of  its  discoverer,  Jendrassik.  Weir  Mitchell 
and  Morris  J.  Lewis'  have  shown  that  this  volitional  re-enforcement  lasts 
for  a  brief  interval  after  the  volition  itself  has  ceased,  and  further,  as  might 
have  been  expected  on  a  priori  grounds,  continued  muscular  exertion  at  last 
enfeebles  the  knee-jerk,  and  this  enfeeblement  also  lasts  for  an  appreciable 
interval  of  time. 

Mitchell  and  Lewis  have  also  pointed  out  that  re-enforcement  of  the 
knee-jerk  may  also  occur  through  sensory  stimulation.  This  has  been  con- 
firmed by  Bowditch  and  Warren"''  and  by  Lombard.^  If  just  at  the  time  the 
patellar  tendon  is  struck  we  touch  the  skin  of  the  patient  anywhere  on  the 
arm,  on  the  body,  or  on  the  leg  with  a  piece  of  ice  or  a  hot  spoon,  or  sud- 
denly twitch  a  hair,  or  pinch  the  skin,  the  knee-jerk  becomes  markedly  exag- 
gerated.* Other  agencies,  such  as  the  emotions,  also  influence  the  result,  as 
Lombard  has  shown  experimentally.^     A  familiar  example  is  that  presented 

1  Mitchell,  S.  Weir,  and  Lewis,  Morris  J.:  Medical  News,  1886,  February  13  and  20,  pp.  169  and  198. 
-  Bowditcb,  H.  P.,  and  Warren,  J.  W.:  Journal  of  Physiology,  1890,  vol.  si.,  Nos.  1  and  2  ;  also  Bow- 
ditch,  H.  P.:  Boston  Medical  and  Surgical  lournal,  ilay  31,  1888. 
3  Lombard,  Warren  Plympton  :  American  Journal  of  Psychology,  October,  1887. 
••  Mitchell,  S.  Weir:  Lecture  on  Muscle  Reactioas,  etc.,  Medical  News,  1888,  June  23. 
6  Loc.  cit. 


GENERAL  CONSIDERATIONS. 


29 


by  an  hysterical  girl  in  whom,  as  Mitchell  expresses  it,  "  fear,  excitement, 
apprehension,  and  perhaps  shame  contribute  largely  to  the  production  of  an 
exaggerated  knee-jerk.  If  in  such  a  girl  we  strike  the  patellar  tendon,  we 
notice  further  that  not  only  is  the  knee-jerk  exaggerated,  but  with  it,  also, 
the  other  leg  flies  up,  and  also  one  arm — usually  the  left.  This  is  the  com- 
bined result  of  the  blow  on  the  tendon  and  of  emotions."  In  like  manner 
volitional  efibrts  which  are  unaccompanied  by  actual  movement,  such,  for 
instance,  as  volitional  efforts  directed  to  a  lost  part — e.  g.,  an  amputated  limb, 
re-enforce  the  knee-jerk.    Again, 

if  a  part  of  the  body  is  faradized  ^^^- 1'^- 

during  the  time  the  knee-jerk  is 
tested,  the  latter  is  also  increased. 
Galvanism  also,  when  passed 
through  any  portion  of  the  body, 
and  especially  when  passed 
through  the  head,  increases  the 
knee-jerk  excessively. 

In  cases  in  which  it  is  impor- 
tant to  determine  whether  or  not 
the  knee-jerk  is  really  exagger- 
ated, the  patient  should  be  seated 
in  a  comfortable  chair,  so  as  to 
have  all  his  muscles  relaxed,  and 
his  eyes  should  be  gently  closed. 

Finally,  in  certain  diseased 
conditions,  the  knee-jerk  is  in- 
hibited by  stimulation  of  the  skin 
or  of  the  peripheral  nerves,  as 
has  been  observed  by  Nothnagel, 
Erb,  and  others.  It  was  noted 
by  Mitchell  that  while  slight  and 
sudden  pains  re-enforce  the  knee- 
jerk,  excessive  pain  now  and  then 
inhibits  it.  For  this  phenome- 
non of  depression  and  inhibi- 
tion of  the   knee-ierk  Mitchell  .  .  ,       , 

1  •  <<  J.  Madison  Taylor's  hammer  for  examining  muscle  and 

proposes   tne    expression       nega-    tendon  reactions.   The  hammer  is  made  of  rubber,  while 
tive  re-enforcement,"  or  "deforce-    the  handle  consists  of  a  piece  of  fenestrated  steel, 
ment." 

The  detailed  method  of  eliciting  the  various  tendon  phenomena  is  of  im- 
portance. The  practical  rule  to  bear  in  mind  is  to  place  the  limb  in  such  a 
position  that  the  muscle,  the  tendon  of  which  is  to  be  struck,  is  slightly 
stretched.  Such  a  position  as  is  assumed  in  semi-flexion  either  of  the  leg  or 
of  the  arm  answers  most  purposes.  Starting  with  the  knee-jerk,  it  will  be 
found  that  the  most  favorable  position  is  that  assumed  by  a  patient  when 
seated  on  a  high  chair  or  table.  The  thigh  and  leg  are  to  be  at  right-angles, 
the  leg  hanging  and  all  of  the  muscles  of  the  limb  relaxed.  It  is  often 
more  convenient  to  seat  a  patient  on  an  ordinary  chair,  and  to  have  him  cross 
one  knee  over  the  other.  This  position  answers  almost  every  j^urpose.  Occa- 
sionally it  is  necessary  to  examine  the  knee-jerk  of  a  patient  who  is  confined 
to  bed.  Under  these  circumstances  it  is  best,  when  possible,  to  turn  the 
patient  on  his  side,  with  the  leg  to  be  examined  uppermost.  The  leg  should 
be  slightly  flexed  and  gently  supported  at  the  lower  part  of  the  thigh  by  the 
disengaged  hand  of  the  physician.  The  amount  of  flexion  is  of  considerable 
importance.     It  should  be  decidedly  less  than  when  the  patient  is  seated. 


30 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


If  the  leg  be  too  much  flexed,  the  muscle  will  be  overstretched,  aud  there  will 
be  no  response.  If,  on  the  other  hand,  the  leg  be  too  little  flexed,  or  nearly 
extended,  the  muscle  will  be  too  much  relaxed,  and,  as  before,  there  will  be 
no  response.  A  convenient  position  for  eliciting  the  elbow-jerk  is  for  the 
operator  to  grasp  the  arm,  extend  it  slowly  from  the  shoulder,  and  tap  lightly 
the  triceps  tendon.  The  biceps-jerk  is  conveniently  tested  by  allowing  the 
arm  of  the  patient,  slightly  flexed,  to  rest  within  the  arm  of  the  operator. 
The  biceps  tendon  is  then  similarly  struck  a  light  blow.  The  jaw-jerk  is 
elicited  by  asking  the  patient  to  allow  the  mouth  to  remain  slightly  open, 
and  then  striking  a  light  blow  upon  the  chin  in  a  downward  direction. 

Fig.  18. 


Lombard's  knee-jerk  meter. 


\i,  under  certain  circumstances,  a  forcible  and  steady  pull  be  made  upon 
the  tendon  of  a  muscle,  a  number  of  rapidly  recurring  contractions  follow. 
This  reaction  is  most  frequently  observed  in  the  gastrocnemius,  and  in  this 
instance  is  termed  the  o«A-/e-c/o«H.5-.  It  is  elicited  as  follows:  The  patient  is 
seated,  and  the  leg,  almost  but  not  completely  extended,  is  supported  by  the 
disengaged  hand  of  the  physician.  The  foot  is  then  seized  and  forcibly  and 
steadilv  flexed  upon  the  leg.  If  the  patient  suflers  from  organic  disease  of 
the  motor  pathways,  or  if  there  be  any  cause  that  greatly  increases  the 
reflex  excitability  of  the  cord,  or  that  decidedly  raises  the  muscle  tonus,  the 
foot  mav  vibrate  rapidly  to  and  fro.  As  the  student  has  doubtless  inferred, 
this  phenomenon  is  not  present  in  health.  Other  clonic  tendon  reactions 
may  also  be  observed,  but  only  when  associated  with  abnormal  conditions. 

in  describijig  the  various  tendon  phenomena  in  a  given  case  we  note,  for 
instance,  whether  the  knee-jerk  be  normal,  whether  it  be  exaggerated,  whether 


GENERAL  CONSIDERATIONS. 


31 


it  be  diminished,  or,  finally,  whether  it  be  absent.  If  the  ankle-clonus  be 
present,  it  is  described  as  slight,  feeble,  marked,  or  excessive.  The  same 
applies  also,  of  course,  to  tendon  reactions  observed  in  other  parts  of  the 
body.  For  the  purpose  of  measuring  the  knee-jerk  with  great  accuracy  a 
delicate  instrument  has  been  invented  by  Lombard.^  In  this  apparatus  the 
patient  lies  upon  one  side,  with  the  leg  to  be  experimented  upon  fixed  in  a 
guttered  splint,  the  foot  being  suspended  in  a  stirrup  by  a  long  string  so  that 
it  is  free  to  move.  The  amount  of  the  excursion  of  the  foot  is  then  recorded 
by  means  of  a  system  of  levers  upon  the  smoked  surface  of  a  revolving- 
cylinder.  However,  this  apparatus  has  for  its  object  experimental  studies  in 
the  laboratory.  For  clinical  use  Dr.  Lombard  has  invented  a  more  simple 
instrument.  The  patient  is  seated  on  a  chair  sufficiently  high  to  prevent  his 
feet  from  resting  upon  the  floor.  By  means  of  a  strong  clamp  this  instrument 
is  fastened  to  the  chair  between  the  legs  of  the  patient.  It  consists  of  a  bar 
which  can  be  pulled  out  or  shortened,  and  which  carries  a  dial  plate  divided 
into  centimetres.  A  slight  swinging  rod  with  a  cross-bar  is  set  so  as  to  drop 
on  the  middle  of  the  tibia.  When  now  the  patellar  tendon  is  struck  a  blow, 
the  leg,  in  response,  raises  the  rod  carrying  before  it  an  index  (Fig.  18 \ 
As  this  instrument  is  too  costly  for  common  use,  Weir  Mitchell  has  devised 
an  exceedingly  simple  meter,  which  is  constructed  of  inexpensive  materials 
(Fig.  19).     A  metre  or  yard-stick  carries  a  light,  very  movable  arrangement 

Fig.  19 


Weir  Mitchell's  knee-jerk  meter. 

of  wire,  about  four  inches  in  height  by  five  in  breadth  (a).  This  is  set  or 
fixed  so  that  the  toe,  rising  with  the  tendon-jerk,  will  push  it  up  the  scale. 
As  it  moves  it  pushes  up,  and  leaves  behind  it  as  a  marker,  a  double  loop  of 
wire  (h). 

In  attempting  accurate  studies  of  the  knee-jerk  in  a  given  case,  we  should 
bear  in  mind  the  observations  of  Lombard,^  that  "  the  extent  of  the  normal 
knee-jerk  is  continually  undergoing  change.  So  great  are  the  variations, 
even  when  the  subject  is  at  rest,  that  a  correct  idea  of  the  activity  of  the 
process  can  be  gained  only  by  avei'aging  the  results  of  twenty  or  more  experi- 
ments. The  average  knee-jerk  varies  in  amount  at  different  times  of  day, 
being,  as  a  rule,  greatest  in  the  morning,  soon  after  breakfast,  and  being  very 
much  less  at  night.     The  decline  which  occurs  as  the  dav  advances  is  verv 


1  Loc.  cit. 


Log.  cit. 


32  NERVOUS  BISEASES  AND  THEIR  TREATMENT. 

irregular,  but,  in  general,  the  knee-jerk  is  larger  after  each  meal.  Finally, 
the  extent  of  the  knee-jerk  may  differ  greatly  on  different  days. 

"  The  causes  of  these  variations  of  the  knee-jerk  are  not  only  alterations  in 
the  muscles  and  nerves  involved  in  the  process,  but,  to  a  still  greater  degree, 
changes  in  the  activity  of  the  central  nervous  system,  either  as  a  whole  or  in 
part.  Thus  fatigue,  hunger,  enervating  weather,  and  sleep,  conditions  which 
decrease  the  activity  of  the  whole  central  nervous  system,  decrease  the  aver- 
age knee-jerk ;  while  rest,  nourishment,  invigorating  weather,  and  wakeful- 
ness, influences  which  increase  the  activity  of  the  central  nervous  system, 
increase  the  average  knee-jerk." 

In  order  to  facilitate  note-taking,  Weir  Mitchell  has  introduced  a  series 
of  symbols  which  are  so  readily  understood  as  to  need  little  explanation,  thus  : 
K  J  -|-  means  that  an  exaggerated  knee-jerk  is  present ;  K  J  -| — |-  means 
that  it  is  excessively  exaggerated ;  K  J  —  means  a  diminished  knee-jerk ; 
A  CI  means  an  ankle-clonus ;  E  J  an  elbow-jerk,  and  so  on.  The  follow- 
ing formulae,  with  the  accompanying  explanation,  are  taken  from  Weir 
Mitchell's  Lecture.^ 

Arms :  R.  E.  J.  0.  Rt.  0.  L.  E.  J.  0.         Rt.  0. 

R.  M.  J.  +  +  Rt.  0.  L.  M.  J.  +       Rt.  0. 

Legs:    R.  K.  J.  25°.  Rt.  40°.  L.  K.  J.  27°.    Rt.  36°. 

R.  M.  J.  quadriceps,  n.  Rt.  n.  L.  M.  J.  n.      .  Rt.  n. 

Station :    —^  — =-  •  Eves  shut. 
A    D 

Explanation.  Arms :  right  elbow-jerk,  none.  Re-enforcement,  none,  etc. 
Right  muscle-jerk,  excessive.  No  re-enforcement,  etc.  Legs :  Right  knee- 
jerk,  25  degrees  Lombard's  meter.  Re-enforcement  sends  lever  to  40  degrees, 
and  these  records  mean  maximum  of  several  trials.     As  concerns  muscle- 

2    1  ^ 
ierk,  n  means  normal,  +  excessive,  and  —  less  than  normal.    Station  --  — |, 
J       '  ,-r,  AD' 

means  the  anterior  sway  is  2  inches,  and  the  dextral  1^. 

A  point  of  practical  value  in  relation  to  the  tendon  reactions  remains  to  be 
stated,  and  that  is,  that  each  tendon  reaction  bears  a  definite  relation  to  cer- 
tain levels  of  the  spinal  cord.  These  levels  correspond  to  the  origins  of  the 
nerve  fibres  supplying  the  muscles  concerned.  Thus  the  anterior  crural 
nerve,  which  supplies  the  quadriceps  muscle,  is  derived  fi'om  the  second, 
third,  and  fourth  lumbar  nerves.  These  arise  from  the  lumbar  cord  at  a 
level  opposite  the  body  of  the  twelfth  dorsal  vertebra.  The  knee-jerk  is 
therefore  directly  affected  by  lesions  of  the  cord  in  this  position.  Similarly 
the  ankle-clonus  is  related  to  the  lumbar  and  sacral  portions  of  the  cord  at  a 
level  opposite  the  upper  portion  of  the  body  of  the  first  lumbar  vertebra. 

In  some  individuals,  especially  those  of  an  hysterical  temperament,  local 
muscular  contractions  may  come  on  spontaneously.  At  times  the  contraction 
involves  only  a  portion  of  a  muscle,  the  swelling  jDroduced  resembling  a 
tumor.  The  latter,  by  reason  of  its  not  infi-equent  spontaneous  disappear- 
ance, is  known  as  a  phantom  tumor.  This  condition  has  been  especially 
studied  by  Weir  Mitchell.  It  is  not  accompanied  by  any  displacement  of 
the  limbs  of  a  part,  but  simply  by  the  appearance  of  an  apparently  foreign 
mass  beneath  the  integument.  It  is  occasionally  noted  in  the  muscles  of  the 
calf,  sometimes  in  the  pectoralis  major,  and  not  infrequently  in  the  muscles 
of  the  abdomen.  In  some  cases  similar  local  swellings  in  the  muscles  may 
lie  produced  by  slight  blows  with  a  percussion  hammer  or  with  the  tip  of  the 
finger. 

1  Lecture  on  Muscle  Reactions,  etc.    Loc.  cit. 


GENERAL  CONSIDERATIONS. 


33 


Fig.  20. 


When  a  blow  upon  a  muscle  is  made  with  sufficient  force  the  muscle 
responds  as  a  whole,  the  phenomenon  being  often  attended  by  a  movement 
similar,  but  less  marked,  to  that  which  is  seen  when  the  tendon  is  struck. 
Muscle-jerks,  as  they  are  called,  were  first  studied  by  Weber,  but  their  best 
clinical  studies  are  by  Buzzard  and  Weir  Mitchell  and  Morris  Lewis.  When 
a  blunt  percussion  hammer  strikes  on  a  muscle,  two  phenomena  follow  to  a 
variable  extent.  First,  the  muscle  responds  by  a  long  contraction,  the 
breadth  of  fibre  struck  rising,  and  highest  near  the  point  struck.  This 
reaction  may  move  the  limb,  as  when  the  extensors  of  the  hand  are  thus 
excited.  Also,  it  is  usual  to  see  or  to  feel,  at  the  point  struck,  a  small,  firm 
contraction,  which  remains  twenty  seconds  or  more,  and  is  called  the  short  or 
hump  contraction.  Both  of  these  responses  vary,  and  are  increased  or  even 
lost  in  certain  forms  of  disease. 

The  muscle-jerk,  as  Mitchell  and  Lewis  showed,  is  identical  with  the  so- 
called  tendon-jerk,  but  is  a  coarser  phenomenon.  The  tendon-jerk  is  the 
reply  to  a  quick  pull  on  the  muscle,  and  is  a  delicate  symptom  easily  lost  or 
increased.  The  direct  muscle-jerk,  unlike  it,  sur- 
vives for  a  time  nerve  sections,  but  is  also,  like  it, 
re-enforcible  by  motion  and  sensation. 

AVe  next  direct  our  attention  to  the  sensory 
symptoms.  These  resolve  themselves  into  those 
of  the  various  general  and  special  senses.  We 
begin,  as  a  rule,  by  investigating  the  tactile  sense. 
This  is  tested  in  various  ways,  such,  for  instance, 
as  touching  a  part  lightly  with  the  finger,  w^ith  a 
feather,  or  with  a  piece  of  cotton-wool.  If  the 
cutaneous  sensibility  be  normal,  the  patient  re- 
sponds to  comparatively  slight  impressions.  A 
ready  method  for  determining  actual  loss  of  the 
tactile  sense  is  to  prick  the  skin  with  a  needle, 
which  for  this  purpose  is  conveniently  mounted 
on  a  cork.  More  accurately,  the  same  thing  is 
accomplished  by  means  of  an  sesthesiometer.  This, 
in  its  simplest  form,  consists  merely  of  a  pair  of 
draughtsman's  compasses  to  which  a  scale  is  so 
attached  as  to  enable  us  to  separate  the  points 
to  specified  distances  (Fig.  20;.  Instead,  how- 
ever, a  graded  rod  bearing  at  right-angles  two 
points,  one  of  them  movable,  such  as  originally 
devised  by  Sievking,  may  also  be  used.  Persons 
in  health  are  able  to  separate  within  certain  limits 

the  two  impressions  made  by  the  points  of  the  sesthesiometer.  If,  however, 
the  tactile  sense  be  impaired,  the  distance  at  which  the  points  can  be  separated 
is  much  increased,  so  that  when  even  widely  apart  they  may  give  rise  to  but 
one  impression  instead  of  two.  In  health,  we  should  be  able  to  separate  the 
points  about  as  follows : 

Mm. 

Tip  of  tongue 1.1 

Red  part  of  the  lip 4.1 

Tip  of  nose 6.8 

Under  the  chin 33.8 

Eyelid 11.3 

Forehead 22.6 

Occiput 27.1 

Vertex        .        .        .- 33.8 

Third  phalanx  of  finger,  volar  surface 2.-2.3 

Second      "         " 4.-  4.5 

First  "         .<..,.  u 5__  55 

Third       "         "       "      dorsal    " 6.8 

Second     "        "       "        "  " 11.3 

3 


Carroll's  sesthesiometer. 


34  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Mm. 

Ball  of  thumb 6.-5.7 

Ball  of  little  finger 5.-5.6 

Centre  of  palm .       .       .       .  8.9 

Back  of  hand 31.6 

Lower  third  of  the  forearm,  volar  surface 15. 

Plantar  surface  of  the  great  toe 15.8 

Forearm  and  leg 45.1 

Knee 36.1 

Neck     .... 54.1 

Back  at  the  fifth  dorsal  vertebra,  lower  dorsal  and  lumbar  region  .        .       .  54.1 

Middle  of  the  neck 67.7 

Upper  arm,  thigh,  and  centre  of  the  back 67.7 

Sacrum,  gluteal  region 44.6 

The  above  data  have  been  culled  from  Landois  and  Stirling's  Text-hook  of 
Human  Physiology. 

Absolute  loss  of  the  tactile  sense  is  termed  ancesthesia.  It  is  often  asso- 
ciated, as  we  will  see,  with  other  phenomena.  Occasionally  we  find  that  our 
patients  react  excessively  to  a  very  slight  touch.  This  condition  is  known 
as  hypercEsthesia.  In  various  nervous  affections  in  which  we  fail  to  discover 
actual  loss  or  impairment  of  the  various  cutaneous  sensibilities,  the  patient 
notwithstanding  complains  of  obscure  subjective  sensations.  Thus,  in  loco- 
motor ataxia  it  is  not  uncommon  for  the  patient  to  complain  of  velvety  or 
cushion-like  sensations  in  the  feet.  At  other  times,  for  example  in  hysteria, 
the  patient  may  complain  of  prickling,  creeping,  or  other  anomalous  sensa- 
tions.    These  phenomena  are  technically  termed  paresthesias.  ■ 

In  studying  the  tactile  sense  it  is  further  of  great  importance  to  note 
whether  the  patient  refers  the  impression  accurately  to  the  point  that  is 
touched.  Not  infrequently,  it  is  found  that  a  patient  correctly  appreciates 
contact,  but  refers  it  to  the  wrong  finger  or  to  the  wrong  segment  of  a  finger 
or  limb,  and  sometimes,  indeed,  to  the  opposite  side  of  the  body.  Thus,  a 
patient  may  refer  a  touch  upon  the  proximal  phalanx  of  a  finger  to  the  meta- 
carpal bone  of  that  finger,  or  a  touch  upon  the  back  of  the  hand  to  the  back 
of  the  forearm  ;  that  is,  the  error  may  be  made  on  referring  the  point  touched 
to  a  segment  of  the  limb  immediately  above.  When  the  impression  is  re- 
ferred to  the  opposite  side  of  the  body,  the  condition  is  known  as  alloeheiria. 
For  this  phenomenon  Weir  Mitchell  proposes  the  term  "touch  squint." 
Occasionally  a  patient  will  distinguish  two  impressions  when  but  one  point 
of  contact  has  been  made ;  that  is,  there  is  a  condition  in  which  the  impres- 
sion is  reduplicated. 

Closely  allied  to  the  tactile  sense  is  the  pressure  sense,  so-called.  By  it  we 
are  enabled  to  determine  the  relative  amount  of  pressure  which  is  exerted 
upon  this  or  that  portion  of  the  body.  For  a  knowledge  of  the  amount  of 
pressure  upon  any  part  of  the  surface,  we  are  indebted  first  to  the  nerves  of 
the  skin,  and  secondly  to  those  supplying  the  deeper  structures.  Every  now 
and  then,  in  various  morbid  conditions,  a  light  touch  is  not  recognized,  and 
the  patient  reacts  only  when  considerable  pressure  is  made.  The  pressure 
sense  may  be  lost  hand-in-hand  with  the  tactile  sense.  JSTot  infrequently, 
however,  it  is  merely  diminished  when  the  tactile  sense  is  comparatively  well 
preserved.  Various  forms  of  special  apparatus  have  been  devised  for  studying 
the  pressure  sense,  but  clinically  they  are  unimportant.  A  convenient  way 
for  testing  it,  is  to  have  the  patient  seated  with  the  backs  of  his  hands  resting 
upon  a  table,  and  then,  having  blindfolded  him,  to  place  various  objects  of 
similar  bulk,  but  varying  weight,  upon  the  two  palms  or  fingers.  Two  vials 
of  the  same  size  containing  different  amounts  of  mercury  answer  this  purpose 
very  well. 

When  we  make  our  studies  of  the  tactile  sense,  we  should  notice  whether, 
when  the  -needle  is  thrust  into  the  skin,  it  also  causes  jdow?.  The  sense  of 
pain,  we  should  remember,  is  entirely  distinct  from  the  tactile  sense  and  may 


GENERAL  CONSIDERATIONS.  35 

indeed  be  lost,  while  the  latter  is  preserved.  In  such  a  case  the  impression 
made  by  the  needle  is  promptly  recognized  and  accurately  localized,  but  at 
the  same  time  the  patient  feels  no  pain,  no  matter  whether  the  needle  be 
thrust  deeply  into  the  skin  or  even  be  moved  about  in  the  rete  mucosum. 
Another  convenient  method  of  testing  the  pain  sense  is  to  touch  the  parts 
with  a  pair  of  thin  metallic  electrodes,  connected  with  a  rapidly  interrupted 
faradic  battery,  and  held  about  half  an  inch  apart.  By  this  means  the  area 
in  which  the  sense  of  pain  has  been  abolished  can  be  accurately  mapped  out. 
In  testing  for  the  pain  sense  in  cases  in  which  it  is  apparently  lost,  parts  that 
are  especially  sensitive  should  be  selected,  such,  for  instance,  as  the  pulp  of 
the  finger  immediately  beneath  the  nail,  or  the  nipple.  If  the  sense  of  pain 
be  altogether  lost  in  a  part,  the  condition  is  termed  analgesia.  It  is  observed 
in  hysteria  and  in  certain  organic  diseases  of  the  cord,  more  especially 
syringomyelia. 

Next  in  order  is  the  study  of  the  sense  of  temperature,  or  the  thermal  sense. 
As  is  well  known,  normal  individuals  can  readily  distinguish  hot  from  cold 
objects.  For  practical  purposes,  this  sense  can  be  readily  tested  by  two  test- 
tubes  or  vials  of  equal  size,  one  of  which  is  filled  with  hot  and  the  other  with 
cold  water.  It  is  sometimes  found  that,  though  the  tactile  sensibility  is  well 
preserved,  the  patient  is  unable  to  distinguish  differences  of  temperature  even 
when  these  differences  are  marked.  Sometimes  he  will  simply  say,  "  I  cannot 
tell,"  and  at  others  will  call  hot  cold  or  cold  hot.  In  the  latter  instance  the 
temperature  sense  is,  of  course,  not  abolished,  but  merely  perverted.  It  is 
best,  in  making  this  test,  to  use  temperatures  that  are  decided.  For  instance, 
water  from  a  temperature  of  40°  to  50^  F.  for  the  cold  test,  and  water  at  a 
temperature  of  110°  to  115°  F.  for  the  hot  test.  It  is  not  infrequently  found 
that  patients  who  have  suffered  from  frequent  exposure  to  inclement  weather 
are  unable  to  distinguish  small  differences  of  temperature.  However,  most 
persons  will  pronounce  objects  at  a  temperature  of  60°  F.  as  cold  or  cool, 
and  at  a  temperature  of  85°  F.  and  uj)ward  as  warm.  Some  are  able  to 
distinguish  between  a  few  degrees  or  even  a  fraction  of  one  degree,  but  the 
ability  thus  to  distinguish  varies  greatly  within  the  limits  of  health.  For 
practical  purposes,  therefore,  as  has  been  already  stated,  decided  tempera- 
tures should  be  used.  The  thermal  sense  is  every  now  and  then  abolished  in 
organic  disease,  as,  for  instance,  syringomyelia. 

Every  area  in  Avhich  an  impairment  of  the  tactile,  the  pressure,  or  the 
pain  sense  is  discovered,  should  be  accurately  outlined  upon  a  chart  or  upon 
the  skin  of  the  patient  by  means  of  an  aniline  pencil.  This  is  of  importance, 
inasmuch  as  we  desire  to  learn  whether  the  impairment  is  in  relation  to  the 
nerve-supply  of  the  skin  of  a  certain  part,  or  whether  it  is  in  relation  to  a 
limb  as  a  whole  or  to  a  segment  of  a  limb.  Thus,  a  lesion  destroying  the 
ulnar  nerve  affects  special  regions  of  the  hand  and  special  fingers.  In 
certain  affections,  however — e.  cj.,  hysteria — we  may  have  an  anaesthesia  which 
involves  the  entire  hand  like  a  glove  or  a  portion  of  the  leg  like  a  stocking. 
Such  an  anaesthesia  is  known  as  segmental  ancesthesia. 

In  certain  cases  it  is  important  to  test  the  muscular  sense.  We  judge 
largely  of  the  positions  of  our  limbs  and  of  the  posture  of  the  body  by  the 
sensations  received  from  the  muscles.  These  keep  us  informed  as  to  the 
relative  degrees  of  contraction  of  the  various  groups.  It  is  obvious  that  in 
ataxia  and  in  various  forms  of  motor  inco-ordination  this  sense  is  much 
diminished.  Further,  the  sensations  received  from  the  muscles  are  correlated 
with  the  sensations  received  from  the  pressure-sense  already  considered,  and 
are  probably  assisted  by  the  impressions  received  from  the  tendons  and 
joints.  The  muscular  sense  can  be  tested  very  readily  by  asking  the  patient 
to  estimate  the  weight  of  various  objects  placed  in  his  hands.     We  may  con- 


36  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

veniently  make  use  of  a  handkerchief,  tying  together  the  opj^osite  corners 
and  suspending  the  loop  thus  formed  from  the  patient's  hand,  the  arm  being 
semi-flexed  and  the  patient  blindfolded.  Various  objects  are  then  suspended 
in  the  handkerchief,  and  the  patient  asked  to  estimate  their-  relative  weight. 

Important  for  us  to  study  also  are  the  cutaneous  reflexes.  These  depend 
upon  the  fact  that  when  the  skin  of  certain  portions  is  irritated  certain  mus- 
cles respond  by  contracting.  Thus,  if  the  sole  of  the  foot  is  irritated,  the 
foot  and  leg  is  suddenly  jerked  upward  by  an  involuntary  action  of  the 
flexor  muscles.  This  phenomenon  is  known  as  the  plantar  reflex.  Similarly, 
if  in  very  young  children  the  palm  be  irritated,  the  hand  is  promptly  closed. 
If  the  walls  of  the  abdomen,  especially  the  epigastrium,  be  irritated,  the 
rectus  and  other  abdominal  muscles  respond.  Similarly,  if  the  back  be  irri- 
tated, the  group  of  the  erector  spines  muscles  contract.  The  cremasteric 
reflex  is  the  name  given  to  the  contraction  of  the  cremaster  muscles  brought 
about  by  irritating  the  inner  surface  of  the  thigh  in  its  upper  third.  The 
tasticle  on  the  side  irritated  is  promptly  retracted.  This  reflex  is  much  more 
active  in  children  than  in  adults. 

Examination  of  the  special  senses  is  next  in  order.  In  this  connection  that 
of  the  eyes  is  of  the  greatest  importance.  It  must  be  made  from  the  standpoint 
of  the  neurologist.  The  various  methods  to  be  pursued  are  described  in  the 
subjoined  section  by  Dr.  Charles  A.  Oliver.  Xext,  the  hearing  should  be  ex- 
amined. This  should  be  tested  by  means  of  a  watch  or  tuning-fork.  Slight 
amounts  of  deafriess  are  of  comparatively  little  significance  to  the  neurologist. 
It  is  important  merely  to  determine  first  whether  marked  deafaess  be  present, 
and  second  whether  the  latter  Ls  due  to  disease  of  the  middle-ear,  disease  of  the 
auditory  nerve,  or  of  the  cortical  auditory  centres.  The  affections  of  the 
auditory  nerve  are  described  in  the  chapter  upon  diseases  of  the  cranial 
nerves.  It  is  of  importance  here  only  to  state  that  should  a  deafriess  be  un- 
explainable  upon  a  nervous  basis,  the  case  should  be  referred  to  an  aurist  for 
examination  and  report.  The  methods  of  testing  the  senses  of  taste  and 
smell  are  also  described  in  the  chapter  upon  diseases  of  the  cranial  nerves. 

In  studying  the  various  phenomena  of  cutaneous  sensibility  present  in 
a  given  case  we  should  note,  at  the  same  time,  whether  the  surface  which  we 
handle  is  unusually  warm  or  cold.  When  the  surface  temperature  differs 
widely  fr'om  the  normal  the  fact  is  readily  perceived  by  the  hand  ;  for  example, 
in  the  legs  in  infantile  paralysis.  For  accurate  purposes,  however,  such  as 
studying  the  surface  temperature  of  the  head  in  cases  of  suspected  brain 
tumor,  a  surface  thermometer  should  be  employed.  Slight  departures  from 
the  normal  are  only  important  when  constant.  Various  precautions  should 
be  used  to  examine  a  part  always  under  the  same  conditions,  as  AVeir  Mitchell ' 
has  shown  that  so  simple  a  fact  as  change  of  posture  in  a  limb  may  slightly 
influence  the  result.^ 

Lastly,  it  is  of  the  utmost  importance  to  study  the  various  phenomena  of 
nutrition  presented  by  the  patient.  These  may  be  general  and  affect  the 
body  as  a  whole,  or  they  may  be  limited  to  special  parts  or  structures.  Dis- 
turbances of  the  general  nutrition  often  possess  a  profound  significance.  This 
is  true  of  general  emaciation,  of  excessive  increase  in  bulk,  of  distortion  of 
the  features,  and  of  change  in  shape  of  the  extremities.  Further,  all  marked 
departures  from  the  normal  standard  of  weight,  taking  height,  age,  and 
other  elements  into  consideration,  are  likewise  of  importance ;  especially  is 
this  true  if  the  patient  presents  a  history  either  of  rapid  loss  or  rapid  gain. 

Special  disturbances  of  nutrition  are  such  as  are  presented  by  the  skin  and 

1  Clinical  Xessons,  Medical  News,  18D4,  vol.  Ixir.  p.  6. 

2  For  an  account  of  normal  surface  temperatures  the  reader  is  referred  to  Landois  and  Stirling's 
Physiology. 


GENERAL  CONSIDERATIONS.  37 

its  appendages,  the  muscles,  the  bones,  and  the  joints.  The  phenomena  pre- 
sented by  the  skin  vary  gi'eatly.  Thus  it  may  feel  unusually  dry  or  it  may 
be  excessiyely  moist ;  in  the  one  case  due  to  diminished,  in  the  other  to  ex- 
cassiye  perspiration.  At  another  time  it  will  be  olxserved  that  the  epithelium 
is  shed  more  readily  or  more  proflisely  than  in  health,  and  that  the  hair  cov- 
ering the  skin,  especially  the  fine  hair  on  the  extremities,  is  dry  and  brittle.  At 
times  unusual  growth  of  hair  may  be  noticed  in  special  regions,  or  the  hair 
of  a  certain  area  of  the  scalp,  face,  or  other  portion  of  the  body  may  be  en- 
tirely lost.  The  nails,  too,  may  present  evidences  of  change  in  nutrition. 
Thus  the  naiLs  of  a  paralyzed  limb  often  grow  more  slowly  than  those  of  the 
normal  side.  Often,  too,  they  present  longitudinal  ridges,  are  rough  and 
unusually  brittle.  In  some  cases  it  is  important  to  test  their  rate  of  growth, 
and  for  this  j^urpose  it  is  convenient  to  make  a  slight  stain  with  nitric  acid 
at  the  root  of  the  nail.  The  mark  is  indelible,  and  enables  us  to  note  the 
amount  of  growth  from  time  to  time. 

Under  special  conditions  the  skin  may  become  excessively  smooth  and 
glazed,  or  local  slouglis,  small  blebs,  or  purpuric  spots  may  occur,  all  due  to 
disturbances  of  nutrition  having  a  nel'^'ous  origin.  To  this  category  also 
belongs  a  vesicular  eruption  known  as  herpes  zoster.  (See  iS^euritis.)  Red- 
ness and  burning  (causalgia)  are  also  occasionally  met  with.  Again,  the 
skin  sometimes  presents  a  condition  which  can  only  be  designated  as  a 
"diminution  of  nutrition  resistance."  It  is  every  now  and  then  observed  in 
jDersons  who  have  suffered  injuries  of  nerves.  The  skin  of  a  part  is  no  longer 
able  to  withstand  slight  blows,  bruises,  or  changes  of  temperature  as  well  as 
formerly ;  thus  a  patient  immersing  both  hands  in  warm  water  far  below  a 
hurtful  temperature  may  have  the  hand  of  a  damaged  limb  severely  scalded, 
wliile  the  sound  hand  escapes. 

Finally,  the  skin  may  undergo  slow  trophic  changes,  such  as  are  seen  in 
scleroderma,  morphoea,  and  hemi-facial  atrophy;  or  it  may  be  unusually 
soft,  swollen,  and  yielding,  as  in  myxoedema. 

The  nutritive  changes  in  the  muscles  are  revealed  especially  by  changes  in 
bulk  and  consistence.  Thus  in  many  organic  palsies  the  muscles  become 
wasted  and  flabby  to  the  feel.  Under  certain  circumstances  local  and  irreg- 
ularly recurring  contractions  of  bundles  of  fibres,  fibrillary  tremors,  are 
observed.  At  other  times,  instead  of  being  atrophied,  they  may  be  much 
enlarged  and  much  firmer  and  denser  than  normal. 

Changes  in  the  bones  are  most  frequently  made  known  to  us  by  a  history 
of  unusual  fragility.  Thus  a  patient  will  tell  us  that  some  slight  and  simjole 
movement,  such  as  stepping  over  a  gutter,  tripping  over  a  mat,  or  even 
throwing  one  thigh  over  the  other,  has  produced  a  fi-acture.  Change  in  the 
shape  and  size  of  bones  is  also  now  and  then  observed,  as  in  acromegaly. 
The  joints,  also,  in  various  nervous  afl^ections,  reveal  most  extraordinary 
changes  called  arthropathies.  These  are  manifested  in  painless  enlargements, 
distortions,  and  atrophies.  Their  occurrence  should  be  especially  sought  for 
in  locomotor  ataxia  and  syringomyelia. 

Very  often  electrical  examination  of  the  nerves  and  muscles  gives  us  most 
valuable  information.  Indeed,  this  is  frequently  the  case  when  no  gross 
physical  changes  are  prasent. 

Both  muscles  and  nerves  when  diseased  respond  to  electrical  stimulation 
in  a  manner  different  from  that  in  health.  The  changes  in  the  "  electrical 
reactions,"  as  they  are  called,  are  of  two  kinds.  First,  the  response  may 
vary  in  amount,  and,  secondly,  it  may  vary  in  character.  The  first  is  termed 
a  quantitative  change,  the  second  a  qualitative  change.  "When  a  nen'e  or 
muscle  reacts  excessively  quantitative  increase  is  present.  When  it  reacts  in 
a  lessened  degree  quantitative  decrease  is  present.     Quantitative  increase  is. 


38  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

therefore,  observed,  when  a  nerve  or  muscle  reacts  to  a  feeble  current  to  a 
greater  extent  than  in  health.  Quantitative  decrease  is  observed  when  the 
muscle  reacts  only  after  a  current  of  decidedly  increased  strength  has  been 
apphed.  When  quantitative  changes  are  slight,  they  are  often  very  difficult 
to  estimate  or  measure.  However,  if  the  disease  be  limited  to  one  leg  or  to 
one  arm,  the  nerves  and  muscles  of  the  corresponding  limb  on  the  opposite 
or  healthy  side  serve  as  ready  standards  of  comparison.  If,  however,  the 
disease  be  bilateral — that  is,  if  it  involve  both  arms  or  both  legs — the  problem 
is  much  more  difficult.  Here  the  researches  of  Erb  come  to  our  assistance. 
He  has  shown  that  the  frontal,  the  spinal  accessory,  the  ulnar,  and  the  pero- 
neal nerves  respond  almost  equally  to  the  same  minimal  current.  Any  one  of 
these  nerves  may,  therefore,  be  selected  as  a  standard  in  studying  quan- 
titative changes.  The  degree  of  quantitative  increase  or  quantitative  de- 
crease may,  of  course,  vary  considerably.  Quantitative  decrea.se,  for  ex- 
ample, is  in  some  instances  comparatively  slight,  while  in  others  it  may 
become  so  great  as  to  amount  to  a  total  loss  of  response.  In  this  connection 
it  is  necessary  to  state  that  this  loss  of  response  occurs  first  to  the  faradie 
current,  and  only  at  a  subsequent  period  to  the  galvanic  current.  To  state 
it  in  other  words,  "  faradie  extinction  "  occurs  first,  "  galvanic  extinction  " 
subsequently. 

The  qualitative  changes  are  characterized  by  the  so-called  reaction  of  de- 
generation. This  embraces  a  diminution  or  loss  of  response  of  the  nerve 
supplying  a  given  muscle  to  the  faradie  and  galvanic  currents,  a  diminution 
or  loss  of  response  of  the  muscle  to  the  faradie  current  and  persistence  of 
response  to  the  galvanic  current,  with  the  following  changes :  First,  the 
response  to  the  galvanic  current  is  in  the  beginning  increased.  Secondly,  the 
response  relative  to  the  closure  of  the  negative  and  of  the  positive  pole  is 
raclically  changed.  This  can  be  best  understood  by  reviewing  briefly  the 
sequence  to  galvanic  stimulation  in  the  normal  nerve  and  muscle.  If  a  nerve 
or  muscle  be  stimulated  by  a  minimal  galvanic  current,  it  will  be  found  that 
a  response  first  occurs  to  negative  closure  ;  that  is,  the  positive  electrode 
(Anode,  An),  being  placed  over  some  indifferent  area — e.  g.,  the  sternum,  and 
the  negative  pole  (Cathode,  Ca)  over  the  nerve  or  muscle  to  be  examined,  it 
wiU  be  noticed  that  a  very  weak  galvanic  current  is  not  followed  by  any  re- 
sponse whatever,  but  that  on  gradually  increasing  the  strength  of  the  current 
a  response  is  finally  obtained  when  the  current  is  closed — i.  e.,  contraction 
upon  negative  (or  Cathodal)  closure.  If  the  poles  be  now  reversed  so  that  the 
negative  pole  rests  upon  the  sternum  and  the  positive  pole  upon  the  nerve  or 
muscle,  no  contraction  is  obtained  either  upon  closing  or  opening  the  current. 
However,  if  the  current  be  gradually  increased  in  strength,  we  notice  that  a 
contraction  occurs  upon  oj^ening  the  current ;  in  other  words,  there  is  present 
Avith  a  strong  current  a  jjositive  opening  contraction.  It  is  now  forther  observed 
that  upon  closing  the  current  there  is  again  a  response  ;  that  is,  there  is  pres- 
ent a  pjositive  closure  contraction.  This  positive  closure  contraction  is,  how- 
ever, decidedly  weaker  than  the  negative  closure  contraction  ;  it  is  equal,  prac- 
tically, to  the  positive  opening  contraction.  If,  with  the  electrodes  again 
reversed,  i.  e.,  the  positive  pole  upon  the  sternum  and  the  negative  pole  upon 
the  muscle,  the  current  be  still  fiirther  increased  in  strength,  it  is  observed 
Avhen  the  current  is  broken  that  a  contraction  of  the  nuiscle  again  occurs, 
though  it  is  notably  weak.  In  other  words,  there  is  now  present  a  negative 
opening  contraction.  If,  with  the  electrodes  in  the  same  position,  the  current 
be  closed,  the  muscle  responds  by  a  tonic  contraction,  that  is,  a  muscle  teta- 
nus (Te)  is  i:)roduced.  Briefly  restated,  the  normal  reactions  take  place  in 
the  following  sequence : 


GENERAL  COySWERATIONS.  39 

CaClC  (Cathodal  closure  contraction). 
AnOC  (Anodal  opening  contraction). 
AnClC  (Anodal  closure  contraction). 
CaOC  (Cathodal  opening  contraction). 

In  the  reaction  of  degeneration  these  phenomena  are  changed,  as  follows : 
It  is  first  noticed  that  the  anodal  closure  contraction  is  more  pronounced.  If 
the  condition  be  more  marked  or  further  advanced,  this  anodal  closure  con- 
traction equals  the  cathodal  closure  contraction,  and  in  the  more  marked 
cases,  or  at  a  later  period,  it  inore  or  less  exceeds  the  latter.  In  other  words, 
in  the  established  reaction  of  degeneration  the  anodal  closure  contraction  is 
the  first  response  obtained  to  a  minimal  current.  It  is  now  also  observed 
that  the  cathodal  opening  contraction  is  more  pronounced,  and  that,  as  the 
condition  becomes  more  marked,  it  soon  equals  the  anodal  opening  contrac- 
tion, and  may  even  exceed  the  latter. 

In  the  reaction  of  degeneration,  therefore,  we  have  a  reversal  in  the 
sequence  of  the  responses  to  the  current.  Further,  we  also  observ^e  that  the 
manner  of  contraction  of  the  muscle  is  different  from  that  of  health.  In 
health  the  response  is  short  and  almost  immediate.  In  the  reaction  of  de- 
generation it  is  slow,  long  drawn,  and  persistent.  The  reaction  of  degenera- 
tion may,  of  course,  be  present  in  varying  degrees.  Occasionally,  also,  the 
phenomenon  appears  to  be  limited  to  the  muscle,  Avhile  the  nerve  which  sup- 
plies the  latter  escaj)es,  or  reveals  but  a  doubtful  change. 

For  convenience  in  note-taking  the  symbols  already  indicated  are  used. 
Thus,  AnClC  =  CaClC  means  that  the  anodal  closure  contraction  is  equal  to 
the  cathodal  closure  contraction,  which  is  indicative  of  the  reaction  of  de- 
generation. When  the  reaction  is  more  pronounced  the  formula  may  read 
AnClC  >  CaClC,  which  means  that  the  anodal  closure  contraction  is  greater 
than  the  cathodal  closure  contraction.  The  symbol  De  R  is  used  briefly  to 
indicate  that  degeneration  reaction  is  present. 

The  reaction  of  degeneration,  as  the  student  has  doubtless  surmised,  is 
principally  of  diagnostic  value.  It  is  never  present  in  lesions  limited  to  the 
upper  segment  of  the  motor  tract ;  that  is,  in  lesions  occurring  either  in  the 
cortex  or  in  the  descending  motor  pathways  in  the  internal  capsule,  the  ci'ura, 
the  pyramids,  or  the  lateral  columns  of  the  cord.  On  the  other  hand,  it  is 
present,  other  things  equal,  in  lesions  involving  the  lower  segment  of  the  motor 
tract;  that  is,  the  anterior  cornua  of  the  gray  matter  of  the  spinal  cord,  the 
cerebro-spinal  nerves,  or  the  terminal  distriljutions  of  the  latter  in  the  muscles. 
In  gradual  and  slowly  progressive  myopathies  simj^le  diminution  of  electrical 
response  alone  is  present. 

The  above  brief  outline  of  the  methods  to  be  pursued  in  studying  causes 
of  nervous  diseases  are  only  intended  to  be  general  in  character.  Individual 
cases  may  demand  special  methods  of  investigation. 


THE  EXAMINATION  OF  THE  EYE  FPM  THE  STANDPOINT  OF  THE 

NEUROLOGIST. 

By  CHARLES  A.  OLIVER,  M.D. 

Practically,  for  the  student's  purpose,  the  examination  of  the  eye  from 
the  standpoint  of  the  neurologist  resolves  itself  into  several  separate  inquiries. 

I.  The  Study  of  the  Condition  and  the  Movements  of  the  Muscles  whicli 
Govern  the  Motion  of  the  Eyeball  and  the  Lids.    The  muscles  in  and  around 


40  NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  eye  are  so  delicately  balanced  and  so  intimately  associated  during  any 
movement  that  may  be  given  to  the  two  organs  and  the  lids,  that  any  discrep- 
ancy in  their  actions  is  often  at  once  apparent  to  both  the  patient  and  the 
observer.  For  instance,  if  the  external  rectus  muscle  be  paralyzed,  the  eye 
will  be  turned  outward  by  the  unopposed  action  of  the  healthy  internal 
rectus  muscle,  thus  producing  a  condition  known  as  pay^alytie  convergent  squint 
or  ahducens  paralysis. 

Should  the  muscle  be  merely  paretic,  the  incompleteness  of  its  action  may 
not  be  manifest  by  ordinary  inspection.  Here  the  patient  will  merely  com- 
plain of  double  vision — diplopia — when  he  looks  toward  the  paralyzed  side. 
In  this  case  the  fault  may  frequently  be  brought  into  view  by  having  him 
gaze  steadily  at  the  upraised  finger  whilst  the  finger  is  moved  in  various 
directions.  If  this  be  done  repeatedly  and  carefully,  the  eyeball  will  be 
found  to  lag  behind  its  fellow  when  the  weakened  muscle  has  been  brought 
into  play.  The  reason  for  this  is  that,  with  the  same  degree  of  nerve-impulse, 
the  weakened  muscle  accomplishes  a  less  result  than  its  healthy  fellow. 

Should  the  paralysis  be  limited  to  certain  related  movements,  when  the  two 
eyes  are  brought  into  definite  action  with  one  another  the  faulty  muscles  will 
be  found  only  when  the  patient  is  induced  to  make  efforts  to  accomplish  these 
movements.  For  example,  the  two  internal  rectus  muscles  may  be  unable  to 
act  simultaneously  so  as  to  permit  the  two  eyes  to  follow  the  upraised  finger- 
tip when  it  is  moved  directly  in  toward  the  patient's  nose — a  condition  known 
as  jxiralysis  of  convergence,  and  most  generally  dej)endent  upon  some  fault  in 
the  nuclear  centres. 

When  several  of  the  extrinsic  muscles  of  the  two  eyeballs  are  suddenly 
affected  the  condition  produced  is  generally  that  of  almost  immediate  and 
ready  total  cessation  of  the  ocular  movements  both  in  attempted  separated 
and  conjoined  actions.  The  most  probable  explanation  of  this  phenomenon 
is,  that  as  the  trunks  of  the  various  nerves  of  the  implicated  muscles  are  so  far 
apart  in  their  various  passages  back  to  their  associated  nuclear  centres,  the 
condition  must  be  dependent  upon  a  sudden  hemorrhage  into  the  nuclear 
region.  Here  the  appearance  of  the  external  symptom,  which  is  ordinarily 
known  as  acute  nuclear  jxdsy,  or  ophthalmoplegia  exterior  acuta,  can  be  most 
easily  understood,  rendering  the  diagnosis  unmistakable. 

In  this  type  of  the  affection  the  iris  and  the  ciliary  muscles  are  uninvolved. 
Should  they,  however,  be  aflfected,  dilatation  of  the  pupil  (iridoplegia)  and 
inability  of  recognition  of  small  objects,  such  as  printed  or  written  characters, 
at  short  distances  without  the  employment  of  proper  correcting  lenses  (cyclo- 
jolegia),  will  be  superadded  to  the  list,  giving  the  term  total  ojjhthalmoplegia. 
Should  the  iris  and  the  ciliary  nuiscles  be  alone  aflfected,  producing  a  mere 
dilatation  of  the  pupil  and  inability  to  accommodate,  interior  ophthalmoplegia 
is  said  to  be  present. 

In  the  chronic  form  of  the  same  disease  the  vertical  muscles  are  generally 
those  which  are  primarily  affected,  the  other  oculo-motor  nerve-grouping-s 
sooner  or  later  following,  as  shown  by  involvement  of  the  other  related 
muscle  series. 

When  the  paresis  is  not  manifest  and  the  patient  asserts  that  he  sees 
double,  dizziness  and  inability  to  niove  about  properly  are  the  most  promi- 
nent symptoms.  Here  the  faulty  muscle  may  be  discovered  by  a  variety 
of  means.  One  of  the  simplest  plans  is  to  have  the  patient  gaze  at  a  distant 
faint  light  alternately  with  his  two  eyes.  If  a  slight  disturbance  exists,  he 
will  assert,  after  a  moment's  explanation,  that  the  light  appears  to  jump  into 
a  new  position  the  moment  that  the  covered  eye  is  exposed  to  the  light.  The 
degree  of  tlie  fault  in  the  muscle  can  be  determined  by  the  use  of  prisms.  To 
do  this  j)roperly  the  prisms  should  be  placed  with  their  bases  toward  the 


GENERAL  CONSIDERATIONS.  41 

position  from  which  the  light  appears  to  jump.  They  are  then  to  be  gradu- 
ally increased  in  power  until  the  movement  ceases.  The  strength  of  the 
prisms  that  is  necessary  to  stop  the  movement  of  the  light  will  give  a 
measure  for  the  degree  of  the  fault. 

Another  plan  that  is  appropriate  for  the  same  character  of  cases  in  the 
sick-room,  and  one  that  does  not  require  any  special  apparatus,  is  to  have 
the  patient  gaze  at  a  dim  light  at  about  five  metres'  distance  with  both  eyes 
open.  A  prism  of  ten  degrees,  with  its  base  up,  is  then  placed  in  front  of  the 
patient's  left  eye.  This  will  produce  an  immediate  doubling  of  the  light  in 
the  vertical  meridian.  If  there  is  any  discrepancy  in  muscle-tone  or  action, 
the  second  light  will  not  only  be  situated  below  the  original  light,  but  will 
be  placed  to  one  side  of  the  light.  The  amount  of  the  lateral  deviation, 
which  represents  in  great  measure  the  degree  of  fault,  can  then  be  estimated 
by  placing  correcting  prisms  with  their  bases  toward  the  side  where  the 
second  image  seems  to  be  situated. 

If  the  fault  be  resident  in  one  or  more  of  the  vertical  muscles,  the  test  is 
practically  the  same,  except  that  the  prism  which  is  used  to  produce  the 
doubling  must  be  much  stronger  and  placed  upon  its  side.  Especially  is 
the  former  so  if  the  test  be  tried  upon  some  object  that  is  situated  but  a  few 
centimetres  in  front  of  the  eye. 

If  desired,  resort  can  be  had  to  one  or  more  of  the  many  devices  that  are 
made  for  studying  the  various  positions  of  artificially  produced  double  objects. 
For  example,  the  jNIaddox  rod  and  its  modifications,  which,  when  jjlaced 
before  one  eye,  cause  a  small  flame  to  be  transformed  into  a  long  line  of 
light,  may  be  used.  This,  which  gives  such  an  object  to  the  patient  that 
prevents  any  fusion  with  the  untransformed  image  of  the  flame  as  seen  with 
the  other  eye,  is  a  most  valuable  form  of  apparatus.  Here,  if  the  line  of 
light  bisects  the  undisturbed  image  of  the  flame,  muscle-balance  in  the  me- 
ridian that  is  tried  is  obtained.  If  the  line  of  light  fails  to  divide  the  flame 
into  two  equal  parts,  correcting  j)risms  may  be  j)laced  in  front  of  the  rod. 

Phorometers,  revolving  prisms,  etc.,  of  the  many  varieties  now  in  common 
use,  may  be  employed  just  as  time,  fancy,  and  inclination  impel. 

Should  the  muscular  insufliciency  be  more  marked,  its  presence  may  be 
determined  by  simply  placing  a  plain  red  glass  before  one  eye  of  the  patient, 
and  then  have  the  patient  gaze  at  a  distant  light.  If  any  pronounced  error 
exists,  he  will  ofttimes  declare  the  presence  and  relative  position  of  a  double 
image  of  the  light,  the  one  being  properly  tinted  and  the  other  appearing 
reddish.  Just  as  before,  the  mere  superimposing  of  correcting  prisms  will 
give  the  degree  of  any  muscular  error.  If  desired,  these  discrepancies  may 
be  noted  upon  appropriate  registers  placed  at  definite  distances  by  the  patient 
himself,  thus  saving  the  time  and  trouble  of  correcting  the  error  by  prisms. 

In  all  of  this  work  it  must  be  remembered  that  the  different  muscles  have 
marked  difl^erences  of  strength,  so  that  the  same  amount  of  nerve  power  that 
is  lost  in  any  two  muscle-groupings  may  produce  different  results  of  loss  of 
muscle  action.  Thus  the  internal  rectus  muscle  is  by  far  the  strongest  of  the 
external  series,  Avhilst  the  superior  and  inferior,  with  possibly  the  obliques, 
are  the  weakest. 

To  estimate  roughly  the  relative  powers  of  any  one  of  these  muscles, 
increasing  strengths  of  prisms  with  their  apices  pointed  toward  the  muscle 
that  is  desired  to  be  studied  may  be  placed  before  the  patient's  eye  whilst 
both  of  his  eyes  are  open  and  gazing  at  a  distant  light.  These  are  to  be 
continued  until  the  light  becomes  doubled.  The  amount  of  prism  strength 
that  is  necessary  to  be  used  can  then  be  gotten  and  compared  with  the 
amount  that  the  muscle  is  said  normally  to  overcome. 

In  some  of  the  irritative  forms  of  spasmodic  contraction  of  both  the  ex- 


42  NERVOUS  DISEASES  A2^D  THEIR  TREATMENT. 

trinsic  and  the  intriusic  groupings  of  the  ocular  muscles  diagnosis  of  the  local 
condition  is  comparatively  easy  from  concomitant  symptoms  and  the  behavior 
of  the  muscle-grouj)ings. 

Care  must  always  be  taken  to  note  the  conditions  under  which  the  testing 
is  done.  The  position  of  the  jDrism,  its  strength,  and  the  eye  before  which  it 
is  placed  should  be  registered.  AVhether  the  test  is  employed  whilst  the  eyes 
are  gazing  at  a  distant  or  at  a  near  object,  the  exact  distance  of  the  test- 
object  if  it  be  nearer  than  five  metres,  and  the  form  of  the  apparatus 
employed  should  all  be  taken  into  account. 

In  some  varieties  of  nerve  disease,  as,  for  instance,  in  disseminated  sclerosis 
and  in  many  congenital  defects  of  the  eyes,  such  as  cataract  or  faulty  devel- 
oj)ment  of  the  retina  and  optic  nerve,  the  eyeballs  are  in  a  state  of  constant 
motion.  This,  which  is  known  as  nystagmus,  is  in  some  cases,  especially  in 
the  congenital  form,  rapidly  increased  when  the  patient  is  excited,  or  T\daen 
he  is  made  to  gaze  intently  at  any  object.  Rarely,  it  may  be  voluntary  in 
type.  Its  presence,  together  with  the  rapidity  and  direction  of  the  oscilla- 
tory movements,  should  always  be  noted. 

If  the  paralysis  be  situated  in  one  or  more  of  the  lid-muscles,  the  want  of 
action  of  the  paralyzed  muscle  and  the  over-result  of  the  action  of  the  oppos- 
ing muscle  will  be  plainly  apparent  at  a  moment's  glance.  One  of  the  most 
frequent  forms  of  this  variety  of  affection  is  known  as  ptosis,  or  drooping  of 
the  upper  eyelid.  It  occurs  as  the  result  of  paralysis  of  the  levator  pal- 
pebrae  muscle.  It  is  both  congenital  and  acquired.  If  of  the  former  variety, 
it  is  generally  due  to  nuclear  disturbance  and  is  bilateral  in  type.  It 
is  of  frequent  occurrence  in  certain  forms  of  hysteria  and  in  congenital 
ataxia.  It  is  also  often  present  in  anaemic  and  badly  nourished  women 
with  uterine  disorder,  and  whilst  passing  through  or  approaching  the  period 
of  menopause.  This  form,  by  reason  of  its  generally  appearing  upon  awak- 
ening from  a  long  sleep,  and  hence,  as  a  rule,  in  the  morning,  is  known  as 
matinal  ptosis. 

The  upper  lid  droops  to  varying  degrees  over  the  eyeball.  Thus,  for  ex- 
ample, if  there  be  paralysis  of  the  cervical  sympathetic,  the  fibres  of  Miiller 
are  affected,  causing  but  a  slight  drooping,  with  but  little  impairment  of 
movement  of  the  lid.  If,  in  pronounced  cases,  attempts  are  made  by  the 
patient  to  raise  the  upper  lid,  the  brow  and  forehead  become  Avrinkled, 
showing  the  compensatory  action  of  the  occipito-frontalis  muscle. 

Lagophthalmos,  or  drooping  of  the  lower  eyelid,  is  readily  recognized  by 
the  undue  prominence  of  the  eyeball,  the  exposure  of  the  lower  portion  of 
the  sclerotic,  the  eversion  of  the  inferior  lachiymal  punctum,  and  the  conse- 
quent stillicidium,  or  flow  of  tears.  The  patient  is  unable  to  close  the  eye. 
The  condition  is  a  frequent  accompaniment  of  both  peripheral  and  central 
nerve  disease,  and  depends  upon  a  paralysis  or  a  partial  loss  of  action  of  the 
orbicularis  oculi  muscle  through  the  disturbance  of  its  governing  nerve — a 
branch  of  the  seventh  pair.  It  forms  one  of  the  most  prominent  symptoms  in 
Bell's  palsy,  and  is  frequently  of  traumatic  origin. 

In  some  cases  where  there  are  other  clinical  evidences  of  so-called  exoph- 
thalmic goitre,  the  upper  lids  will  be  found  to  lag  when  downward  move- 
ments are  given  to  the  globes.  This,  which  is  known  as  the  vo)i  Grafe  sign, 
is  best  obtained  whilst  the  patient  is  lying  upon  his  back  and  his  head  rest- 
ing upon  a  pillow.  While  in  this  position  the  finger-tips  are  to  be  extended 
at  about  seventy  centimetres  from  the  patient's  face  and  in  the  median  line 
on  a  line  with  the  forehead.  After  having  the  patient  fixedly  gaze  with  his 
two  eyes  at  the  finger-tip,  the  finger  is  to  be  slowly  moved  in  a  curved  direc- 
tion toward  the  patient's  breast,  when,  if  the  sign  be  present,  the  eyeballs  will 
follow  the  finger-tip  and  the  upper  lids  will  lag  behind. 


GENERAL  CONSIDERATIONS.  43 

II.  The  Study  of  the  Pupillary  Phenomena.  The  size  of  the  pupil  is 
modified  by  many  conditions  of  the  nervous  system.  Independent  of  local 
changes,  as  in  nearsightedness  and  glaucoma,  where  the  pupil,  as  a  rule,  is 
large,  it  is  more  or  less  dilated  in  amblyopia,  or  deficient  vision  from  nerve 
disorder,  and  amaurods,  or  loss  of  vision  from  nerve  degeneration.  It  is  also 
found  quite  large  in  the  earlier  stages  of  aneurismal  pressure  upon  the  optic 
nerve,  in  paralysis  of  the  sphincter  muscle  of  the  iris,  in  neuroses  of  functional 
type,  and  in  peripheral  irritation.  Cerebral  compression  also  produces  it. 
During  childhood  and  youth  it  is  large  ;  and,  lastly,  it  must  be  remembered 
that  the  local  application  of  certain  drugs  known  as  mydriatics  renders  it 
greater  than  normal. 

The  opposite  condition,  contraction,  is  found  in  farsightedness,  in  old  age, 
and  in  retinal  hyperesthesia.  Meningeal  inflammation,  cerebral  irritation, 
and  certain  stages  of  convulsive  seizures  frequently  j)rovoke  it.  Certain 
drugs,  known  as  myotics,  when  either  locally  applied  or  internally  adminis- 
tered, produce  it. 

For  proper  study,  the  relative  sizes  and  shapes  of  the  two  pupils  should 
be  carefully  estimated  during  exposure  of  one  or  both  of  the  eyes  to  light- 
stimulus.     During  this  test  the  patient  is  to  face  a  window  or  a  light. 

In  many  cases  of  nerve  disease  of  degenerative  type,  as  in  epilepsy  and 
general  paralysis  of  the  insane,  the  pupils  are  frequently  unequal  in  size, 
irregular  in  outline,  without  any  signs  of  local  inflammation,  and  constantly 
varying.  These  changes  can  be  satisfactorily  determined  by  either  looking 
at  the  pupils  through  an  ordinary  magnifying  lens ;  or,  better,  by  looking 
through  a  convex  lens  of  twelve-to-sixteen-cliopter  strength  placed  in  an 
ophthalmoscopic  mirror. 

Having  determined  the  equilibriuvi  of  the  pupil,  as  it  is  termed,  whilst  the 
eyes  are  in  a  passive  state,  as  it  were,  the  actions  of  the  sphincter  muscle  of 
the  iris  under  the  various  forms  of  stimulus  that  are  usually  applied  to  it  are 
next  to  be  tried. 

As  is  well  known,  the  sphincter  muscles  of  the  irides  respond  and  the 
pupils  become  smaller  when  light-stimulus  is  thrown  upon  the  retina.  This, 
Avhich  is  known  as  iris  response  to  light-stimulus,  is  frequently  afiected  in 
various  forms  of  intracranial  disorder.  For  example,  in  degenerations  and 
pressures  upon  the  optic  nerves,  chiasm,  and  optic  tracts,  in  disturbances  in 
the  region  of  the  floor  of  the  fourth  ventricle,  and  in  changes  in  those 
strands  of  the  third  nerve  which  are  intended  to  innervate  the  sphincter 
muscle  of  the  iris.  To  obtain  the  response,  the  patient  should  be  made  to 
keep  both  eyes  open.  Then,  whilst  he  gazes  directly  ahead  into  space,  the 
eyes  are  to  be  alternately  covered  and  exposed.  If  the  muscle  responds 
properly,  the  corresponding  pupil  will  be  immediately  contracted  when  the 
eye  is  brought  into  view. 

Where,  although  there  is  free  movement  of  the  iris  to  the  so-called  accom- 
modation-reflex (see  below),  the  pupil  remains  flxed  at  some  definite  area 
whilst  light  is  thrown  upon  the  retina,  the  condition  is  known  as  the  Argyll 
Robertson  pjupil.  This  peculiar  want  of  response  of  the  iris  to  this  form  of 
stimulus  is  generally  seen  in  disease  of  the  posterior  columns  of  the  spinal 
cord,  and  is  believed  by  many  to  be  produced  by  innervation  of  the  radiary 
fibres  of  the  iris,  upon  which  as  a  lever,  as  it  were,  the  sphincter  muscle  of 
the  iris  membrane  plays.  As  just  explained,  the  iris  is  able  to  respond  only 
when  the  patient  makes  efforts  to  look  at  near  objects.  The  symptom  is 
readily  gotten  by  alternately  exposing  and  covering  the  two  eyes  to  sudden 
flashes  of  strong  light-stimulus  whilst  the  eyes  are  made  to  gaze  into  darkness. 

Iris-refiex  to  accommodation,  which  is  rendered  manifest  by  a  contraction  of 
the  pupil  when  the  eye  is  made  to  look  at  a  near  object,  is  the  next  most 


44  NERVOUS  DISEASES  AND  THE  IE  TREATMENT. 

important  sign.  If  broken,  as  it  is  in  cases  of  nuclear  origin  and  in  some 
rare  instances  of  spinal  disturbance,  the  iris  muscle  will  fail  to  act  when  the 
lens  is  sufficiently  increased  in  strength  by  the  action  of  the  ciliary  muscle  to 
allow  small  objects  at  short  distances  to  be  properly  focused  upon  the  retina 
(known  as  the  act  of  accommodation).  To  determine  whether  this  reflex  is 
in  proper  working  order  the  size  of  the  pupil  is  to  be  accurately  estimated 
whilst  the  patient  is  made  to  gaze  at  a  distance.  A  pencil  or  pen-tip  is  then 
to  be  suddenly  placed  directly  in  line  with  the  distant  object  looked  at,  at 
about  35  to  40  centimetres'  distance  from  the  eye.  If  the  reflex  be  intact, 
the  pupil  will  immediately  contract  and  remain  so  as  long  as  the  act  of  focus- 
ing of  the  eye  upon  the  near  object  remains. 

A  third  and  most  important  reflex-act  of  the  iris  is  that  known  as  iris- 
reflex  to  convergence.  In  reality,  it  is  a  mere  addition  to  the  second  reflex. 
Here  two  eyes  are  simultaneously  acted  upon  instead  of  one,  thus  bringing  a 
third  factor — the  associated  impulse  of  the  two  internal  rectus  muscles — into 
play.  To  obtain  it  properly,  the  two  eyes  are  made  to  gaze  simultaneously  at 
a  distant  object.  The  pencil-tip  is  suddenly  brought  in  the  middle  line  of  the 
face  before  the  two  eyes.  If  the  impulse  be  correctly  applied,  three  acts  will 
take  place  ;  correct  focusing  of  the  two  eyes,  with  simultaneous  contraction 
of  the  pupils  and  inward  deviation  of  the  two  eyes.  It  is  seen  to  be  dis- 
turbed in  some  rare  cases  of  beginning  or  ending  nuclear  palsy  and  in  com- 
mencing isolated  paresis  of  the  internal  rectus  muscles. 

A  fourth  reflex  of  the  iris  consists  in  a  peculiar  dilatation  of  the  pupil 
which  is  produced  by  irritation  of  the  sympathetic  nerve.  It  is  known  as 
the  sympathetic  iris-reflex.  It  can  readily  be  produced  in  many  subjects  by 
pricking  or  pinching  the  cutaneous  fibres  of  the  cervical  sympathetic  in  the 
back  of  the  neck.  Its  absence  in  some  cases  is  designative  of  some  disturb- 
ance in  the  reflex  act.  In  other  neuroses,  especially  of  a  degenerative  type, 
it  will  be  noticed  that  the  pupil  becomes  alternately  larger  and  smaller  with- 
out any  seeming  impulse  being  given  to  the  organ.  This  peculiar  ataxic 
movement  may  occur  several  times  before  the  pupil  becomes  fixed.  It  can 
be  easily  recognized  by  an  ordinary  magnifying  glass  whilst  the  patient  is 
made  to  gaze  out  of  a  window.  It  is  of  great  value  in  the  recognition  of  the 
earliest  degenerative  stages  of  posterior  spinal  sclerosis,  and  might  well  be 
termed  pupillary,  or,  better,  iris-innervation  sign.  At  times,  it  may  be  most 
prominently  brought  into  view  by  having  the  eye  turned  as  far  to  one  side 
as  the  patient  can  possibly  move  it,  when  the  ataxic  movements  immediately 
appear. 

In  some  types  of  nerve  disease  where  there  are  lesions  of  an  irritative 
nature,  as  in  the  earlier  stages  of  some  of  the  more  common  forms  of  periph- 
eral neuritis,  it  will  be  found  that  a  spasmodic  contraction  followed  by  a 
momentary  dilatation  of  the  pupil,  known  as  hipjms,  takes  place.  This 
symptom  can  be  best  studied  by  the  aid  of  a  magnifying  lens,  whilst  the 
patient  is  made  to  look  out  into  difiuse  daylight.    It  has  been  seen  in  hysteria. 

In  some  cases  of  hemianopsia  (vide  page  47),  where  the  conducting  paths 
of  the  reflex  arc  between  the  retinse  and  the  sphincter  muscles  of  the  irides 
are  afiected,  as  in  pressure  upon  and  in  degeneration  of  certain  portions  of  the 
optic  chiasm  or  of  one  of  the  optic  tracts,  the  pupil  fails  to  become  smaller 
when  light  is  thrown  upon  the  blind  area  of  the  field  of  vision.  This  symp- 
tom, which  is  known  as  the  Wernicke  sign,  or,  more  properly,  hemianopic  iris- 
inaction  sign,  can  be  gotten  in  various  ways.  The  easiest  and  the  most  certain 
method  found  of  use  by  the  writer  is,  first,  to  illuminate  faintly  the  front  of 
the  patient's  eye  by  a  beam  of  light  obtained  from  a  piece  of  plain  looking- 
glass  that  li^s  been  illuminated  by  a  hght  placed  over  and  back  of  the  patient's 
head.     This  amount  of  feeble  illumination  does  not  seem  to  disturb  the  get- 


GENERAL  CONSIDERATIONS.  45 

ting  of  the  sign.  Whilst  the  eye  is  inuminated  a  concave  mirror,  as  found 
in  one  of  the  common  forms  of  ophthalmoscope,  is  held  so  as  to  bring  a 
strong  focus  of  light  from  various  points  in  the  periphery  of  the  field  of 
vision  to  play  upon  the  pupil.  In  this  experiment  it  is  always  best  to  com- 
mence at  the  blind  halves  of  the  field.  If  the  sign  be  present,  the  pupil  will 
not  contract  until  the  stray  beam  of  light  has  reached  the  borders  of  the  re- 
maining fields  of  vision — showing  that  the  break  in  conduction  has  been  in 
the  sensorimotor  loop  of  the  visual  apparatus,  which,  as  we  know,  is  anterior 
to  the  region  of  the  corpora  quadrigemina.  This  fact,  in  association  with  the 
hemianopsia,  therefore  locates  the  intracranial  lesion  either  in  the  optic  chiasm 
or  in  the  optic  tract. 

At  times  many  important  data  as  to  the  question  of  action  of  the  ciliary 
muscle  in  grave  nerve  cases,  especially  where  the  pupil  is  dilated,  might  be 
obtained  by  resort  to  the  so-called  catoptric  ted.  The  method  is  quite  easy, 
A  narrow  beam  of  light  from  a  candle  or  a  taper  should  be  allowed  to  fall 
obliquely  upon  the  pupillary  area.  If  this  area  be  magnified  by  a  strong 
convex  lens,  three  images  of  the  candle-flame  will  be  seen.  By  now-  asking 
the  patient  to  attempt  to  look  at  a  near  object,  the  more  deeply  situated 
images  of  the  flame  will,  if  the  pupil  does  not  contract  too  much,  be  found 
to  separate,  showing  that  the  lens  has  increased  in  convexity,  which  must 
have  been  produced  by  contraction  of  the  ciliary  muscles. 

If  the  pupil  be  too  small  for  this  procedure,  the  plain  mirror  retinoscope 
may  be  employed  to  study  the  presence  or  absence  of  the  reversal  of  move- 
ment of  the  reflexes  as  the  instrument  is  gradually  approached  to  the  eye. 
If  a  reverse  movement  takes  place  when  the  mirror  comes  close  to  the  organ, 
accommodation  exists,  thus  proving  the  presence  of  ciliary  muscle  action. 

Ill,  The  Study  of  the  Condition  of  the  Interior  of  the  ilye  by  Magnifying 
Lenses  and  the  Ophthalmoscope.  Practically,  nearly  the  whole  of  the  inte- 
rior of  the  eye,  with  the  exception  of  a  small  zone  around  the  ciliary  body 
and  muscle,  can  be  laid  bare  for  examination  by  one  of  these  two  methods. 
The  first  plan  consists  in  brilliantly  illuminating  the  anterior  part  of  the 
organ  by  a  convex  lens  and  looking  at  the  illuminated  portion  through  a 
magnifier.  By  it,  the  layers  of  the  cornea,  the  aqueous  humor,  the  iris,  the 
greater  part  of  the  lens,  and  the  anterior  portion  of  the  vitreous  humor  can 
be  brought  distinctly  into  view.  The  second  exhibits,  in  addition,  the  greater 
part  of  the  vitreous  hvimor,  the  posterior  two-thirds  of  the  choroid  and  retina, 
and  the  optic  nerve-head.  Congenital  anomalies,  signs  of  active  and  chronic 
inflamniation,  venous  and  arterial  engorgements,  depositions  and  atrophies, 
all  can  be  revealed  and  recognized  by  these  methods.  The  former  plan,  which 
soon  becomes  comparatively  easy  of  performance  by  constant  repetition,  is 
known  as  lateral,  oblique,  or  focal  illumination,  and  should  be  carefully  em- 
ployed whenever  thought  necessary. 

The  latter  plan,  known  as  ophthahnoscopy,  is  much  more  difficult,  and,  in 
fact,  constitutes  an  art  in  itself.  For  this,  two  methods  are  usually  employed. 
One  is  known  as  the  direct  method,  as  the  object  within  the  eye  is  looked 
directly  at,  and  the  other  is  described  as  the  indirect  method,  because  an  aerial 
image  of  the  object  is  what  is  looked  at.  In  the  indirect  method  the  instru- 
ment is  held  at  some  distance  from  the  patient's  eye  and  the  organ  gazed  at 
through  an  intervening  convex  lens.  In  the  first,  the  object  is  seen  erect  and 
in  its  true  position,  thus  giving  rise  to  the  term  erect  or  upright  image.  In 
the  second,  or  indirect  plan,  the  aerial  image  of  the  object  in  the  eye  is  both 
inverted  (thus  giving  the  term  inverted  image)  and  reversed. 

In  practice  it  is  always  best  to  study  the  various  layers  of  the  eye,  com- 
mencing at  the  cornea.  To  do  this  quickly  with  the  direct  method,  strong 
convex  lenses  are  to  be  employed  first.     These  are  to  be  gradually  weakened 


46  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

until  the  level  of  the  fundus  or  background  of  the  eye  is  reached.  The  disk 
or  optic  nerve-head  is  first  to  be  sought  for,  and  then  the  surrounding  retina 
and  choroid  are  to  be  carefully  studied.  If  the  indirect  method  is  employed, 
the  positions  of  the  ophthalmoscope  and  the  convex  lens  are  to  be  changed  in 
relation  to  the  patient  and  the  observer. 

In  health  the  disk  appears  as  a  pinkish-whitish-gray  plaque.  Its  borders 
are  distinct,  and  it  is  bounded  by  a  whitish  ring  which  is  edged  with  pigment. 
From  or  about  its  centre  a  series  of  light-colored  arteries  escape  and  sub- 
divide as  they  pass  out  into  the  retina.  Into  this  same  area  about  the  same 
number  of  dark-tinted  veins  which  have  arisen  from  much  finer  stems  can  be 
seen  to  pass.  The  general  color  of  the  nerve-head  is  of  a  dull  gray-red.  The 
eye-ground,  which  is  stippled,  becomes  darker  and  more  compact  as  it  gets 
nearer  to  the  region  of  the  most  distinct  vision.  The  macula  itself  often 
appears,  especially  by  the  upright  image,  as  a  longitudinal  oval  ring  of  a 
faint  yellowish  tinge,  whilst  the  fovea  glimmers  at  the  bottom  of  the  macula 
as  a  pale  straw-colored  dot  of  reflex. 

Should  there  be  inflammation  of  the  nerve-head,  as  in  descending  optic 
neuritis  from  meningitis,  the  disk  edges  will  become  hazy,  the  surface  slightly 
and  irregularly  elevated,  and  its  circulation  will  be  rendered  visible,  giving 
it  an  angry,  swollen,  and  over-vascular  appearance.  There  is  turgidity  of 
both  the  veins  and  the  arteries  of  the  retina,  notably  the  former.  The  vessels 
are  tortuous  and  the  veins  throb  and  pulsate  upon  the  slightest  occasion.  The 
general  color  of  the  fundus  becomes  more  rosy  in  hue,  whilst  in  the  graver 
forms  flame-shaped  hemorrhages  and  haze-like  areas  make  their  appearance. 

If  a  true  blocking  and  distention  of  the  intravaginal  spaces  in  the  optic 
nerve  sheaths  just  posterior  to  the  globe  occurs,  as  is  so  common  in  cerebral 
tumors  and  other  coarse  intracranial  lesions  of  infectious  type,  the  nerve- 
head  will  be  pushed  far  forward  into  the  interior  of  the  eye,  giving  rise  to 
the  condition  known  as  2>cvpillitis  or  choked  disk.  Here  the  picture  is  typical. 
The  nerve-head  stands  out  into  the  vitreous.  The  retinal  vessels  are  hidden 
in  many  places  in  the  disk  and  surrounding  retina  as  they  pass  to  and  from 
the  nerve-head.  Fine  capillary  and  numerous  clumplike  and  fan-shaped 
hemorrhages  are  seen  irregularly  distributed  in  and  around  the  swollen  nerve. 
The  veins  of  the  retina  are  engorged,  twisted,  and  turbid,  with  deeply  pig- 
mented blood,  whilst  the  corresponding  arteries  are  reduced  to  mere  threads 
of  pallid  blood. 

Later,  degeneration  changes,  both  cicatricial  in  type  and  fatty  in  nature, 
take  place,  giving  the  eye-ground  characteristic  appearances  which  in  many 
instances  are  almost  unmistakable  as  to  the  former  condition. 

IV  The  Study  of  Vision.  This  part  of  the  subject  naturally  divides 
itself  into  two  parts.  The  first,  that  known  as  central 'vision,  or,  better,  the  vision 
of  fixation ;  whilst  the  second  is  that  which  is  ordinarily  termed  excentric  or 
peripheral  vision.  The  former  teaches  much  as  to  the  transparency  of  the 
aqueous,  lens,  and  vitreous  humors  and  their  equality  of  structure  and  regu- 
larity of  surface.  It  immediately  shows  the  power  of  adaptability  of  the 
lens,  and  thus  indirectly  gives  the  condition  and  Avorking  capabilities  of  the 
ciliary  mviscle  and  its  accessories ;  it  registers  the  physiological  power  of  the 
most  important  and  most  frequently  employed  sensory  elements  of  the  retina  ; 
and,  lastly,  it  distinctly  states  the  degree  of  working  power  of  both  the  con- 
ducting apparatus  to  the  cortical  layers  and  the  visual  elements  of  the  cortex 
themselves. 

To  obtain  the  proper  answer,  so-called  test-letters,  which  by  experiment 
and  study  have  been  found  to  be  visible  at  definite  distances  by  great  num- 
bers of  presumably  healthy  eyes,  are  arranged  upon  charts.  These  cards  are 
suspended  upon  well-lighted  walls,  and  the  patients  are  requested  to  name 


GENERAL  CONSIDERATIONS.  47 

the  smallest  lines  of  letters  that  are  visible  to  each  eye  separately.  If  the 
line  of  type  named  be  that  for  which  the  distance  used  is  intended,  the  visual 
acuteness,  as  it  is  termed,  is  said  to  be  normal.  If  vision  be  less,  the  degree 
of  the  remaining  amount  is  to  be  noted  in  an  appropriate  manner. 

When  color  is  employed,  care  must  be  taken  that  the  amount  of  the  color 
area  that  is  exposed  is  properly  gauged  for  the  special  color  used.  This  is 
necessary  on  account  of  a  vast  difference  between  the  visibility  of  the  dif- 
ferent colors  at  the  same  distance. 

In  testing  near  objects  a  double  purpose,  as  before  hinted,  is  served. 
Not  only  is  the  amount  of  central  vision  obtained,  but  the  ability  of  the  so- 
called  accommodation  or  focusing  apparatus  of  the  eye  is  determined.  This  is 
accomplished  by  means  of  small  ordinary  printed  matter  or  reading-types,  as 
they  are  termed.  Trying  each  eye  separately,  the  nearest  and  furthest  points 
of  distinct  vision  for  the  smallest  type  that  is  visible  are  to  be  registered. 

If  vision  be  so  low  that  the  letters  cannot  be  deciphered,  an  outstretched 
hand  can  be  held  up  at  varying  distances  from  the  patient,  and  request  made 
to  state  how  many  fingers  are  raised.  If  vision  be  still  lower  than  this, 
various  forms  of  concentrated  or  artificial  light  may  be  thrown  upon  the 
patient's  open  eye,  whilst  he  is  desired  to  state  the  direction  from  which  they 
appear. 

In  the  second  form  of  study  the  extent  of  the  field  of  vision,  as  it  is  com- 
monly termed,  and  the  general  condition  of  its  entire  area  are  obtained. 
Several  plans  are  pursued,  but  for  the  sick-room  and  in  situations  where  com- 
plicated apparatus  is  not  easy  of  access,  small  squares  or  circular  areas  of 
color  pasted  upon  large  black  objects  are  extremely  useful.  Whilst  the 
patient  is  made  to  gaze  fixedly  at  some  object,  as,  for  example,  a  mark  upon 
a  blackboard  or  even  a  small  square  of  white  held  directly  in  front  of  the 
eye  that  is  to  be  examined,  the  color  area  is  to  be  gradually  moved  in  from 
the  iDcriphery  until  it  is  first  seen.  This  point  is  then  to  be  registered.  Re- 
joeating  this  at  a  dozen  or  more  meridians  around  the  central  object,  the 
various  registries  are  to  be  connected  together  by  a  series  of  concentric  lines, 
thus  giving  a  map,  as  it  were,  of  the  boundary  of  the  field  of  vision  for  the 
color  that  has  been  tried.  After  this  has  been  done  the  color  square  is  to  be 
carried  directly  inward  until  it  covers  the  object  that  the  patient  is  gazing  at. 
Note  is  then  to  be  made  whether  it  becomes  dim  or  is  lost  at  any  place.  In 
the  office  and  clinic-room,  where  most  careful  work  is  necessary,  more  accu- 
rate results  can  be  obtained  and  quickly  registered  by  one  of  the  numerous 
so-called  perimeter's. 

The  extent  and  forms  of  the  fields  of  vision  are  subject  to  many  variations ; 
in  fact,  they  become  one  of  the  most  valuable  and  certain  symptoms  in  the 
differential  diagnosis  of  grave  nerve  disease,  and  frequently  give  answer  as 
to  the  situation  and  significance  of  ocular  and  cerebral  disturbance.  Irreg- 
ularly and  markedly  contracted  into  a  series  of  indentations  in  many  forms 
of  retinal  and  choroidal  inflammation ;  ever  changing  and  most  confusing 
to  beginners  in  numerous  functional  neuroses  ;  dotted  with  scotomatous  areas 
in  coarse  changes  in  the  intraocular  coats  ;  darkened  and  even  annihilated  in 
the  areas  of  central  fixation,  as  in  macular  changes  of  retrobulbar  disturb- 
ances ;  and  split  into  almost  symmetrical  quarters  and  halves  known  as 
tetranopsic  and  hemiauopsic  field  defects  by  chiasmic,  optic  tract,  and  cortex 
lesions — it  can  be  readily  seen  how  much  information  can  be  gotten  by  care- 
ful work  in  this  direction. 

Briefly,  the  hemianoj^ic  defects  are  subdivided  into  the  following  varieties  : 

(a)  Kight  homonymous  hemianopsia,  which  means  that  the  area  of  either 
complete  or  incomplete  loss  of  vision  includes  all  that  portion  of  each  visual 
field  that  is  situated  to  the  right  side  of  the  fixation  object,  thus  showing  that 


48 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


there  is  some  break  in  the  sensory  fibres  which  are  distributed  to  the  left 
halves  of  the  retina.  This  condition,  as  can  be  easily  seen  by  Fig.  21,  in- 
dicates that  the  disturbance,  if  not  multiple,  is  situated  in  the  left  brain  back 
of  the  optic  chiasm. 

(b)  Left  homonymous  hemianopsia.  This  is  the  opposite  condition  of  the 
first  variety.  It  signifies  that  the  imperfection  of  vision  includes  all  that 
portion  of  each  visual  field  which  is  situated  to  the  left  side  of  the  point  of 
fixation,  thus  showing  that  there  is  some  break  in  the  sensory  fibres  which 
are  distributed  to  the  right  halves  of  the  retina.  This  condition,  as  can  be 
seen  by  the  figure,  shows  that  the  disturbance,  if  single,  is  in  the  right  brain 
posterior  to  the  optic  chiasm. 


Fig.  21. 


LEFT  VISUAL  FIELD. 
Fixation  Point. 


RIGHT  VISUAL  FIELD. 
Fixation  Poitit. 


(c)  Bitemporal  hemianopsia  or  lateral  heteronymous  hemianopia.  This 
is  a  condition  of  fault  in  the  two  visual  fields  where  the  imperfection  includes 
the  temporal  or  outer  halves  of  each  field  of  vision,  thus  showing  that  there 
is  some  break  in  the  sensory  fibres  which  are  distributed  to  the  nasal  or  inner 
halves  of  the  retina.  This  condition,  as  can  be  seen  by  the  figure,  shows  that 
the  disturbance  is  situated  either  directly  above,  below,  in  front  of,  or  behind 
the  optic  chiasm  itself. 

(d)  Binasal  hemianopsia  or  medial  heteronymous  hemianopia.  This 
means  that  there  is  a  fault  in  the  two  visual  fields  which  includes  their  nasal 
or  medial  halves.  It  shows  that  the  sensory  fibres  that  are  distributed  to  the 
temporal  or  outer  halves  of  the  two  retinae  are  not  acting.  This  variety, 
which  is  very  rare,  and  which  means  loss  of  binocular  vision  to  the  patient, 
necessarily  signifies,  as  can  be  seen  by  the  figure,  that  there  most  probably  is 
a  multiple  lesion. 

The  sup'erior  and  the  infei'ior  varieties  of  the  hemianopic  field  defects  are 


GENERAL  CONSIDERATIONS.  49 

practically  subdivided  into  the  same  groupings,  except  that  here  the  terms 
superior  and  inferior  are  substituted  for  the  terms  temporal  and  nasal. 

At  times  it  may  be  necessary  to  obtain  a  gross  estimate  of  the  condition  of 
the  color  sense.  This  is  easily  done  by  any  of  the  simple  modifications  of 
Holmgren's  series  of  wools.  The  skeins  being  thrown  promiscuously  upon 
the  table,  a  test  wool  is  handed  to  the  patient.  One  eye  is  to  be  tried  at  a 
time.  AVithout  naming  the  color,  the  patient  is  requested  to  choose  the 
nearest  match  to  the  test  skein.  One  or  two  trials  with  the  test  wools  of 
rose,  green,  and  red  will  soon  elicit  the  character  of  color  vision  possessed  by 
the  patient. 

V.  The  Study  of  Trophic  and  other  Changes  in  the  Eyeball  and  its 
Adnexa.  In  addition  to  the  above  methods  for  detecting  the  motor  and 
the  sensory  anomalies  of  the  organ,  it  becomes  important  to  ascei'tain  its 
trophic  condition.  Here  is  where  the  determination  of  the  degree  of  deeply 
seated  ocular  and  cutaneous  sensibility  are  so  important,  ^sthesiometers  of 
various  kinds  with  especially  adapted  points  for  the  cornea  may  be  employed. 
Wisps  of  cotton  carefully  twisted  and  coiled  upon  the  corneal  surface  with- 
out touching  the  lid-edges  often  can  be  made  vise  of  to  determine  the  sensi- 
bility of  this  membrane.  So,  too,  local  thermometry  on  and  around  the 
anterior  face  of  the  organ  can  be  frequently  brought  into  good  service  in  the 
ready  recognition  of  atrophic  and  degenerate  areas  from  peripheral  nerve 
disease,  such  as  is  so  often  found  in  the  later  stages  of  herpes  zoster-ophthal- 
micus.  Where  local  inflammation  is  present,  as  in  chronic  irido-cyclitis  or 
in  that  dread  disease,  sympathetic  irritation,  more  decided  pressure  with  the 
finger-tip  upon  or  over  the  afiected  parts  frequently  evokes  evidences  of 
tenderness  and  of  pain. 

Again,  the  deep  and  superficial  vascularity  of  the  anterior  segment  of  the 
globe  should  be  looked  at.  The  presence  of  the  circular  rim  of  fatty  degen- 
eration around  the  edge  of  the  cornea  should  be  sought  for.  The  condition 
of  the  lachrymal  apparatus ;  marks  of  inflammatory  thickenings  even  in  the 
upper  and  lower  culs-de-sac ;  the  degree  of  tonicity  of  the  globe,  which  can 
be  best  done  empirically  by  pressure  with  the  finger-tips  through  the  over- 
lying lid ;  the  depth  of  the  anterior  chamber  as  expressive,  for  instance,  of 
lens  swelling  in  the  shallowed  chamber  and  low-grade  ciliary  inflammation 
in  the  deepened  one — all  should  be  noted. 

The  relative  prominence  of  the  two  eyes  should  always  be  ascertained. 
To  do  this  various  contrivances  have  been  made,  but  here  as  elsewhere  visi- 
ble expressions  can  be  better  depended  upon  than  mere  mechanical  apparatus. 
Palpation  and  auscultation  for  the  determination  of  deeply  seated  orbital 
bruit  are  also  of  value. 

Further,  cases  arise  where  it  becomes  necessary  to  determine  whether  the 
symptoms  are  real  or  are  intentionally  or  unintentionally  counterfeited. 
Here  there  is  a  large  field  of  investigation  which  can  be  multiplied  accord- 
ing to  skill  and  ingenuity.  Prisms,  secretly  arranged  so  as  to  produce 
seemingly  true  double  images,  or  to  provoke  incorrect  positions  of  previously 
unseen  natural  objects,  can  be  used.  Lenses  so  placed  and  mydriatics  so 
employed  as  to  produce  unrecognized  changes  of  focusing  power  in  the 
patient's  two  eyes  so  that  he  is  not  made  aware  of  which  eye  is  actually  in 
use,  are  of  great  value;  whilst  interposition  of  opaque  objects  and  the  use  of 
apparatuses  by  which  the  patient  is  unwittingly  made  to  employ  his  averred 
bad  eye ;  and  even  in  complete  general  ansesthesia,  carried  sufficiently  into 
effect  as  to  render  the  patient  confused  when  placed  in  supposed  dangerous  sit- 
uations, etc.,  during  the  first  stage  of  recovery  from  its  effects,  are  all  useful ; 
all  can  frequently  be  successfully  applied.  The  induction  of  an  hypnotic 
condition  might  be  of  value  in  some  of  these  cases. 

4 


50  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

In  all  of  tliis  work  each  and  every  ocnlar  symptom  that  may  appear  of 
importance  to  the  proper  elucidation  of  the  cause  of  disturbance  should  be 
studied.  Here  the  intelligent  association  of  the  entu-e  grouping  of  the  ocular 
conditions  are  alone  useful  for  correct  data.  Evernhing  tliat  is  relevant 
should  be  noted,  accurate  register  of  passing  symptoms  should  be  taken,  and 
the  uncertainties  of  cases  so  constantly  repeated  as  to  obviate  all  past  diffi- 
culties. If  this  be  done  most  carefully  and  painstakingly,  it  will  be  a  source 
of  great  happiness  and  pleasure  to  \'ealize  that  all  of  the  findings  have 
reached  a  plane  of  certainty  that  other  observers  tln-ough  carelessness  and 
consequent  ignorance  have. sought  for  in  vain. 


CHAPTER  II. 
GENERAL  MORBID  STATES  OF  THE  NERVOUS  SYSTEM. 

By  F.  X.  DERCUM,  M.D. 

NEURASTHENIA. 

Among  the  first  of  the  various  morbid  states  of  the  nervous  system  to 
claim  our  attention  is  the  one  now  generally  known  under  the  name  of 
neurasthenia,  and  for  which  the  laity  use  the  expressions  "  nervous  exhaus- 
tion "  and  "  nervous  prostration."  The  fact  that  it  is  widely  difHised  through 
almost  every  community  renders  its  study  of  peculiar  importance. 

Strangely  enough,  an  impression  exists  not  only  among  the  laity,  but  also 
among  physicians,  that  the  affection  which  we  are  about  to  consider  is  a 
comparatively  recent  one ;  is  one  which  is  the  outcome  of  the  high  pressure 
and  the  great  wear  and  tear  of  modern  civilization.  That  this  is  an  error  a 
brief  study  of  the  subject  soon  convinces  us.  Certainly,  all  peoples  ancient, 
as  well  as  modern,  have  been  subject  at  various  times  to  the  same  etiological 
factors  which  we  know  produce  neurasthenia  to-day ;  and,  while  space  does 
not  permit  us  to  refer  to  the  pages  of  history  to  support  us  in  this  assertion, 
there  can  be  no  doubt  of  its  truthfiilness.  Medical  men  have  recognized, 
though  vaguely,  the  existence  of  this  affection  ever  since  the  sixteenth  cen- 
tury, and  in  the  seventeenth  and  eighteenth  centuries  allusions  to  this  affec- 
tion and  various  descriptions  of  it  continue  to  appear.^  However,  the  early 
descriptions  are  obscure  and  permeated  by  grotesque  pathological  theories. 
Moreover,  they  make  no  distinction  between  neurasthenia  and  the  related 
states  of  hysteria  and  hypochondria.  To  Robert  Whyte,  of  Edinburgh,' 
belongs  the  credit  of  first  differentiating  between  these  three  affections  and  of 
more  or  less  correctly  outlining  the  condition  now  known  as  neurasthenia. 
This  he  did  as  early  as  1765  in  his  work  on  Nervous  Dkorders.  He  recog- 
nized three  classes  of  these  disorders,  and  in  speaking  of  them  says :  "  The 
complaints  of  the  first  of  the  above  classes  maybe  called  simply  nervous ; 
those  of  the  second,  in  compliance  with  custom,  may  be  said  to  be  hysteric, 
and  those  of  the  third  hypochondriac.'"  Unfortunately,  he  did  not  give  the 
"  nervous  "  condition  that  he  recognized  a  more  specific  name.  Sandras,  in 
1851,  first  used  the  expression  "nervous  state"  {etat  nerveux),  and  for  which 
Bouchut  later  substituted  the  word  "  nervousness  "  (nervosisme). 

The  first  use  of  the  word  neurasthenia,  as  applied  to  this  condition,  is 
almost  universally  ascribed  by  medical  writers  to  George  M.  B.  Beard.  This, 
however,  is  an  error,  the  credit  really  belonging  to  another  American  j^hysi- 
cian.  Dr.  E.  H.  Van  Deusen,  of  Kalamazoo,  Mich.,  who  first  used  the  word 

1  For  a  detailed  history  of  this  portion  of  the  subject  the  reader  is  referred  to — Arndt :  Die  Neuras- 
thenie,  ihr  VVesen,  ihre  Bedeutung  und  Behandlung,  etc.  Wien,  1885.  Also,  Mliller,  F.  C. :  Geschichte 
der  Neurasthenic,  in  Handbuch  der  Neurasthenic.     Leipzig,  1893. 

2  Whyte,  Robert :  Observations  on  the  Nature,  Causes,  and  Cure  of  those  Disorders  which  have 
been  commonly  called  Nervous,  Hypochondriac,  or  Hysteric.    Edinburgh,  1765. 


52  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

in  the  supplement  to  the  Biennial  Rejjort  to  the  Michigan  Asylum  for  the 
Insane  for  1867,  under  the  heading  of  "Observations  Upon  a  Form  of 
Nervous  Exhaustion  (Neurasthenia)  Culminating  in  Insanity,"  and  who 
says,  among  other  things :  "  Our  observations  have  led  us  to  think  that  there 
is  a  disorder  of  the  nervous  system,  the  essential  character  of  which  is  well 
expressed  by  the  term  given  above,  and  so  uniform  in  development  and 
progress  that  it  may  with  propriety  be  regarded  as  a  distinct  form  of  disease." 
He  further  gives  a  tolerably  clear  account  of  the  affection.  Beard's  first 
paper  upon  the  subject  did  not  appear  until  1869,  in  the  Boston  Medical  and 
Surgical  Journal.  However,  that  the  term  neurasthenia  is  really  older  and 
was  not  invented  by  either  of  these  physicians  is  proven  by  the  fact  that  it 
is  found  in  the  first  edition  of  Dunglison's  Medical  Dictionary,  published  in 
1833,  side  by  side  with  its  German  equivalent,  Nervenschtoaeche.  Contem- 
porary English,  French  and  German  dictionaries  do  not  contain  it.  As  to 
who  actually  invented  the  word  is,  therefore,  still  a  matter  of  mystery. 

Definition.  Neurasthenia  in  its  simplest  form  is  a  condition  in  which  there 
is  a  more  or  less  marked  and  persistent  diminution  of  nervous  energy,  together 
with  an  increased  reaction,  mental  and  physical,  to  external  impressions.  In 
other  words,  we  have  two  principal  symptoms,  nervous  weakness  and  nervous 
irritability.  Diminished  resistance  to  fatigue  implies  diminished  resistance  to 
impressions  from  without.  Weakness  and  irritability  seem  thus  to  be  neces- 
sarily associated. 

Neurasthenia,  fiirther,  is  an  affection  which  does  not  limit  itself  to  any 
part  of  the  nervous  apparatus,  but  affects  it  as  a  whole.  Medical  writers,  it 
is  true,  have  divided  it,  clinically,  into  cerebral  and  spinal  types,  according 
as  one  or  the  other  group  of  symptoms  predominate,  but  every  case  presents 
overwhelming  evidences  of  a  generalized  affection.  It  is  extremely  probable 
that  brain,  cord  and  peripheral  nervous  system  all  suffer,  although,  of  course, 
in  varying  degrees.  Almost  as  a  corollary  it  follows  that  the  essentials  of  the 
symptomatology  are  always  the  same,  but  that  individual  cases  vary  greatly 
in  their  details. 

Neurasthenia  being  an  affection  extremely  generalized  in  character,  it  is 
•often  found  associated  with  other  affections,  such  as  hysteria,  hyphochondria 
and  other  functional  and  organic  diseases.  Unfortunately,  this  association 
has  led  to  considerable  confusion  in  the  minds  of  medical  men,  and  a  few 
have  gone  so  far  as  to  deny  the  existence  of  neurasthenia  as  a  separate  affec- 
tion. The  fact,  however,  that  simple  and  uncomplicated  cases  of  neurasthe- 
nia are  constantly  met  with — the  fact  that  cases  in  which  the  symptoms  of 
simple  nervous  fatigue,  without  any  other  etiological  factors  than  overwork, 
present  themselves — leaves  us  no  alternative  but  to  accord  it  a  separate 
place  in  our  classification.  Moreover,  as  we  progress  in  our  study  of  this 
affection,  we  will  find  that  the  symptoms  presented  are  those  of  a  constantly 
recurring  "symptom  group,"  and  that  we  have  a  well-marked  clinical  entity 
with  which  to  deal.  Pathological  considerations,  as  we  will  presently  see, 
also  point  in  the  same  direction. 

At  the  very  outset  of  our  study  we  find  that  neurasthenia  resolves  itself 
into  two  great  groups :  First,  simple  neurasthenia,  and  secondly,  neurasthenia 
associated  with  other  diseases.  With  these  ideas  before  us  "let  us  turn  our 
attention  to  questions  of  cause. 

Etiology.  As  in  other  affections,  the  causes  of  neurasthenia  can  be 
separated  into  predisposing  and  exciting.  Among  the  predisposing  is,  first 
and  foremost,  heredity.  In  a  large  number  of  the  cases  that  come  under 
our  notice  this  factor  is  present.  We  frequently  find  on  questioning  the 
patient  that  either  the  mother  or  father,  or  perhaps  both,  have  been  "nerv- 
ous" or  very  irritable,  or  perhaps  have  suffered  greatly  with  headaches. 


GENERAL  MORBID  STATES.  53 

Only  exceptionally  do  Ave  find  insanity,  epilepsy  or  organic  ner%^ous  diseases 
in  the  family  history.  Indeed,  the  occurrence  of  such  a  history,  especially  if 
it  be  marked,  should  make  us  suspect  that  the  patient  is  not  suffering  from 
neurasthenia,  but  is  in  the  deyelopniental  period  of  some  psychosis  or  some 
form  of  organic  nervous  disease.  The  importance  of  this  fact,  in  yiew  of 
the  prognosis,  is  such  that  it  should  not  be  oyerlooked.  Neurasthenia,  even 
when  hereditary,  has  no  factors  in  common  with  the  "  neuropathic  constitu- 
tion." The  hereditarily  neurasthenic  individual  is  merely  one  who  makes 
his  start  in  life  with  a  nervous  system  in  which  cell  wear  and  tear  take 
place  readily,  and  in  whom  the  recuperative  power  is  feeble.  He  has  no 
innate  predisposition  to  insanity,  sclerosis  or  other  nervous  diseases,  as  has 
the  hereditarily  neuropathic  subject.  Closely  allied  to  the  question  of  hered- 
ity is  the  occurrence  of  various  diseases  in  the  parents  which  are  calculated  to 
depress  vitality,  such,  for  instance,  as  tuberculosis  and  sj^^hilis ;  that  is,  the 
children  of  such  parents,  without  having  tuberculosis  or  inherited  syphilis, 
may  readily  become  neurasthenic.  Strangely  enough,  too,  a  history  of  gout 
in  the  ancestry  is  not  uncommon.  Whether  gout  directly  predisposes  the 
offspring  to  neurasthenia,  or  whether  the  fact  that  a  gouty  ancestry  is  often 
synonymous  with  a  dissipated  and  alcoholic,  and  therefore  enfeebled,  stock, 
are  questions  that  we  cannot,  of  course,  determine.  The  clinical  relationship 
of  the  gouty  ancestry  to  neurasthenia,  however,  remains. 

That  the  abuse  of  stimulants  by  the  parents,  great  age  of  the  father,  and, 
in  fact,  all  enfeebling  and  depressing  influences  in  the  ancestry,  tend  to  pro- 
duce neurasthenically  disposed  offspring,  is  a  matter  readily  comprehended. 
Consanguineous  marriages,  it  should  be  remarked,  are  likely  to  produce  a 
neuropathic,  rather  than  a  neurasthenic,  stock. 

Next  in  importance  to  heredity  is  education.  A  child,  otherwise  healthy, 
is  often  brought  up  so  loosely,  is  so  indulged  in  every  whim  and  caprice,  is  so 
pampered  and  petted,  so  thoroughly  "spoiled,"  that  when  circumstances 
force  the  grown-up  lad  or  adult  woman  to  face  the  serious  Cjuestions  of  life, 
energy,  will-power,  judgment,  self-control,  nervous  strength  in  all  its  forms, 
are  sadly  lacking.  A  rude  awakening  and  a  succession  of  painflil  crises, 
together  with  the  suffering  they  entail,  are  potent  factors  in  the  develop- 
ment of  neurasthenia.  On  the  other  hand,  children  who  are  brought  up 
harshly,  or  too  rigidly ;  who  are  denied  the  ordinary  pleasures  of  childhood 
and  youth,  and  upon  whom  a  too  close  application  to  study,  and  perhajDs  to 
physical  labor,  has  been  forced,  are  also  likely  to  develop  sooner  or  later  into 
neurasthenic  men  and  Avomen.  Further,  an  education  that  provides  a  child 
simply  with  desk  instruction,  with  books  to  the  exclusion  of  physical  exer- 
cise ;  or  an  education  that  taxes  a  child  too  much  in  one  direction,  such  as 
music  or  drawing,  is  also  attended  by  grave  dangers.  The  absurd  and  often 
cruel  custom  of  forcing  prolonged  musical  training,  requiring  many  hours  of 
daily  practice,  upon  children  who  have  no  special  or  natural  musical  talent, 
and  who  have,  in  addition,  all  the  other  tasks  of  school,  is  only  too  common 
in  this  country.  The  nervous  system  of  the  child,  like  a  steel  blade  untem- 
pered,  is  soft  and  unresisting ;  tempered  too  highly,  it  is  brittle  and  fragile, 
and  tempered  unevenly,  is  full  of  Aveaknesses. 

Among  predisposing  causes  we  should  also  mention  occupation.  Persons 
whose  business  is  attended  by  great  strain  and  excitement,  by  worry  and 
uncertainty,  such  as  inventors,  speculators  or  promoters  of  great  enterprises, 
are  very  apt  to  become  neurasthenic.  Other  occupations,  CA^en  if  they  entail 
a  great  amount  of  AA'ork,  provided  there  be  "emotional  rest,"  do  not  of  them- 
selves entail  neurasthenia.  Causes  relating  to  the  hygiene  of  occuj^ations  are 
not  here  considered. 

Social  position  does  not  seem  to  exercise  a  markedly  predisposing  influence. 


54  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Many  of  our  patients  are,  it  is  true,  of  the  wealthy  classes,  and  yet  at  the 
doors  of  our  hospitals  is  an  equally  large  number  of  indigent  sufferers  clamor- 
ing for  admission. 

The  married  or  unmarried  state  markedly  influences  the  tendency  to  neu- 
rasthenia. A  much  larger  number  of  neurasthenics  are  unmarried,  and  this 
is  true  alike  of  men  and  women.  In  single  men  special  causes,  generally 
absent  in  the  married,  such  as  masturbation,  sexual,  alcoholic,  and  other  ex- 
cesses, are  present.  In  single  Avomen,  though  excesses  and  infractions  of  the 
moral  law  are  much  less  frequent,  the  unaided,  and  often  unequal,  battle  with 
the  w^orld  is  to  blame.  Sometimes,  as  we  will  see,  simple  sexual  abstinence  is 
of  itself  a  predisposing  cause. 

Some  writers  claim  that  neurasthenia  is  more  frequent  in  men.  We  should, 
however,  remember  that  a  very  large  number  of  female  neurasthenics  fall 
into  the  hands  of  gynecologists,  and  that  therefore  statistics  on  this  point, 
especially  from  private  practice,  are  not  reliable. 

Neurasthenia  is,  as  would  be  expected,  most  common  during  the  years  of 
most  active  life — namely,  from  twenty  to  forty-five  or  fifty.  It  has  been 
claimed  by  various  writers  ( Bouveret,  von  Hoesslin)  that  race  is  occasionally 
a  factor  in  neurasthenia.  It  is  stated  that  Hebrews  and  Slavs  are  especially 
liable.  Regarding  Hebrews,  the  peculiar  conditions  under  which  they  have 
lived  for  so  many  centuries  may  in  part  account  for  this  condition.  To  Slavs 
this  explanation,  of  course,  does  not  apj^ly. 

Among  the  exciting  causes  of  neurasthenia  is,  first  and  foremost,  overwork. 
The  capacity  of  every  individual  for  work  is  limited.  It  varies  greatly  in 
different  persons,  and  in  estimating  the  question  of  overwork  this  should  be 
borne  in  mind.  The  character  of  the  work  also  is  very  important  in  this 
connection.  What  one  man  can  execute  with  ease  may  be  a  very  exhausting 
labor  to  another.  Thus,  one  of  the  most  typical  cases  of  neurasthenia  which 
it  has  been  the  writer's  fortune  to  see,  occurred  in  the  person  of  a  coal  miner 
who  gave  up  the  work  of  mining  for  the  more  pleasant  and  lucrative  calling 
of  a  country  schoolmaster.  In  the  mine  he  had  been  perfectly  well ;  in  his 
new  position,  however,  he  became  rapidly  neurasthenic,  and  this,  too,  in  the 
face  of  the  fact  that  the  character  of  the  work  required  only  the  most  ele- 
mentary knowledge  and  that  the  number  of  pupils  was  very  limited. 

It  is  commonly  believed  that  neurasthenia  is  the  outcome  especially  of  men- 
tal overwork.  Sometimes,  however,  overwork  that  is  purely  physical,  if  long 
continued,  leads  to  neurasthenia  of  the  most  intractable  form.  To  this  point 
we  will  presently  return. 

It  is  surprising  how  much  work  can  really  be  accomplished  by  well-trained 
men  without  neurasthenia  being  induced.  An  added  factor,  however,  emo- 
tional excitement,  is  very  potent  for  ill ;  indeed,  emotional  unrest  of  itself  is 
a  cause  second  in  importance  only  to  overwork.  Excitement  of  a  pleasurable 
character — for  example,  the  excitement  of  success — acts  rather  as  a  stimu- 
lant. It  is  excitement  of  a  depressing  character,  such  as  worry  and  dis- 
appointment, vexation  and  grief,  that  acts  deleteriously.  An  interesting 
example  of  the  power  of  overwork  and  of  dejoressing  emotions  to  produce 
neurasthenia  is  found  in  nursing.  A  mother  nursing  her  sick  child  through 
a  long  illness  is  not  only  subjected  to  great  physical  strain  by  loss  of  sleep, 
but  especially  by  the  prolonged  emotional  strain  entailed  by  the  painful 
uncertainty  regarding  the  recovery  of  the  patient.  Contrasted  with  this  the 
paid  nurse,  who  discharges  the  same  duties  and  loses  an  equal  amount  of 
sleep,  experiences  but  slight  strain  and  remains  well.  Her  emotions  are  but 
secondarily,  if  at  all,  called  into  play. 

Various  causes  that  tend  to  debilitate  tend  also  to  produce  neurasthenia. 
Among  these  may  be  mentioned  excessive  child-bearing  and  prolonged  lacta- 


GENERAL  MORBID  STATES.  55 

tion.  Nervous  exhaustion  is  also  apt  to  follow  certain  acute  illnesses,  such  as 
typhoid  fever,  malaria,  and  especially  influenza. 

One  of  the  most  powerful  and  most  frequent  of  the  exciting  causes  of 
neurasthenia  is  trauma.  Accidents  of  all  kinds,  especially  if  they  be  accom- 
panied by  fright,  such  as  is  the  case  in  railway  accidents,  tend  to  produce 
a  neurasthenia  that  is  often  profound  and  very  persistent.  Two  factors  are 
generally  present  in  such  cases :  first,  the  physical  injury,  and,  secondly,  the 
emotional  shock.  They  are  considered  in  detail  in  Chapter  IV.  Among 
other  exciting  causes  are  all  forms  of  dissipation  and  excess ;  everything 
that  exhausts  the  nervous  system  tends  to  produce  neurasthenia.  The  ex- 
cesses of  the  votaries  of  Bacchus  not  only  entail  loss  of  sleep,  but  also  the 
weakness  consequent  upon  over-stimulation.  Later,  after  the  alcoholic  habit 
is  fully  acquired,  the  symptoms  of  neurasthenia  are  complicated  by  those  of 
chronic  alcoholic  poisoning.  What  is  true  of  alcohol  is  true  of  tea,  coffee,  and 
tobacco.  Sexual  excess  is  also  a  potent  factor.  This  applies,  of  course,  to  both 
sexes.  A  very  profound,  bed-ridden  neurasthenic,  for  many  months  under 
care  of  the  writer  at  the  Philadelphia  Hospital,  was  a  woman  who  had  been  at 
one  and  the  same  time  the  mistress  of  three  different  men.  Sexual  gratification 
by  unnatural  means,  it  need  hardly  be  said,  is  also  very  injurious,  although 
regarding  masturbation,  it  must  be  admitted  that  the  habit  is  sometimes  car- 
ried on  to  a  surprising  extent  and  yet  the  individual  remains  apparently  well. 
This  is,  however,  the  exception  and  not  the  rule.  An  exceedingly  dangerous 
practice  is  that  which,  we  fear,  is  only  too  common  among  married  persons — 
namely,  the  interruption  of  the  sexual  act  by  the  withdrawal  of  the  male  at 
the  moment  of  ejaculation.  An  equally  harmful  practice  is  the  unnatural 
prolongation  of  the  act. 

As  opposed  to  sexual  excess,  sexual  abstinence  every  now  and  then  pro- 
duces nevirasthenia.  The  number  of  instances  is,  however,  we  are  convinced, 
very  small,  and  it  probably  occurs  only  in  cases  of  long-continued  and  sup- 
pressed excitement,  such  as  sometimes  exists  in  engaged  persons,  especially 
when  the  engagement  is  of  long  duration. 

The  above  causes  embody  briefly  the  various  factors  producing  simple  and 
uncomplicated  neurasthenia,  neurasthenia  simplex. 

A  moment's  reflection  will  convince  the  reader  that  nervous  exhaustion  is 
frequently  the  outcome  of  various  other  functional  and  organic  affections. 
Thus,  a  persoD.  who  has  tuberculosis  may  present,  in  addition  to  the  specific 
symptoms  of  that  disease,  also  those  of  neurasthenia.  This  is  likewise  true 
of  anaemia,  chlorosis,  and  other  nutritional  disturbances.  Again,  functional 
or  organic  disease  of  the  stomach  or  intestines  or  of  the  generative  apparatus, 
may  so  affect  the  general  nutrition  as  to  produce  symptoms  of  nervous  weak- 
ness. It  is  very  plain  that  a  neurasthenia  arising  from  any  of  these  causes 
differs  radically  from  neurasthenia  simplex,  and  that  its  natural  designation  is 
neurast henia  symptomatica. 

Symptomatology.  Contrary  to  our  experience  in  many  other  nervous  dis- 
eases, the  patient  presents  no  striking  physical  peculiarities.  There  is  no 
gross  abnormality  in  the  walk,  no  local  palsy,  no  muscular  spasm,  no  inco- 
ordination of  movement.  There  are  none  of  those  obvious  features  that 
so  often  enable  us  at  a  glance  to  relegate  a  given  case  to  this  or  that  group  of 
diseases.  Frequently  it  is  only  after  our  patient  begins  to  talk  that  we  gain 
an  idea  of  the  character  of  his  affection.  He  begins  by  telling  us  how  he 
feels,  and  we  soon  become  impressed  with  the  subjective  character  of  many  of 
the  symptoms.  Physical  symptoms  are  present,  it  is  true,  but  we  soon  learn 
that  in  the  majority  of  cases  they  are  brought  to  the  surface  only  by  system- 
atic examination.  The  patient  is  rarely  talkative.  Only  after  repeated 
questioning  we  learn  that  he  is  "nervous;"  that  he  gets  easily  excited  and 


56  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

"upset ;"  that  he  can  no  longer  work  as  he  did  ;  that  he  gets  tired  before  the 
day  is  half  over ;  that  he  can  hardly  sleep  at  night ;  that  when  he  awakes  in 
the  morning  he  feels  completely  exhausted ;  that  his  head  aches ;  that  his 
heart  palj^itates ;  that  his  memory  is  impaired ;  that  he  has  to  force  himself 
to  eat ;  that  his  food  lies  heayily  in  his  stomach ;  that  his  bowels  are  con- 
stipated ;  and  so  on  and  on  through  a  long  train  of  distressing  symptoms. 
To  these  may  be  added  a  long  list  of  sexual  troubles. 

One  could  hardly  expect  such  a  jjatient  to  be  cheerful.  As  a  matter  of 
fact,  he  is  generally  depressed  and  worried  about  himself.  Often,  too,  he  gets 
anxious  and  fearful  if  left  alone ;  or,  again,  feels  oppressed  in  company  or 
crowds.  Sometimes  he  feels  afraid  to  stay  in  the  house ;  at  other  times  afraid 
to  stay  in  the  open  street.  In  other  words,  he  may  have,  in  addition  to  his 
general  symptoms,  those  of  an  unnatural  fear. 

In  outward  apj^earance  neurasthenics  diifer  greatly.  If  marked  depression 
exists  it  may  affect  the  walk,  the  attitude,  the  facial  expression,  the  manner, 
and,  in  short,  the  entire  bearing  of  the  patient.  If  dej)ression  be  absent  or 
but  slight,  all  of  these  symptoms  may  be  wanting.  Again,  it  not  infi'e- 
quently  happens  that  the  neurasthenic  subject  has  an  excellent  physical 
develoj)ment,  and  this  may  give  his  fi'iends  the  impression  of  his  having 
very  good  health.  Men  of  fine  physique  who  have  been  the  victims  of 
overwork  may  bear  little  or  no  outward  trace  of  their  breakdown,  at  least 
for  a  time. 

We  will  see  as  we  progress  that  the  symptoms  of  neurasthenia  are  of  two 
kinds :  first,  essential  symptoms,  and,  secondly,  adventitious  symptoms.  The 
first  are  those  which  essentially  attach  to  the  condition,  and  ahvays  j^resent 
the  phenomena  of  weakness  and  irritability.  The  others  are  secondary  out- 
growths of  the  various  disturbances  of  function,  and  may  or  may  not  be 
present.  This  division  into  primary  or  essential  symptoms,  and  secondary  or 
adventitious  symptoms,  we  will  find  very  useflil.  It  simplifies  a  subject  other- 
wise difficult  and  complicated,  and  renders  our  conceptions  clear  and  accurate. 

When  analyzed  relative  to  their  distribution  the  symptoms  resolve  them- 
selves into : 

Motor, 
Sensory, 
Psychic,  and 
General  Somatic. 

Motor  Disturbances.  The  patient  almost  invariably  complains  of 
muscular  weakness.  In  the  large  majority  of  cases  this  sense  of  weakness  is 
founded  upon  actual  feebleness  of  the  muscles.  If  the  patient  be  asked  how 
far  he  is  able  to  Avalk  he  will  frequently  give  as  answer  an  absurdly  small 
distance.  Very  often  he  will  volunteer  the  information  that  he  cannot  stand 
long,  that  he  grows  so  tired  that  he  is  compelled  to  lie  down.  When  tested 
by  the  dynamometer  it  is  found  that  his  grip  is  markedly  weak.  Occasion- 
ally, however,  to  our  surprise,  the  grip  is  normal ;  but  in  this  instance,  if  the 
patient  be  made  to  repeat  the  grip  a  number  of  times  in  succession,  we  find 
that  it  quickly  grows  weaker,  and  in  a  little  while  the  index  of  the  instru- 
ment may  even  fall  to  zero.  In  other  words,  the  patient  may  be  able  by 
sudden  eflfort  to  simulate  a  normal  condition,  but  he  cannot  maintain  it. 
Symptoms  of  fatigue  soon  make  their  appearance,  and  the  weakness  becomes 
very  evident.  This  incapacity  for  prolonged  muscular  exertion  may  be 
regarded,  as  we  will  see,  as  representing  one  of  the  fiindamental  features 
of  neurasthenia. 

Weakness  of  the  legs  and  back  is  complained  of  more  frequently  than 
weakness  of  the  arms,  but  in  all  cases  the  condition  is  found  to  be  more  or 
less  general.     Decided  local  weakness  is  rare,  and  when  found  should  suggest 


GENERAL  MORBID  STATES.  57 

hysteria  or  other  ftmctioual  or  organic  disease.     Actual  paralysis  is  never 
observed  in  simple  neurasthenia. 

A  phenomenon  observed  with  sufficient  frequency  to  be  worthy  of  note  is 
muscular  tremor.  In  the  experience  of  the  writer,  it  is  absent  in  the  majority 
of  cases.  It  is  more  often  seen  when  the  neurasthenia  is  the  result  of  trauma 
or  fright.  As  might  be  expected,  it  becomes  more  pronounced  with  emo- 
tional excitement.  It  is  rather  a  fine  tremor,  and  is  often  inconstant  and 
irregular.  Occasionally  it  is  betrayed  by  the  handwriting.  It  may  be 
limited  to  the  hands  or  may  be  widely  diffiised  over  the  muscles  of  the  limbs 
and  trunk — notably  in  traumatic  cases.  Allied  to  this  tremor  are  spasmodic 
and  irregularly  recurring  contractions  of  small  bundles  of  muscle  fibres,  either 
in  the  truncal  muscles  or  in  those  of  the  extremities.  They  closely  resemble 
the  fibrillary  contractions  seen  in  the  muscles  in  poliomyelitis,  and,  like 
tremor,  they  are  more  frequent  in  cases  of  traumatic  origin.  Slight  spasms 
or  twitchings  are  occasionally  seen  in  the  orbicularis  jDalpebrarum,  in  the 
fibres  of  the  frontals,  and  elsewhere  about  the  face  in  neurasthenic  subjects. 
Occasionally  a  tendency  to  twitching  or  brief  spasm  exists  in  some  of  the 
muscles  of  the  extremities.  It  is  perhaps  most  frequently  met  with  in  the 
muscles  of  the  calf 

The  tendon  reactions  of  neurasthenics  are  likewise  important  and  interest- 
ing. The  knee-jerks  are  in  the  majority  of  cases  decidedly  exaggerated  ;  but 
if  an  attempt  be  made  to  elicit  the  reaction  repeatedly  and  in  close  succes- 
sion, marked  diminution  of  the  response  and  even  disappearance  may  be 
observed.  In  other  words,  the  nerve  centres  concerned  in  the  production  of 
this  tendon  reaction  may  become  exhausted.  In  some  cases,  instead  of  being 
exaggerated  at  the  outset  the  jerk  may  be  normal  or  even  less  than  normal. 
Should  the  knee-jerk  be  altogether  absent,  and  remain  so  during  tests  made 
by  Jendrassik's  method  of  re-enforcement  (see  page  28)  we  should  at  once 
look  for  signs  of  organic  disease. 

Exaggerated  tendon  reactions  are  also  noted  elsewhere.  The  tendons  of 
the  tricej)s,  of  the  biceps,  and  the  various  tendons  at  the  wrLst  may  react  in 
an  exaggerated  manner.  An  ankle  clonus  may  also  be  present,  although  it 
is  never  so  marked  nor  so  prolonged  as  we  find  in  organic  disease  of  the 
cord.  It  is  generally  of  less  extent  and  rapidly  exhausted.  Regarding 
these  tendon  phenomena  in  neurasthenics,  it  should  also  be  stated  that  they 
are  much  more  marked  during  excitement.  This  is  doubtless  the  reason  Avhy 
they  vary  from  time  to  time.  Thus  an  ankle  clonus  present  at  one  occasion 
may  be  absent  at  another ;  and  two  observers  examining  the  same  patient 
in  immediate  succession  may  obtain  different  results  because  the  first  has  for 
the  time  being  exhausted  the  tendon  reactions.  These  points  are  of  im- 
portance in  view  of  the  medico-legal  aspects  of  the  traumatic  form  of 
neurasthenia. 

At  times  the  muscles  also  respond  in  a  manner  similar  to  the  tendons 
when  tested  by  percussion.  Rarely  the  nerve  trunks  are  also  mechanically 
irritable,  so  that  tapping  will  produce  slight  contractions  in  the  muscles 
supplied. 

Sensory  Disturbances.  The  sensory  disturbances  of  neurasthenia  are 
exceedingly  numerous  and  varied.  Being  subjective,  many  of  them  are  inca- 
pable of  any  but  indirect  verification.  They  range  from  vague,  generalized, 
abnormal  feelings,  often  incapable  of  description,  to  others  which  are  definite 
in  character  and  limited  to  certain  portions  of  the  body.  Thus,  some  patients 
suffer  from  a  vague  and  general  feeling  of  distress  that  can  only  be  described 
by  saying  that  they  "  feel  badly  all  over."  Others,  again,  will  complain  of 
a  general  feeling  of  fatigue,  and  some  of  a  sense  of  profound  exhaustion. 
Very  often  the  patient  tells  us,  "  I  feel  tired  all  the  time,"  and  sometimes 


58  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

adds,  "  I  always  feel  like  lying  down,  and  am  not  comfortable  even  then." 
This  feeling  of  general  fatigne  is  rarely  absent  in  simple  neurasthenia.  In 
profound  cases  it  may  be  hidden  and  obscured  by  a  host  of  other  symptoms. 
Among  sensations  less  generalized  are  such  as  "  lightness  "  or  "  emptiness  "  of 
the  head,  or  a  sense  of  "  constriction  "  or  "  pressure  "  about  the  head.  Some- 
times the  patient  complains  that  his  limbs  feel  heavy,  as  though  they  could 
not  be  moved,  and  at  other  times  as  though  they  were  without  all  feeling. 
Vague  sensations  of  tightness,  of  pressure,  or  other  uneasiness  may  be  referred 
to  this  or  that  j)ortion  of  the  trunk. 

At  other  times  a  feeling  of  uncertainty  in  making  voluntary  movements  is 
present.  Sometimes  associated  with  this  peculiar  symptom,  though  often 
independently,  we  have  a  feeling  of  uncertainty  in  regard  to  surrounding 
objects.  In  such  cases  the  patients  complain  of  being  giddy,  and  may,  indeed, 
present  the  symptoms  of  more  or  less  marked  vertigo.  Mild  forms  of  giddi- 
ness are,  however,  more  common  in  neurasthenia  than  actual  vertigo.  That 
this  symptom  is  directly  related  to  the  nervous  asthenia  there  can  be  no  doubt. 
It  appears  to  be  due  to  the  lessened  vasomotor  control  of  the  cerebral  vessels, 
so  that  slight  effort  or  change  of  posture  affects  the  intra-cranial  circulation.  It 
is  not  impossible  also  that  at  times  it  is  due  to  an  actual  weakness  of  the  various 
centres  concerned  in  co-ordinating  movement.  It  not  only  gives  rise  to  very 
distressing  subjective  symptoms,  but  now  and  then  is  sufficiently  marked  to 
disturb  the  equilibrium.  Beard  and  Charcot  both  refer  this  symptom  to  the 
asthentic  state.  However,  in  vertigo  from  simple  neurasthenia,  objective 
symptoms— that  is,  symptoms  patent  to  the  observer — are  far  less  often 
present  than  in  vertigo  observed  in  organic  disease  of  the  cerebellum,  ear 
disease,  or  gastric  disturbances.  In  the  neurasthenic  patient,  the  subjective 
sense  of  uncertainty  may  be  so  great  that  he  will  grasj)  surrounding  objects 
to  prevent  from  falling,  but  in  reality  he  has  comparatively  little  difficulty 
in  maintaining  his  equilibrium.  At  least  actual  staggering  and  inco-ordinate 
movements  are  rarely  observed.  When  the  severer  forms  are  met  with  in 
nervous  exhaustion,  it  is  very  probable  that  they  are  due  to  concomitant 
gastric  troubles.  The  latter  are,  as  we  will  learn,  exceedingly  common. 
Neurasthenic  vertigo  is  sometimes  almost  continuous,  and  is  then  a  very 
distressing  symptom,  and  one  of  the  most  difficult  to  treat.  More  frequently, 
however,  it  occurs  at  irregular  intervals.  It  may  follow  mental  or  physical 
effort,  such  as  reading,  writing,  unusual  bodily  exertion,  or  even  such  slight 
acts  as  moving  about  in  bed  or  the  taking  of  food.  It  is  a  symptom  of  fatigue. 
Further,  too  much  stress  cannot  be  laid  upon  the  frequency  of  its  occurrence 
in  neurasthenic  subjects.  It  is  extremely  probable  that  the  larger  number 
of  cases  of  vertigo,  certainly  the  milder  forms,  are  not  due  to  ear  or  other 
pei'ipheral  affections,  but  to  exhaustion  of  the  nerve-centres. 

Among  the  less  vague  sensory  symptoms  are  various  pains  which  affect  the 
head,  back,  and  limbs.  They  may  be  described  in  general  as  dull,  diffuse 
pains  or  aches,  which  in  the  milder  forms  suggest  the  sensations  of  simple 
fatigue.  It  is  extremely  probable,  moreover,  that  even  when  most  pro- 
nounced, they  are  nothing  more  than  exaggerated  fatigue  sensations.  Head- 
ache is  one  of  the  most  common  of  these  symptoms.  When  present  in  the 
milder  degree,  it  is  described  simply  as  a  dull  feeling  or  a  dull  aching.  As 
a  rule,  it  is  not  diffused  over  the  entire  head,  but  is  seated  in  the  occiput  and 
the  upper  part  of  the  back  of  the  neck,  or  over  the  brow,  or  just  above  the 
eyes.  Of  these  regions,  the  occipital  is  by  far  the  most  frequent.  Other 
situations  ai'e  occasionally  described,  but  it  is  probable  that  in  such  cases 
other  factors  secondary  in  value  come  into  play.  These  we  will  presently 
discuss.  "  Very  commonly  the  headache  is  accompanied  by  the  sense  of  pres- 
sure or  constriction,  already  mentioned,  and  the  patient  feels  as  though  a 


GENERAL  MORBID  STATES.  59 

tight  band  had  been  placed  around  the  head.  Various  other  anomalies  of 
sensation  are  occasionally  present.  For  instance,  patients  sometimes  com- 
plain of  great  heaviness,  or  of  throbbing  and  "whirling"  sensations  in  the 
head.  It  is  extremely  probable  that  these  curious  sensations  are,  many  of 
them,  if  not  all,  the  results  of  various  intracranial  circulatory  disturbances, 
and  are  not  directly  fatigue  sensations.  They  must,  therefore,  be  regarded 
as  adventitious.  "Lightness"  of  the  head  is  not,  as  a  rule,  associated  with 
aching,  but  rather  with  giddiness. 

Neurasthenic  headache,  when  mild,  disappears  upon  the  mere  cessation  of 
work.  The  average  statement  by  the  patient  is  that  mental  effort  of  any 
kind  brings  it  on,  or,  if  it  be  already  present,  leads  to  exacerbations.  It  may 
in  some  cases  be  so  severe  as  to  be  practically  continuous.  The  practitioner 
should  be  cautioned  not  to  confuse  it  with  attacks  of  migraine,  which  so 
often  complicate  neurasthenia.  Migraine  is  here,  as  elsewhere,  to  be  differen- 
tiated by  the  fact  that  it  occurs  in  paroxysms,  that  it  affects  chiefly  one  side  of 
the  head  and  face,  that  it  is  accompanied  by  more  or  less  marked  disturbances 
of  the  sympathetic  nervous  system,  such  as  flushing  or  pallor  of  the  affected 
side  and  contraction  or  dilatation  of  the  pupil,  and  still  further  by  the  occur- 
rence of  various  prodromal  symptoms. 

Backache  is  another  of  the  more  common  sensory  disturbances.  It  is  most 
frequently  referred  to  the  small  of  the  back,  though  occasionally  to  the  mid- 
scapular  region  or  to  the  sacrum.  It  also  is  pre-eminently  a  fatigue  sensation. 
It  is  dull  and  diflfiise  in  character  and  varies  greatly  in  degree.  Sometimes 
the  patient  finds  relief  by  lying  down  and  resting.  At  others  the  pain  is 
severe  and  constant.  Like  neurasthenic  headache,  it  is  brought  on  or  made 
worse  by  exertion.  Further,  we  should  be  careful  not  to  confound  neuras- 
thenic iDackache  Avith  the  backache  associated  with  diseases  of  the  uterus 
and  Ovaries.  The  latter  is  to  be  differentiated  by  gynecological  examination, 
and  also  by  the  difference  in  the  character  of  the  pain.  This,  it  will  be 
found,  is  described  rather  as  the  pain  of  constant  soreness  and  of  irritation, 
than  the  aching  of  fatigue.  Frequently,  however,  a  neurasthenic  patient  is 
at  the  same  time  the  victim  of  pelvic  disease,  and  in  such  instance  a  differen- 
tiation is  neither  possible  nor  necessary. 

Aching  in  one  or  more  limbs  is  occasionally  present  in  nervous  exhaustion, 
although  this  is  far  less  common  than  headache  or  backache.  When  present, 
it  is  described  as  dull  and  difflised,  and  may  affect  one  or  more  limbs.  Thus, 
in  a  case  for  some  time  under  the  writer's  care,  there  was  decided  aching  in 
both  legs.  The  patient,  who  was  a  collector,  was  in  the  habit  of  walking 
great  distances  daily.  Another  instance  was  that  of  a  young  woman  who  stood 
behind  a  counter  many  hours  every  day,  and  who,  in  addition  to  other  neur- 
asthenic symptoms,  developed  persistent  aching  in  the  left  leg.  This  pain 
was  so  pronounced  as  to  be  for  a  time  the  most  prominent  feature  of  the  case. 
It  yielded,  however,  quite  readily  to  rest  and  massage.  Occasionally  the 
aching  is  referred  to  a  joint,  or,  more  accurately  speaking,  to  the  neighbor- 
hood of  a  joint,  and  in  such  instance  care  should  be  taken  that  such  a  case 
be  not  mistaken  for  rheumatism,  organic  disease  or  hysteria.  An  example 
occurred  in  the  person  of  a  young  man  of  nineteen,  who  presented  himself  with 
an  aching  pain  in  the  right  wrist.  Examination  failed  to  elicit  increased  pain 
on  motion,  nor  were  there  other  evidences  of  joint  affection.  Evidences  of 
hysteria  were  also  wanting,  but  examination  did  elicit  various  signs  of  neur- 
asthenia. Finally  it  was  learned  that  in  his  occupation,  that  of  pocket-book 
maker,  the  right  hand  and  wrist  were  used  all  day  long  in  folding  leather.  It 
is  very  probable,  therefore,  that  the  pain  was  in  reality  a  fatigue  sensation. 
In  addition  to  aching,  or  sometimes  without  it,  there  may  be  present  in  the 
limbs  various  anomalies  of  sensation,  such  as  "throbbino-"  or  "thrilling." 


60  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Occasionally  the  patient  complains  of  tremulous  feelings,  although  tremor  is 
not  really  present.  It  is  probable  that  these  sensations  are  only  indirectly 
fatigue  phenomena,  and  that  they  depend  either  upon  circulatory  or  obscure 
nervous  disturbances.  So  regarded  they  merit  the  term  adventitious,  just  as 
do  the  various  sensory  anomalies  referred  by  patients  to  the  head. 

Leaving  now  the  vague  sensations  and  the  diifuse  achings,  we  come  to 
sensory  disturbances  much  more  definite  in  character.  First  among  these  is 
spinal  tenderness.  In  many  cases  of  neurasthenia,  we  find  that  the  patient 
flinches  when  we  pass  the  finger,  even  though  we  do  so  lightly,  over  the 
spinous  process.  The  patient  reacts  as  though  the  spine  and  the  skin  above  it 
were  hypereesthetic  or  tender  in  certain  places.  Patients  sometimes  complain 
of  this  condition  previous  to  examination,  having  made  the  discovery  for 
themselves.  Most  frequently,  however,  it  is  discovered  by  the  physician.  As 
it  is  revealed  by  a  slight  pressure  it  is  probable  that  its  seat  is  superficial. 
Indeed,  some  years  ago,  the  writer  demonstrated  the  fact  that  this  tender- 
neis  may  be  made  to  disappear  for  a  time  by  a  local  injection  of  cocaine. 
The  spine,  it  should  be  remembered,  is  not  tender  along  its  entire  length, 
but  only  in  certain  small  areas  or  spots.  These  are  found  preferably  in 
certain  situations,  more  especially  over  the  seventh  cervical  vertebra,  the 
mid-dorsal  region,  the  dorso-lumbar  juncture,  the  mid-lumbar  region,  the 
sacrum  or  the  coccyx.  Their  area  is  generally  very  small.  Frequently 
such  a  spot  can  be  covered  by  the  tip  of  the  thumb.  Occasionally,  how- 
ever, the  trouble  is  much  more  pronounced  and  serious.  There  may  be 
not  only  tenderness,  but  also  spontaneous  pain  which  seems  to  the  patient 
deep-seated,  as  though  it  involved  the  vertebrae  themselves,  and  is  variously 
described  as  "a  burning"  or  as  an  intense  "soreness."  It  is  increased  by 
pressure  and  movement.  Like  simple  backache,  it  may  be  so  slight  as  to 
be  relieved  by  lying  down,  or  it  may  be  so  severe  as  to  constitute  the  prin- 
cipal feature  of  the  case  and  may  dominate  all  of  the  other  symptoms.  It  is 
this  condition  which  has  given  rise  to  the  term  "spinal  irritation." 

Closely  allied  to  spinal  tenderness  is  cutaneous  hypersesthesia.  This  may 
exist  over  the  back,  the  sides  of  the  trunk,  the  front  of  the  chest,  the  epigas- 
trium, and  the  extremities.  The  scalp  may  become  exquisitely  sensitive ;  or 
the  face,  the  teeth,  the  gums,  the  nipple,  or  the  testicle  may  sufier.  It  is  also 
noteworthy  that  in  some  neurasthenics  a  trivial  wound  causes  an  amount  of 
pain  out  of  all  proportion  to  the  injury. 

Anaesthesia  is  never  present  in  simple  neurasthenia.  Patients,  however, 
frequently  complain  of  numbness  of  the  extremities.  This  numbness  is 
readily  provoked  by  slight  pressure  exerted  either  on  the  nerve  trunks  or 
in  their  immediate  neighborhood.  Thus,  if  a  neurasthenic  remain  in  a  fixed 
position  for  a  short  time,  such  as  sitting  with  the  knees  crossed  or  sitting 
upon  a  chair  with  the  backs  of  the  thighs  resting  upon  the  hard  edge,  he  may 
develop  numb  feelings  in  the  legs.  These  are  comparable,  no  doubt,  to  the 
"  asleep  "  or  "  pins  and  needle  "  feelings  which  prolonged  pressure  will  bring 
on  in  perfectly  healthy  persons.  These  numb  feelings  occur  in  some  neur- 
asthenics even  spontaneously  or  are  attributed  by  them  to  apparently  inade- 
quate causes,  such  as  the  weight  of  the  clothing  or  the  constriction  of  a  garter. 

The  disorders  of  cutaneous  sensibility  present  in  addition  various  strange 
symptoms,  adventitious  in  character,  and  comparable  in  every  way  to  the  anom- 
alies of  sensation  already  mentioned  in  discussing  the  general  sensory  disturb- 
ances. These  patients  often  complain  of  formication  or  prickling  sensations. 
Sometimes  these  are  described  as  "velvety."  Occasionally  the  patient  feels 
as  though  a  light  touch  were  being  passed  over  this  or  that  portion  of  the 
body  or  a?  though  water  were  flowing  over  the  side  of  the  face  or  over  a  por- 
tion of  a  limb ;  sometimes,  too,  there  is  a  subjective  sense  of  heat,  especially 


GENERAL  MORBID  STATES.  61 

between  the  shoulder-blades,  and  at  other  times,  though  more  rarely,  there 
is  a  subjective  sense  of  coldness  of  the  surface.  This  may  be  localized  and, 
rarely,  even  widely  difliised.  Sometimes  it  is  combined  with  the  sensation  of 
flowing  water  just  mentioned. 

Visual  Didurbances.  K ot  only  are  the  disturbances  of  the  general  and 
cutaneous  sensibilities  of  great  importance,  but  so  are  those  of  some  of  the 
special  senses,  notably  of  vision.  For  instance,  it  is  very  common  for  patients 
to  complain  that  they  are  not  able  to  read  for  more  than  a  few  minutes, 
and  that  if  they  persist  for  any  length  of  time  the  letters  become  blurred  and 
indistinct.  Frequently  they  tell  us  that  they  cannot  sew,  cannot  write,  or, 
in  fact,  perform  continuously  any  work  which  requires  close  or  persistent  use 
of  the  eyes.  Such  use,  if  attempted,  is  followed  sooner  or  latter  by  head- 
ache, or,  it  may  be,  by  vertigo,  or  by  a  sensation  of  painful  tension  in  the 
eyes  themselves.  Hand-in-hand  with  this,  vision  becomes  difficult.  The  first 
symptom,  therefore,  which  the  function  of  vision  in  neurasthenics  presents  is 
weakness.  A  moment's  reflection  will  convince  us  that  this  weakness  may 
be  made  up  of  different  elements.  First,  the  cerebral  centres  themselves 
may  be  so  asthenic,  may  be  so  readily  exhausted,  as  to  unfit  them  for  the 
reception  of  impressions  for  any  but  an  exceedingly  short  period  of  time. 
This  form  of  visual  weakness  is  probably  connected  with  the  mental  confu- 
sion, the  headache,  the  vertigo,  and  other  symptoms  of  intracranial  distress 
that  follow  in  certain  cases  attempts  at  reading. 

Secondly,  there  may  be  a  loss  of  working  power  in  the  retina,  and  also  in 
the  accomicQodative  apparatus  of  the  eye  itself.  As  regards  the  retina,  the 
weakness  may  make  its  appearance  in  two  different  ways  ;  there  may  be,  in 
one  instance,' a  loss  of  power  to  appreciate  continuously  a  small  object  held 
at  convenient  focal  distance  from  the  eye.  This  is  observed  every  now  and 
then  in  examining  a  neurasthenic  patient  with  the  perimeter.  The  point  of 
fixation  readily  seen  at  first  becomes,  as  the  examination  progresses,  less  and 
less  distinct,  uiatil  finally  it  disappears  altogether.  After  a  fe^y  minutes'  rest 
it  mayjeturn,  but  only  to  disappear  again.  This  phenomenon  is  undoubtedly 
a  fatigue  symptom,  and  must  be  referred  directly  to  the  macula  lutea.  It 
must,  of  course,  be  distinguished  from  the  similar  fatigue  symptom  observed 
in  healthy  persons  by  remembering  that  in  the  latter  it  is  noted  only  after  a 
very  prolonged  effort.  Retinal  weaknass  may  also  show  itself  by  a  change 
in  the  visual  field.  The  latter  may  be  slightly  diminished  or  contracted,  as 
though  the  peripheral  portions  of  the  retina  were  less  sensitive  than  they 
should  be.  It  not  infrequently  happens  in  the  beginning  of  an  examina- 
tion that  the  answers  given  by  the  patient  indicate  a  normal  field ;  indeed, 
this  is  true  of  the  majority  of  neurasthenic  cases.  However,  as  the  exam- 
ination progresses,  or  if  the  tests  be  frequently  repeated,  the  answers  be- 
come less  and  less  certain  as  regards  the  periphery,  until  finally  the  picture 
of  a  contracted  visual  field  is  produced.  It  thus  appears  that  the  con- 
tracted visual  field  of  neurasthenic  patients  is  in  reality  a  fatigue  symptom. 
This  is  rendered  the  more  probable  when  the  ordinary  method  of  taking- 
the  field,  that  is,  moving  the  test-object  from  the  periphery  to  the  centre,  is 
reversed,  and  the  test-object  is  moved  fi'om  the  centime  to  the  periphery. 
The  field  obtained  is  apt  to  be  much  smaller  than  by  the  ordinary  method, 
for  by  starting  from  the  centre  the  retina  is  fatigued  long  before  the  periph- 
eral portions  are  reached. 

In  some  patients  the  eyes  present  in  addition  also  slight  hj^Dersesthesia. 
They  seem  to  be  somewhat  sensitive  to  bright  light.  The  hvperfesthesia  is 
apparently  retinal,  and  may  be  so  marked  as  to  lead  the  patient  to  remain 
indoors  or  to  lead  him  to  begin  voluntarily  the  use  of  smoked  glasses. 

It  appears  from  the  above  considerations  that  the  sense  of  sight  presents 


62  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  same  symptoms  as  are  found  elsewhere  in  neurasthenia,  namely,  weak- 
ness and  irritability.  In  addition,  there  is  present  in  a  very  large  number 
of  cases  a  lessening  in  the  power  of  accommodation.  This,  also,  is  a  fatigue 
symptom,  and,  like  its  congeners,  inconstant  and  variable.  Its  presence  is 
related,  not  only  to  the  amount  of  work  execu.ted  by  the  eyes  themselves, 
but  also  to  the  general  condition  of  the  patient.  The  muscles  of  accommo- 
dation reflect  more  or  less  accurately  the  general  tonus  of  the  other  muscles 
of  the  body,  and  especially  is  this  the  case  in  neurasthenics,  in  whom  irrita- 
bility goes  hand-in-hand  with  weakness.  We  can  understand,  therefore,  that 
independently  of  the  condition  of  the  eye  the  accommodative  power  may 
rise  or  fall  according  to  the  condition  of  the  patient.  Further,  it  is  very 
probable  that  the  fatigue  of  the  eyes,  so  easily  brought  on  in  neurasthenics, 
is  due  especially  to  the  weakness  of  the  accommodative  apparatus  and  to  but 
a  slight  extent  to  exhaustion  of  the  retina.  Further,  inasmuch  as  the  con- 
vergence of  the  eyes,  necessitated  in  accommodation  to  near  objects,  severely 
taxes  the  internal  recti,  the  latter  reveal  every  now  and  then  a  slight  in- 
sufficiency.    This,  it  need  hardly  be  said,  is  also  a  fatigue  symptom. 

From  what  has  been  said  we  can  readily  understand  that  the  oculist  should 
frequently  be  unable  to  find  defects  in  the  eye  itself  or  that  he  should  fail  to 
find  in  its  apparatus  of  accommodation  or  in  its  extrinsic  muscles  sufficient 
anomalies  to  account  for  the  symptoms  presented.  Indeed,  it  not  infre- 
quently happens  that  the  eye  examination  is  practically  negative,  and  that 
the  defects  discovered  are  so  slight  as  hardly  to  justify  correction. 

Besides  the  various  eye  symptoms  already  discussed,  neurasthenics  may 
present  others  not  so  easy  of  interpretation.  Patients  will  sometimes  say 
that  "  everything  appears  misty,"  or  as  though  objects  were  seen  through 
a  veil ;  or  they  may  even  have  attacks  during  which,  for  a  brief  instant, 
vision  is  lost.  Sometimes,  too,  they  will  say  that  everything  looks  dull  or, 
perhaps,  exceedingly  bright ;  or  that  familiar  neighborhoods  look  strange,  or 
familiar  faces  unnatural ;  that  near  objects  look  as  though  far  away,  or  that 
they  appear  excessively  small  or  excessively  large.  In  part,  these  curious 
anomalies  of  sensation  are  to  be  referred  to  the  disturbed  nutrition  of  the 
retina,  but  the  greater  number  are  doubtless  due  to  disordered  action  of  the 
nerve  centres.     They  are  clearly  adventitious  in  character. 

The  pupillary  phenomena  of  neurasthenia  are  also  interesting  and  signifi- 
cant. As  a  general  thing  the  pupils  are  rather  large,  sometimes  markedly 
so.  They  may  also  react  less  promjitly  to  light.  Hippus,  that  is,  alternate 
contraction  and  dilatation  of  the  pupil,  is  also  frequently  observed  in  neuras- 
thenics, especially  under  excitement.  It  may  occur  independently  of  light 
stimulation.  When  marked  it  is  almost  always  accompanied  by  exaggeration 
of  the  knee-jerks.  Inequality  of  the  pupils  is  also  observed  in  neurasthenia, 
but  it  is  ahvays  transient  in  character.  Permanent  inequality  of  the  pupils, 
of  course,  suggests  organic  disease.  The  observer  should,  however,  bear  in 
mind  the  existence  of  slight  physiological  inequalities.  Fixed  or  contracted 
pupils  also  suggest  organic  disease.  If  present  the  symptoms  of  locomotor 
ataxia,  or  of  grave  cerebral  disease,  such  as  j)aretic  dementia,  should  be 
sought  for. 

Disorders  of  Hearing.  Comparable  to  the  various  symptoms  of  weakness 
presented  by  the  visual  sense,  we  would  expect,  pei'haps,  to  meet  with  more 
or  less  disturbances  of  hearing.  Deafness,  properly  speaking,  does  not  obtain, 
and  an  examination  of  the  ear  is  frequently  negative,  just  as  is  the  corre- 
sponding examination  of  the  eye.  However,  a  patient  will  frequently  say,  "  I 
cannot  hear  right.  There  is  something  the  matter  with  my  ears."  Symptoms 
of  hypereesthesia,  less  often  present  among  the  visual  phenomena,  are  very 
frequently  met  with  here.     Patients  suffer  exquisitely  from  noises  even  when 


GENERAL  MOBBIT)  STATES.  63 

the  latter  are  insignificant.  On  this  account  they  will  sometimes  isolate  them- 
selves in  secluded  rooms  of  their  homes,  and  even  then  may  find  no  relief. 
Various  parsesthesias,  comparable  to  the  adventitious  symptoms  observed  in 
visual  sense,  are  also  observed  here.  They  are,  however,  far  more  distressing. 
They  consist  of  various  forms  of  tinnitus,  and  are  described  by  the  patients 
as  "  roaring,"  "  bvizzing,"  "  whistling,"  or  "  ringing,"  and  at  other  times  as 
"throbbing,"  "beating,"  "pulsating,"  or  "ticking"  sounds.  They  are 
brought  on  by  fatigue,  either  mental  or  physical.  These  symptoms  are  often 
among  the  most  distressing  and  persistent  from  which  the  patient  sufiers. 

Disorders  of  Smell.  Disorders  of  the  sense  of  smell  are  very  uncommon. 
However,  impairment  or  loss  of  smell  is  sometimes  noted  in  traumatic 
neurasthenia.  Occasionally,  also,  we  have  symptoms  of  olfactory  hyper- 
sesthesia.  In  such  instances  the  patient  is  excessively  sensitive  to  odors.  He 
will  complain  of  the  odors  of  flowers,  of  the  odors  of  the  kitchen,  or  of  vari- 
ous perfumes,  even  when  these  are  barely  perceptible  to  others.  It  is  not 
improbable,  too,  that  patients  sometimes  experience  olfactory  parsesthesias,  and 
are  annoyed  by  disagreeable  odors  which  apparently  have  no  existence. 

Disorders  of  Taste.  Disorders  of  taste  are  somewhat  more  common  than 
those  of  smell.  Patients  will  sometimes  say  that  they  cannot  taste  anything  ; 
that  everything  "tastes  like  sawdust,"  or  "tastes  queer."  More  frequently 
they  will  complain  of  bitter,  salty,  sweet,  or  acid  tastes.  The  latter  are  in 
part  actual  parsesthesias,  and  in  part  due  to  disordered  secretions.  Occa- 
sionally some  one  article,  like  bread,  presents  an  altered  taste  ;  or,  it  may  be, 
that  an  entire  class  of  foods,  e.  g.,  animal  foods,  acquire  a  peculiar  and  often 
offensive  flavor. 

Psychic  Disturbances.  Among  the  most  interesting  symptoms  of 
neurasthenia  are  the  psychic  disturbances.  Considerable  confusion  has  ex- 
isted with  regard  to  them,  but  we  will  find  that  they  are  easy  of  comprehen- 
sion, and  that  they  arrange  themselves  into  a  natural  order.  At  the  outset 
we  meet  with  a  marked  and  characteristic  symptom,  namely,  a  diminution  in 
the  capacity  for  sustained  intellectual  effort.  Just  as  the  patient  is  incapable 
of  long-continued  physical  labor,  so  is  he  incapable  of  long-continued  mental 
labor.  The  attempt  to  do  mental  work  sooner  or  later  brings  on  symptoms 
of  exhaustion.  A  certain  task  may  be  properly  begun,  but  soon  the  patient 
experiences  difficulty  in  keeping  the  attention  fixed  ujDon  it.  Gradually  this 
difficulty  increases  until  at  last,  instead  of  clear  and  distinct  ideas,  vague 
and  confusesd  impressions  alone  obtain.  At  the  same  time,  painful  sensations 
about  the  head  arise,  such  as  tightness,  headache,  giddiness,  and  even  vertigo. 

The  difficulty  of  concentrating  the  attention  may  be  so  great  as  to  lead  to 
an  habitual  state  of  distraction  and  inattention.  Hand-in-hand  with  this 
there  arises  a  more  or  less  marked  dislike  for  intellectual  labor.  The  patient 
finds  that  he  must  force  himself  to  his  work,  and  is  often  tempted  to  seek 
temporary,  though  treacherous,  aid  in  stimulants.  Naturally  the  patient 
becomes  alarmed,  and  he  complains  to  the  physician  that  he  is  "  losing  his 
memory,"  or  that  he  is  "  losing  his  mind."  Indeed,  the  phrase  "  loss  of 
memory"  is  one  of  the  most  common  expressions  used  by  neurasthenics. 
However,  it  is  obviously  incorrect.  A  patient  will  give  a  most  circumstantial 
history  of  his  case,  not  omitting  unimportant  details,  and  will  in  other  ways 
show  that  there  is  actually  no  impairment  of  memory  whatever.  The  diffi- 
culty really  consists  in  a  lack  of  the  power  of  concentrating  the  attention. 
The  patient  does  not  remember,  because  he  has  really  never  comprehended, 
or,  more  properly  speaking,  has  never  apperceived  that  which  he  has  read  or 
heard. 

Mental  fatigue  is  also  evidenced  by  a  number  of  other  symptoms.  For 
instance,  ideas  do  not  seem  to  present  themselves  as  readily,  or  in  the  same 


64  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

rapid  succession  as  in  health.  There  is,  so  to  speak,  a  lack  of  spontaneity  in 
thought,  and  this  the  patient  himself  well  recognizes,  often  saying,  "  I  cannot 
think."  There  is  also  in  these  patients  an  undoubted  lessening  in  the 
strength  of  the  will.  The  patient  does  not  feel  the  stimulus  to  exertion,  and 
is  even  convinced  at  times  that  effort  is  useless.  He  believes  that  he  can 
accomplish  nothing  ;  he  has  no  courage,  no  confidence  in  himself.  Associated 
with  this  state  is  also  a  lack  of  decision.  The  patient  is  frequently  so  vacil- 
lating that  it  is  necessary  for  his  friends  to  decide  the  most  trivial  matters 
for  him. 

Added  to  the  other  symptoms,  we  have  more  or  less  marked  irritability. 
The  most  trifling  causes  often  excite  and  anger  the  neurasthenic  patient. 
He  is  also  apt  to  be  morbidly  sensitive,  and  often  feels  intensely  hurt  by 
fancied  neglect  or  oversight  on  the  part  of  relatives  or  friends.  He  expe- 
riences changes  in  the  emotions  more  readily  than  in  health.  Thus,  totally 
inadequate  causes  may  provoke  marked  depression,  and  at  other  times 
laughter.  A  play  at  the  theatre  or  a  newspaper  account  of  a  murder  may 
provoke  him  to  tears.  In  other  words,  his  emotional  equilibrium  is  readily 
disturbed.  This  condition  differs  from  the  similar  state  observed  in  hysteria 
in  that  the  exciting  causes  for  the  emotional  changes  are  always  such  as 
would  produce  the  same  emotion  in  health,  though  to  a  far  less  degree.  In 
hysteria  this  rule  does  not  apply. 

The  patient  is  also  introspective.  The  various  disturbances  of  sensation 
which  he  experiences  more  and  more  alarm  him  until,  finally  he  is  habitually 
on  the  alert  for  suspicious  symptoms.  He  thinks  because  he  has  attacks  of 
palpitation  of  the  heart  that  he  has  incurable  heart-disease,  or  because  he 
feels  the  throbbing  of  a  pulsating  aorta  that  he  has  a  tumor  or  an  aneurism,  or 
because  his  urine  is  cloudy,  possibly  from  phosphates,  that  he  has  spermator- 
rhoea. The  patient  suffers  from  nosophobia.  The  associated  mental  depres- 
sion is  sometimes  so  profound  as  to  suggest  true  hypochondria.  It  is,  how- 
ever, important  to  remember  that  the  mental  depression  of  neurasthenia  differs 
from  true  hypochondria  in  that  the  patient  can  be  more  or  less  readily  con- 
vinced by  the  physician  that  he  is  not  the  subject  of  any  organic  disease ; 
that  there  is  really  no  organic  heart  affection,  no  aneurism,  no  real  spermator- 
rhoea. In  other  words,  in  simple  neurasthenia  the  patient  still  has  the  power 
of  appreciating  evidence  regarding  his  case  when  properly  presented.  He 
is  not  the  victim  of  actual  delusions.  Unfortunately,  however,  patients  are 
met  with  who  have  so  far  transgressed  the  limits  of  mental  health  that  the 
belief  in  some  special  disease  is  definite  and  fixed,  and  who  sometimes  weave 
about  this  belief  a  series  of  more  or  less  systematized  delusions.  It  is  unneces- 
sary to  say  that  such  cases  suffer  from  actual  insanity  and  not  from  simple 
neurasthenia.  Indeed,  we  not  infrequently  find  in  this  class  of  patients  a 
more  or  less  marked  neuropathic  family  history. 

In  addition  to  the  irritability  and  the  mental  depression  exhibited  by  many 
patients,  they  sometimes  show  a  distinct  loss  of  the  sense  of  the  proprieties. 
While  morbidly  sensitive  themselves,  they  do  not  hesitate  to  discuss  in  the 
presence  of  non-medical  persons  their  most  intimate  symptoms  in  greatest 
detail,  and  often  using,  in  order  to  make  themselves  clear,  expressions  that 
are  not  only  offensive  to  the  ears,  but  often  absolutely  disgusting.  It  is  not 
improbable  that  this  condition  is  the  result  of  the  constant  introspection  and 
the  constant  dwelling  upon  nosophobic  ideas. 

Among  other  changes,  too,  we  notice,  now  and  then,  a  distinct  lessening  in 
the  affection  for  near  relatives,  so  much  so  that  it  attracts  the  attention  of 
the  latter.  Sometimes  this  condition  is  brought  to  the  attention  of  the  phy- 
sician by  the  patient  himself,  who  may  say,  "I  no  longer  care  for  my 
mother,"  or  "I  no  longer  care  for  my  children  as  I  should."     At  the  same 


GENERAL  MORBID  STATES.  65 

time,  if  the  question  be  radically  tested,  the  patient  will  usually  react  in  a 
normal  manner,  though  perhaps  in  a  lessened  degree. 

Not  only  does  the  patient  lack  the  capacity  for  sustained  intellectual  labor, 
not  only  is  he  irritable  and  depressed,  but  he  frequently  presents,  in  addition, 
the  symptoms  of  an  apparently  causeless  fear.  That  fear  and  weakness 
should  go  together  is  natural.  Everywhere  in  nature  they  are  associated. 
That  a  person  whose  nervous  system  is  exhausted  should  also  be  morbidly 
afraid  is,  therefore,  not  surprising.  We  find,  too,  as  we  study  our  cases,  that 
this  emotion  varies  greatly  in  character  and  degree.  It  may  be  vague  and 
ill  defined,  and  may  consist  merely  of  a  general  feeling  of  anxiety.  More 
frequently,  however,  it  takes  definite  shape,  or  comes  on  acutely  at  certain 
times.  Often  it  is  associated  with  striking  visceral  symptoms.  One  of  the 
most  common  forms  is  a  fear  which  in  some  patients  accompanies  attacks 
of  palpitation  of  the  heart.  The  emotion  is  often  so  great  as  to  give  rise  to 
the  most  marked  outward  signs.  In  some  cases  it  is  apparently  the  direct 
outcome  of  the  heart  symptoms,  the  patient  believing  that  he  has  some  serious 
organic  disease  and  that  death  itself  is  threatening.  Similarly  a  patient  with 
sudden  and  strange  sensations  in  the  head  may  fear  death  by  apoplexy,  while 
another  with  sinking  and  other  distressing  sensations  in  the  epigastrium,  asso- 
ciated with  an  attack  of  acute  indigestion,  may  feel  as  though  he  were  about 
to  die  of  utter  weakness. 

In  other  cases  attacks  of  fear  occur  spontaneously  and  independently  of 
visceral  disturbances.  In  this  instance  the  fear  seems  to  be  of  purely  nerv- 
ous origin,  and  while  somatic  symptoms  are  frequently  present  they  are  alto- 
gether secondary.  The  patient  has  no  idea  of  threatening  death  from  heart, 
brain,  or  other  disease,  but  simply  experiences  a  sense  of  fear  which  is  un- 
complicated, and  which  may  be  slight  or  so  intense  as  to  be  hoi'rible  and 
overwhelming.  If  the  attack  be  severe  the  limbs  become  relaxed,  the  patient 
sinks  into  a  chair,  or  may  even  fall  to  the  ground.  The  face  becomes 
pale,  the  body  moist  with  a  cold  sweat,  the  pulse  small  and  rapid,  and  the 
respiration  hurried  and  irregular.  As  in  intense  fright  from  other  causes^ 
the  sphincters  may  even  become  relaxed,  and  the  bladder  and  the  bowels- 
spontaneously  voided.  Attacks  of  such  severity  are  uncommon.  More  fre- 
quently they  are  of  such  a  character  that  the  patient  is  able  to  conceal  them 
or  to  disguise  their  nature.  It  should  be  remarked  in  this  connection  that, 
patients  rarely  mention  voluntarily  the  various  symptoms  of  fear  which  they 
experience. 

In  addition  to  the  two  forms  of  fear  above  mentioned,  namely,  the  fear 
having  its  origin  in  visceral  disturbances  and  spontaneovis  fear,  we  have  attacks, 
occur  which  are  associated  more  or  less  closely  with  certain  definite  or  fixed 
ideas.  Thus,  a  neurasthenic  patient  may  experience  a  morbid  fear  when  left 
alone,  or  he  may  experience  fear  in  the  presence  of  strangers  or  of  crowds ; 
or  he  may  be  attacked  by  fear  in  the  dark  or  in  his  own  room  or  in  the  open 
street.  These  special  fears  find,  as  Bouveret  truly  claims,  a  fitting  analogue 
in  the  fear  which  healthy  persons  experience  when  standing  at  a  great  height, 
even  though  they  may  be  in  a  perfectly  safe  position.  It  is  exceedingly  prob- 
able that  in  neurasthenia  the  faculties  are  so  weakened  that  ordinary  sur- 
roundings no  longer  give  a  sense  of  security.  Fear  is  therefore  a  natural 
consequence.  It  is  doubtless  in  this  way  that  spontaneous  fear  arises  in  the 
healthy  person  when  the  latter  looks  down  from  a  great  height.  He  misses 
the  security  of  his  ordinary  surroundings.  As  might  be  expected,  a  large 
number  of  these  sj^ecial  forms  of  fear  have  been  described.  Thus,  the  fear 
which  comes  on  spontaneously  in  some  neurasthenics  when  they  find  them- 
selves in  open  places  is  called  agoraphobia.  The  fear  which  comes  on  in 
narrow  or  closed  places,  claustrophobia ;  the  fear  of  being  alone,  monopjhobia; 

5 


QQ  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  fear  of  crowds,  anthropophohia ;  the  fear  of  darkness,  nydophohia ;  the 
fear  of  storms,  astropjhohia ;  the  fear  of  special  localities,  topophohia.  Certain 
neurasthenics,  perhaps  as  a  result  of  some  partesthesia  of  cutaneous  sensi- 
bility, feel  as  though  they  were  being  contaminated  by  everything  they  touch. 
This  fear  has  been  termed  mysophobia,  or  the  fear  of  filth.  Persons  who  have 
become  neurasthenic  by  the  shock  and  fright  of  railway  accidents  often  suffer 
from  attacks  of  fear  on  seeing  or  hearing  a  train  of  cars,  and  often  find  it,  on 
this  account,  impossible  to  travel  on  railways.  This  form  of  fear  has  been  called 
siderodromophobia.  It  can  be  readily  seen  that  these  names  could  be  multi- 
plied almost  Avithout  end.  For  instance,  Bouveret  has  called  the  fear  which 
comes  on  in  some  neurasthenics  on  assuming  the  upright  position  stasophobia; 
and  Beard  has  even  framed  such  expressions  as  pJwbophobia,  fear  of  fears, 
and  pantophobia,  fear  of  everything.  Unfortunately  these  names,  while  they 
define  certain  morbid  fears,  often  give  rise  to  the  impression  that  all  of  these 
various  forms  are  intrinsically  different,  and  also  that  they  are  actual  psychoses. 
Indeed,  they  are  often  so  considered,  the  error  arising  from  the  fact  that  simi- 
lar morbid  fears  also  occur  in  the  insane. 

Among  the  most  important  symptoms  still  to  be  considered  is  insomnia.  It 
is  sometimes  one  of  the  earliest  of  the  symptoms  presented.  It  varies  greatly 
in  degree.  A  patient  may,  for  instance,  find  it  difficult  to  fall  asleep,  or  the 
sleep  may  be  so  light  that  the  slightest  sound  awakens  him,  and  the  night 
may  be  spent  in  alternately  falling  asleep  and  waking.  More  commonly, 
however,  the  patient  falls  asleej^  readily,  but  finds  that  he  awakes  at  an  earlier 
hour  than  usual,  and  further  that  his  sleep  has  not  been  refreshing.  If  the 
insomnia  becomes  more  pronounced,  the  hours  of  sleep  become  progressively 
shorter,  the  patient  awaking  earlier  and  earlier  until  at  last  a  few  hours  or  a 
few  minutes  may  constitute  the  entire  sleep ;  or  he  may  even  pass  nights  and 
days  in  succession  without  any  sleep  whatever.  As  a  rule,  such  sleep  as  is 
obtained  is  light ;  occasionally  it  is  heavy  and  profound.  In  every  instance, 
however,  the  patient  feels  unrefreshed  on  wakening ;  indeed,  the  various 
fatigue  sensations  are  more  pronounced  than  ever.  He  will  frequently  say 
to  the  doctor  that  he  feels  completely  exhausted  on  awakening ;  that  he  feels 
as  though  he  had  worked  hard  all  night.  After  taking  breakfast  the  feeling 
of  fatigue  is  somewhat  relieved,  and,  as  a  rule,  it  becomes  less  marked  as  the 
morning  advances.  Xot  only  are  neurasthenic  patients  troubled  with  insom- 
nia, but  they  frequently  dream  a  great  deal.  They  seem  to  rehearse  in  their 
sleep  the  various  experiences  of  the  day.  More  often  the  dreams  are  of  an 
unpleasant  character,  the  patient  dreaming  of  murders,  of  horrible  occurrences 
and  of  terrible  accidents,  and  while  so  doing  may  wake  up  suddenly  in  a 
paroxysm  of  fright.  Startling  dreams,  that  is,  dreams  attended  with  fright, 
are  verv  common  in  neurasthenia  of  traumatic  origin.  Eegarding  the  amount 
of  sleep  and  also  its  character,  the  physician  should  be  cautioned  about  always 
accepting  the  statements  of  the  patients.  One  of  the  most  common  errors 
made  by  neurasthenics  is  in  relation  to  the  amount  of  sleep  actually  obtained. 

We  have  in  neurasthenics  now  and  then  peculiarities  of  speech,  and  even 
of  handwriting,  to  which  it  is  well  to  allude  for  a  moment.  Patients  some- 
times speak  slowly  and  enunciate  their  words  in  a  slurred  and  slovenly  man- 
ner. There  is  nothing,  however,  in  their  manner  of  speaking  which  is  in  any 
way  comparable  to  the  halting  or  scanning  speech  found  among  the  insane. 
When  asked  to  speak  clearly  they  always  prove  their  ability  to  do  so.  We 
are  frequently  impressed  with  the  fact  that  they  talk  as  though  they  Avere 
tired,  and  that  for  this  reason  they  do  not  articulate  properly.  Even  the 
voice  seems  to  have  a  tired  ring.  Patients  are  also  seen  who  speak  too  rapidly 
and  run  their  words,  syllables,  and  even  their  phrases  together. 

As  regards  the  handwriting,  peculiarities  are  noticed  not  so  much  in  the 


GENERAL  MORBID  STATES.  67 

writing  demanded  by  the  daily  occnpation,  as  in  letters  to  relatives  and  friends. 
In  the  latter  it  is  apt  to  be  hasty,  jerky,  and  irregular.  Occasionally  both 
words  and  letters  are  incompletely  formed,  and  here  and  there  letters,  sylla- 
bles, and  even  whole  words  may  be  omitted.  A  letter  so  written  is  like  the 
speech,  merely  slurred  and  slovenly,  and  is  of  itself  no  evidence  of  insanity, 
because  the  patient  himself  is  fully  conscious  of  the  errors  that  he  makes,  and 
because  other  letters  demanding  care  and  accuracy,  e.  g.,  business  letters,  are 
written  properly. 

General  Somatic  Disturbances.  These  consist  of  disturbances  of  diges- 
tion, of  circulation,  of  secretion,  and  of  the  sexual  functions. 

Digestive  Disturbances.  The  digestive  disturbances  of  neurasthenia  are 
of  peculiar  importance.  They  are  among  the  most  common  of  the  symptoms 
presented,  among  the  most  distressing  to  the  patient,  and  among  the  most 
difficult  for  the  physician  to  treat.  They  are  sometimes,  though  infrequently, 
but  slightly  pronounced  ;  at  other  times  so  severe  as  to  be  suggestive  of  organic 
disease.  As  elsewhere  the  first  symptom  that  we  meet  is  weakness.  The 
j^atient  having  taken  a  moderate  quantity  of  food  feels  at  first  no  special 
distress ;  but  after  the  lapse  of  a  greater  or  smaller  interval  of  time,  sensa- 
tions of  weight,  of  oppression,  and  of  general  discomfort  about  the  epigas- 
trium make  their  appearance.  Sometimes  they  are  accompanied  by  a 
sensation  of  distention,  and  an  examination  will  often  disclose  an  excess  of 
gas  in  the  stomach.  Frequently  the  condition  is  attended  by  eructations. 
If  the  case  be  more  ]3ronounced,  in  addition  to  the  mere  sense  of  weight 
and  oppression,  pain  is  referred  to  the  epigastrium,  and  also,  at  times,  to 
the  back  betAveen  the  shoulder-blades.  If  we  examine  the  epigastrium  we 
find  that  it  is  slightly  sensitive  to  pressure.  It  is  not,  however,  paintlil  as 
in  inflammation,  ulcer,  or  other  organic  trouble ;  nor,  do  we  find  that  the 
stomach  is  dilated,  but  simply  distended.  The  tongue  is  clean,  or  at  most 
but  slightly  coated.  If  the  gastric  juice  be  examined,  analysis  may  reveal 
no  marked  change  in  the  amount  of  pepsin  or  hydrochloric  acid  present. 
Frequently,  however,  a  more  or  less  decided  diminution  in  the  amount  of 
free  acid  is  noted,  and  at  times,  indeed,  the  latter  may  be  entirely  absent. 
Thus  far  the  trouble  is  still  purely  functional.  Digestion  is  much  delayed, 
and  often  the  stomach  is  not  emptied  before  it  is  time  to  take  the  next  meal. 
Nausea  may  be  present,  but  vomiting  is  quite  rare.  This  atonic  indigestion 
is  not  always  limited  to  the  stomach,  but  may  involve  the  intestine.  In  such 
cases. there  is  more  or  less  meteorism.     Constipation  is  the  rule. 

Patients  suffering  from  even  this  mild  form  of  gastro-intestinal  neuras- 
thenia, or  nervous  dyspepsia,  as  it  is  more  commonly  termed,  are  subject  to 
attacks  of  palpitation  of  the  heart,  the  attacks  coming  on  when  the  indiges- 
tion is  at  its  height.  If  the  trouble  continue  for  some  time,  mental  depres- 
sion with  nosophobia  sooner  or  later  appears.  Occasionally  during  an  attack 
of  indigestion  the  patient  feels  heavy  and  sleepy  and  entirely  incapacitated 
for  intellectual  or  physical  eflbrt.  Frequently  the  indigestion  is  accompanied 
by  giddiness.  The  appetite  is  apt  to  be  capricious.  If  there  be  marked 
mental  depression  it  is  diminished,  but  every  now  and  then  it  is  increased. 
Further,  the  j)atient,  after  taking  food,  feels  unsatisfied,  or,  after  the  lapse  of 
half  an  hour  or  an  hour,  feels  as  though  he  had  not  had  his  regular  meal. 
As  a  rule,  neurasthenic  patients  consume  but  little  fluid.  Infrequently,  how- 
ever, thirst  is  increased. 

In  neurasthenia  of  long  standing  digestive  disturbances  are  far  more  pro- 
nounced. Shortly  after  ingesting  food,  the  patient  experiences  a  sense  of 
weight  and  discomfort,  together  with  marked  distention  and  oppression  in  the 
epigastrium.  Frequently  it  happens  that  eructation  is  grossly  insuflicient  or 
does  not  occur  at  all,  or  only  after  very  prolonged  and  distressing  intervals. 


68  NEEVOrS  DISEASES  AND  THEIR  TBEATMEXT. 

At  times  it  t\"ou1c1  seem  as  tlioiigh  there  -were  a  veritaljle  spasm  of  the  cardiac 
opening  -wliich  prevented  the  escape  of  the  gas.  When  making  a  physical 
examination  of  such  a  case  Tve  sometimes  find  that  distention  is  so  marked  as 
to  approach  actual  dilatation.  During  eructations  portions  of  the  contents  of 
the  stomach  may  be  carried  into  the  oesophagus,  and  thus  give  rise  to  the 
familiar  symptoms  of  heartburn  or  pyrosis.  AVhile  in  a  large  number  of 
cases  the  indigestion  is  marked  by  a  greatly  diminished  quantity  or  even 
absence  of  hydrochloric  acid,  there  are  instances  in  "^hich  this  acid  seems  to 
be  in  excess,  and  others,  agaiu,  in  which  butyric,  lactic,  and  other  acids  are 
present  as  the  result  of  fermentation.  The  tongue  in  cases  of  this  kind  Ls  coated, 
and  there  is  more  or  less  tenderness  of  the  epigastrium.  "We  now  have  the  evi- 
dences of  an  actual  gastric  catarrh.  In  other  words,  the  atonic  indigestion 
noted  in  simple  cases  of  neurasthenia  becomes  gradually  more  and  more  aggra- 
vated, and  finally  leads  to  more  or  less  marked  structural  changes.  The  intes- 
tinal distention  and  meteorism  present  are  also  apt  to  be  accompanied  by 
transient  pains,  and,  in  addition,  the  abdomen  may  also  be  decidedly  sensitive 
to  pressure.  At  times  patients  suffer  from  attacks  of  pain  in  ceitain  places,  as 
the  ileo-csecal  region,  and  also  at  the  junction  of  the  transverse  and  descend- 
ing colon.  These  attacks  are  evidently  due  to  collections  of  gas,  and  appear 
to  be  associated  with  paralytic  distention  in  one  part  of  the  bowel,  together 
■with  spasm  in  another.  Hand- in-hand  with  this,  constipation  is  generally 
verv  marked,  the  contents  being  often  completely  dry  and  exj^elled  only  with 
great  difficulty.  At  other  times,  instead  of  constipation,  there  is  present  a 
diarrhoea  of  relaxation.  Frequently,  too,  in  these  patients,  evacuation  of  the 
bowels  is  attended  by  a  sense  of  nervous  exhaustion,  the  patient  being  often 
completely  prostrated  and  compelled  to  lie  down  after  each  movement.  Oc- 
casionally mucous  colitis,  in  which  the  patient  passes  more  or  less  frequently 
masses  of  fibrinous  or  mucous  exudation  fr'om  the  bowel,  is  present.  The  dry 
contents  of  the  bowel  are  voided  covered  with  this  material,  or  it  may  be  that 
this  substance  is  passed  in  large  quantities  during  attacks  simulating  diarrhoea. 
Circukdory  Disturbances.  The  disturbances  of  the  circulatory  apparatus 
consist  in  modifications  of  the  force  and  rhythm  of  the  heart's  action,  in  the 
character  and  fr-equency  of  the  puLse,  and  in  more  or  less  marked  altera- 
tions of  vasomotor  tonus.  Perhaps  the  most  striking,  if  not  indeed  the  most 
common,  svmptom  of  circulatory  disturbance  in  neurasthenia,  is  the  palpita- 
tion of  the  heart,  already  mentioned.  As  pointed  out,  this  symptom  is  most 
often  associated  with  digestive  disturbances,  though  it  is  not  necessarily  de- 
pendent upon  the  latter.  It  commonly  occurs  at  that  period  of  digestion  when 
the  process  seems  to  have  been  slowed  or  arrested  and  when  marked  gaseous 
distention  of  the  stomach  has  taken  place.  It  may  also  be  associated  with 
marked  gastralgic  pains.  During  an  attack  the  patient  is  often  much  dis- 
tressed, and  frequently  sufiers  fi-om  fear.  The  heart  beats  violently  and 
with  increased  rapidity  against  the  chest-walls,  while  the  arteries,  wherever 
they  can  be  seen,  throb  excessively.  Sometimes  the  face  is  pale ;  more  fre- 
quently it  is  flushed.  The  patient  complains  of  oppression  of  breathing. 
After  a  longer  or  shorter  interval  the  attack  passes  over.  The  pulsations 
of  the  heart,  which  may  have  increased  to  120  or  130  a  minute,  rapidly 
fall  to  near  the  normal.  Such  an  attack  is  the  most  common  of  the  various 
cardiac  disturbances  noted  in  neurasthenia.  However,  every  now  and  then 
the  patient  has  a  seizure  which  resembles  an  attack  of  true  angina  pectoris. 
Charcot,  who  has  minutely  described  this  condition,  separates  such  a  seizure 
into  three  periods.  The  first  jDeriod  is  purely  prodromal,  and  may  last  sev- 
eral houi-s,  or  even  an  entire  day,  or  may  recur  several  times  before  the 
actual  onset  of  the  crisis.  During  its  continuance  the  patient  experiences 
sensations  of  pain  about  the  heart,  a  feeling  of  oppression,  of  fulness  of  the 


GENERAL  MORBID  STATES.  69 

left  half  of  the  body,  sensations  of  choking,  and  diflBculty  of  swallowing. 
In  addition,  he  has  a  cough,  is  irritalile,  has  insomnia,  and  loss  of  appe- 
tite. Suddenly,  when  the  second  period  has  arrived,  the  patient  feels  an 
intense  griping  in  the  pmecordial  region,  accompanied  by  extreme  nausea 
and  indescribable  terror.  The  pnecordial  pain  radiates  through  the  chest  to 
the  left  brachial  plexus  and  down  the  left  arm.  Sometimes  it  is  felt  even 
in  the  left  leg.  At  the  time  that  the  paroxysm  occurs  the  face  is  pale,  cold, 
and  liyid.  The  respiration  becomes  slow  and  seems  to  stop  during  inspu'a- 
tion,  which  is  gasping.  The  pulse  and  the  heart-beats  can  scarcely  be  felt. 
The  pupils  become  contracted,  equally  so,  on  both  sides.  The  agitation  of  the 
patient  is  extreme.  He  grasps  in  all  directions  for  support.  He  feels  as 
though  he  Avere  about  to  faint  or  about  to  die.  The  second  period  lasts  from 
three  to  six  minutes.  The  most  impoi'tant  points  in  the  clinical  picture  are 
the  paleness  of  the  face,  the  smallness  of  the  pulse,  and  the  feebleness  of  the 
heart-beats.  There  is  apparently  a  universal  peripheral  vascular  spasm,  in- 
volving probably  also  the  arteries  of  the  heart  itself.  The  third  period  makes 
its  appearance  by  a  change  in  the  color  of  the  face,  which  becomes  red  and 
hot.  A  similar  change  is  also  observed  in  the  left  half  of  the  body.  The  pul- 
sations of  the  heart  are  now  very  apprecialDle,  and  become  more  and  more 
energetic.  The  puLse-rate  is  from  130  to  140  a  minute,  with  intermissions 
every  ten  or  fifteen  beats.  The  respii*ation  is  very  frequent,  but  always  pant- 
ing, with  a  tendency  to  arrest  during  inspiration.  This  period  lasts  from  ten 
to  fifteen  minutes.  It  is  characterized  by  an  intense  vasomotor  reaction. 
The  arterial  spasm  of  the  preceding  period  is  succeeded  by  dilatation  of  the 
peripheral  vessels.  In  the  last  and  final  period  the  pulse-rate  falls.  At  the 
same  time  the  oppression  diminishes.  The  patient,  however,  trembles  all 
over ;  his  face,  his  lips,  his  limbs,  and  even  his  teeth  may  chatter.  This 
trembling  may  last  from  half  an  hour  to  an  hour.  Fortunately,  attacks  of 
such  severity  are  not  frequent,  but  it  is  well  to  be  aware  that  such  attacks 
do  occur  in  neurasthenia,  and  that,  though  very  distressing,  they  are  far  less 
serious  than  true  angina. 

The  puLse-rate,  which  is  temporarily  increased  in  attacks  of  cardiac  palpi- 
tation and  also  in  attacks  of  pseudo-angina,  is  every  now  and  then  more  or 
less  permanently  increased.  In  other  words,  there  is  present  in  some  cases  of 
neurasthenia  a  more  or  less  permanent  form  of  tachycardia.  (This  tachy- 
cardia is  unassociatecl  with  any  symptoms  suggestive  of  Graves'  disease. 
There  are  no  prominent  eyeballs  and  no  increase  in  the  volume  of  the  thyroid 
gland.)  It  would  appear  that  through  frequently  recurring  attacks  of  palpi- 
tation the  puLse-rate  is  more  or  less  permanently  raised,  and  that  it  often 
remains  for  long  periods  of  time  at  100  or  120.  During  a  period  of 
unusual  quiet  the  rate  may  fall,  say,  to  95  or  90  in  a  minute.  However, 
when  there  is  a  variation,  it  is  more  frequently  that  which  is  produced  by 
fatigue  and  excitement,  and  the  pulse-rate  shows  a  still  further  exacerba- 
tion. It  is  not  uncommon  for  150  to  160  beats  to  be  counted  in  the  minute 
in  such  an  attack.  Tachycardia  is  sometimes  associated  with  a  history  of 
shock  and  fright. 

Bouveret  describes  a  malignant  form  of  tachycardia,  but  it  is  doubtftil 
whether  this  can  properly  be  claimed  as  a  sj'mptom  or  even  an  outcome  of 
neurasthenia. 

In  a  few  cases,  a  heart  murmur,  evanescent  in  character,  has  been  noted. 
It  is  mentioned  by  Bouveret,  Richter,  and  others.  Of  late  it  has  been  again 
studied  by  John  K.  Mitchell.^  It  may  be  rendered  audilile  by  requesting 
the  patient  to  make  a  change  in  posture,  such,  for  instance,  as  sitting  up  in  bed 

1  Mitchell,  John  K. :  Transactions  College  of  Physicians  of  Philadelphia,  1892.  siv.  132. 


70  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

after  having  lain  still  on  the  back  for  some  time.  In  addition  to  the  slight 
accentuation  of  the  first  and  second  sounds,  a  soft  but  distinct  blowing 
murmur  is  heard  near  the  apex,  systolic  in  time.  It  disappears  in  a  few 
seconds,  but  may  be  again  provoked  by  additional  change  in  posture  or 
other  slight  physical  exertion. 

More  interesting,  however,  than  either  palpitation,  spurious  angina  or  the 
tachycardia  thus  far  considered,  are  the  symptoms  of  loss  of  general  vasomotor 
tonus.  These  are  present  in  the  larger  number  of  cases.  For  instance, 
neurasthenic  patients  often  suffer  from  involuntary  flushing  of  the  face  and 
of  other  portions  of  the  body.  Not  only  is  this  loss  of  vasomotor  tone  refer- 
able to  the  smaller  vessels,  but  it  is  even  manifested  in  the  larger  trunks. 
One  of  the  most  common  symptoms,  indeed,  observed  in  neurasthenia  is 
aortic  pulsation.  The  patient  feels  a  deep-seated  throbbing  in  the  epigas- 
trium, and  this  is  so  marked  that  it  can  readily  be  verified  by  the  hand  of 
the  physician.  It  is  a  most  distressing  symptom,  for  the  patient  is  apt 
to  believe  that  he  has  some  serious  organic  disease.  Less  often  the  throbbing 
sensation,  instead  of  being  felt  in  the  aorta,  is  felt  in  the  limbs.  Here  again 
it  is  excessively  persistent  and  distressing. 

In  order  to  convey  to  the  reader  a  proper  idea  of  the  condition  of  the 
vasomotor  apparatus,  it  is  well  to  relate  the  experiments  of  Mosso  and  Anjel. 
Mosso,  it  will  be  remembered,  demonstrated  by  means  of  a  plethysmograph, 
that  in  a  healthy  man  whose  arm  is  fixed  in  the  apparatus,  and  who  gives 
himself  up  to  some  intellectual  effort,  the  arm  shows  a  distinct  diminution  in 
size.  In  other  words,  a  reaction  takes  place  through  the  vasomotor  appara- 
tus, by  means  of  which  the  vessels  of  the  limb  become  slightly  contracted, 
while  at  the  same  time  those  of  the  brain  become  dilated.  Anjel'  starting 
with  this  result,  demonstrated  that  in  neurasthenic  subjects  a  similar  reaction 
takes  place,  but  that  it  is  evanescent.  There  is  at  first  a  sudden  and  marked 
reaction,  but  it  almost  immediately  disappears  ;  this  may  be  followed  by  an- 
other reaction  and  again  by  a  sudden  fall.  Thus  we  have  the  irritability 
and  the  weakness  of  the  vasomotor  apparatus  absolutely  demonstrated. 

Feebleness  of  the  circulation  is  further  shown  by  coldness  and  often 
lividity  of  the  extremities. 

Disturbances  of  the  Secretions.  In  a  large  number  of  neurasthenics,  there 
is,  as  Beard  long  ago  pointed  out,  an  insufficient  ingestion  of  liquids.  The 
patient  really  suffers  from  deficient  thirst.  In  keeping  with  this  fact  there 
is  a  diminution,  not  only  in  the  secretions  of  the  stomach  and  intestines,  but 
also  a  deficient  secretion  of  saliva  and  a  consequent  abnormal  dryness  of 
the  mouth.  In  addition  there  is  unusual  dryness  of  the  skin  and  scalp, 
and  there  can  be  no  doubt  that  in  some  instances  premature  loss  of  hair  is 
directly  traceable  to  this  cause.  Not  only  is  the  secretion  of  perspiration 
diminished,  but  there  is  also  a  diminution  in  the  quantity  of  urine.  In  a 
case  of  neurasthenia  of  traumatic  origin  recently  under  the  care  of  the 
writer  the  amount  of  urine  voided  in  the  twenty-four  hours  was  but  little 
over  four  ounces.  Hand-in-hand  with  this,  the  patient  ingested  almost  no 
fluid.  In  keeping  with  this  general  diminution  of  secretion  we  sometimes 
have  unusual  dryness  of  the  joints,  so  that  when  the  fingers  or  limbs  are 
forcibly  moved  crackling  sounds  are  produced.  Occasionally  these  sounds 
are  noticed  in  the  back  of  the  neck  on  suddenly  rotating  the  head,  and  are  in 
such  instances  to  be  referred  to  the  joints  of  the  articular  processes  (Bouveret). 

As  opposed  to  the  condition  of  diminished  perspiration,  we  sometimes  have 
more  or  less  marked  hyperidrosis.  This  hyperidrosis  may  be  general  or 
local.     Frequently  it  is  transitory  in  character,  the  patient  sweating  freely 

1  Angel :  Archiv  f.  Psych.,  1884,  xv.  618. 


GENERAL  MORBID  STATES.  71 

upon  slight  emotional  or  intellectual  excitement  or  upon  slight  physical  exer- 
tion. Thus  many  neurasthenics  on  attempting  to  read  or  to  Avrite  find  that 
their  head  and  neck  become  moist  with  perspiration.  In  sudden  and  tran- 
sient sweatings  the  perspiration  is  distinctly  thin  and  watery.  Very  often, 
instead  of  being  transient,  it  is  continuous,  and  is  especially  noticed  in  the 
hands.  In  some  cases,  this  sweating  of  the  hands  is  so  marked  that  the 
patients  will  wet  various  objects  which  they  touch,  as  in  a  case  cited  by 
Beard,  where  a  bookkeeper  was  forced  to  put  a  blotting-pad  under  his  hand 
before  attempting  to  write,  in  order  to  avoid  soiling  his  book.  The  moist 
hand  of  the  neurasthenic  is  nearly  always  a  cold  hand.  Again,  the  perspi- 
ration in  the  continuous  or  constant  form,  instead  of  being  watery,  as  in  the 
transient  form,  is  decidedly  sticky  and  often  unpleasant  in  odor.  This  is 
more  especially  the  case  when  the  sweating  occurs  in  the  axilla  and  the  groin. 
Occasionally  sweating  occurs  only  when  the  patient  lies  down,  and  when 
the  muscles  and  the  vasomotor  appai-atus  are  relaxed.  Sometimes  it  is  so 
marked  at  night  as  to  cause  veritable  night-sweats. 

Not  only  is  the  perspiration  affected,  but  the  oil  glands  also  suffer,  and  as 
a  consequence  acne  is  a  very  common  occurrence. 

Instead  of  a  simple  diminution  in  the  quantity  of  urine  voided,  the  latter 
may  be  decidedly  increased.  In  such  cases  the  symptom  is  of  necessity  con- 
comitant with  unusual  thirst.  More  often  there  is  an  apparent  increase  only. 
Thus  a  patient  under  a  slight  emotional  excitement  passes  an  unusual  quan- 
tity of  urine,  and  is  obliged  to  empty  the  bladder  at  comparatively  short 
intervals.  It  will  be  found  that  when  the  period  of  excitement  has  passed 
away  a  long  interval  occurs,  during  which  a  small  quantity  of  urine  only  is 
voided.  We  must,  therefore,  distinguish  between  a  temporary  or  spurious 
polyuria  and  a  true  polyuria.  Temporary  polyuria  occurs  especially  after 
attacks  of  fear  with  cardiac  palpitation.  It  may  also  occur  after  physical 
exertion.  Cases  in  which  there  is  marked  increase  in  the  frequency  of  mic- 
turition are  frequently  traumatic  in  origin.  This  sympton  may  be  so  marked 
as  to  suggest,  at  first  sight,  cystitis  or  other  bladder  trouble.  Pain  is,  how- 
ever, rarely  complained  of.  When  questioned,  the  patient  will  simply  say 
that  when  the  desire  is  felt  he  must  go  at  once  lest  he  soil  his  clothing. 

As  opposed  to  this,  patients  will  sometimes  complain  that  they  cannot 
pass  their  water  readily  or  freely.  Examination  fails  absolutely  to  disclose 
any  local  trouble.  The  condition  is  evidently  psychic  and  similar  to  that 
which  occasionaly  occurs  in  normal  individuals  who  cannot  void  the  urine  in 
the  presence  of  strangers. 

While  the  urine  is  sometimes  actually  increased  in  quantity  this  symptom 
is  rarely  so  striking  as  to  suggest  a  genuine  diabetes  insipidus.  Even  if  this 
should  be  the  case,  it  must  be  remembered  that  the  symptom  disappears 
when  the  treatment  is  directed  to  the  neurasthenia  itself.  It  should  be  re- 
marked, in  this  connection,  that  transient  glycosuria  has  been  noted  in 
neurasthenia.  This  symjDtom,  however,  should  always  be  regarded  with 
suspicion,  and  other  signs  pointing  to  the  existence  of  a  true  diabetes  mellitus 
should  be  carefully  sought  for.  Similarly  albumin  has  every  now  and  then 
been  detected  in  the  urine,  and  the  remarks  just  made  in  regard  to  glycosuria 
apply  equally  to  it.  In  this  connection  it  is  important  to  remember  the  cases 
of  albuminuria  in  lithemic  states  recently  so  well  described  by  Da  Costa.^ 

The  most  common  condition  of  the  urine  observed  in  neurasthenia  is  an 
excess  of  uric  acid  and  urates.  It  is  very  common  for  the  patient  to  pass 
urine  which  almost  immediately  afterward  becomes  cloudy,  and  which  on 
being  allowed  to  stand  shows  an  excessive  deposit.     In  many  neurasthenics 

1  Da  Costa,  J.  M.  :   American  Journal  of  the  Medical  Sciences,  January,  1893,  p.  1. 


72  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

this  condition  is  a  transitory  one.  It  should  also  be  distinguished  from  that 
which  occurs  in  normal  individuals  who  are  exposed  to  great  heat,  and  in 
whom,  as  a  consequence  of  sweating,  the  urine  is  naturally  concentrated. 

It  occasionally  happens  that,  instead  of  the  above  condition,  the  patient 
voids  a  urine  Avhich  is  cloudy  while  it  is  being  passed,  but  becomes  clear  upon 
cooling.  Such  a  urine  becomes  cloudy  again  on  being  heated.  The  condi- 
tion is  that  known  under  the  name  of  phosi^haturia.  It  is  noted  every  now 
and  then  in  persons  who  are  otherwise  healthy,  but  its  frequent  occurrence 
in  neurasthenic  subjects,  and  the  facts  that  it  is  sometimes  connected  with 
irritation  of  the  bladder  or  of  the  urethra,  and  that  it  is  so  often  associated  in 
the  patient's  mind  Avith  sexual  disorder,  make  it  of  importance  here.  The 
patient,  already  predisposed  to  nosophobic  ideas,  imagines  that  he  is  suffering 
from  spermatorrhoea. 

It  is  probable  that  in  a  large  number  of  cases  the  excess  of  phosphates  is 
simply  apparent,  the  condition  really  depending  upon  a  diminished  acidity 
of  the  urine.  In  some  instances,  however,  the  phosphates  are  shown  to  be  in 
excess  by  actual  analysis.  Similarly  oxalic  acid  in  the  form  of  oxalate  of 
lime  is  occasionally  present  in  large  quantity.  This  is  especially  apt  to  be  the 
case  when  dyspeptic  symptoms  are  marked.  Oxaluria,  probably,  because  of 
the  sharp-pointed  octohedral  crystals  so  often  present,  is  occasionally  accom- 
panied by  symptoms  of  bladder  and  urethral  irritation. 

Sexual  Disturbances.  Symptoms  referable  to  the  sexual  apparatus  occur 
in  a  large  number,  if  not  in  the  majority,  of  neurasthenics.  This  is  true  of 
both  sexes.  Occasionally  they  are  so  marked  as  to  dominate  the  entu-e  clinical 
j^icture,  so  much  so  that  many  writers  term  the  condition  "  sexual "  neuras- 
thenia. It  is  commonly  supposed  that  masturbation  and  sexual  excesses  are 
necessary  factors  in  their  production,  but  this  is  an  error.  They  may  exist,  at 
least  in  their  less  marked  forms,  in  neurasthenia  pure  and  simple.  However,  as 
we  have  ah'eady  seen,  masturbation  and  sexual  excess  are  every  now  and  then 
the  principal  causes  of  a  nervous  exhaustion,  and  we  should  not  be  surprised 
to  find  in  such  a  case  sexual  symptoms  most  prominent. 

In  men  these  symptoms  are  commonly  as  follows :  If  the  patient  be 
unmarried,  he  complains  of  frequent  nocturnal  seminal  emissions,  and  bases 
numerous  nosophobic  ideas  upon  this  symptom.  He  attributes  all  of  his 
physical  depression  to  this  cause,  and  is  frequently  very  despondent.  If  the 
patient  be  married,  he  complains  that  the  ejaculation  occurs  prematurely,  and 
also  that  it  is  not  accompanied  by  the  usual  pleasurable  sensations.  Later  on, 
if  the  condition  becomes  more  marked,  he  complains  that  the  act  can  no 
longer  be  satisfactorily  accomplished,  because  erection  is  incomplete,  and, 
furtlier,  that  the  genitals  seem  more  or  less  anaesthetic.  This  condition  may 
deepen  into  one  in  which  no  erection  whatever  can  occur,  and  in  which  more 
or  less  marked  diminution  of  sensation  is  demonstrated  by  examination.  Early 
in  the  history  of  his  case  the  patient  is  apt  to  imagine  that  he  is  suffering 
from  spermatorrhoea,  especially  if  there  be  present  phosphaturia,  or  if  he  be 
the  victim  of  a  gleet  or  other  chronic  urethral  irritation.  However,  under 
these  circumstances,  the  microscope  fails  to  demonstrate  spermatorrhoea,  but 
later  on,  when  the  loss  of  sexual  power  has  become  actual  and  marked,  sper- 
matozoids  may  be  found.  We  should  remember  in  this  connection  that  very 
many  neurasthenics  indulge  in  nosophobic  ideas  with  regard  to  their  sexual 
apparatus  when  no  sexual  disturbances  whatever  exist.  JNIany  a  young  man 
in  whom  seminal  emissions  occur  with  but  normal  frequency  believes  that  he 
is  losing,  or  has  lost,  his  sexual  power.  This,  as  has  just  been  pointed  out,  is 
very  common  in  those  who  suffer  from  phosphaturia. 

Associated  with  the  weakness  and  irritability  of  the  sexual  apparatus  Ave 
ha\"e  also  various  partesthesias.     These  consist  of  pricking,  creeping,  or  throb- 


GENERAL  MORBID  STATES.  73 

bing  sensations  referred  to  the  urethra  and  penis  or  to  the  testicles.  They 
are  at  times  extremely  distressing  and  are  most  difficult  to  relieve.  Occasion- 
ally there  is  excessive  hyperesthesia  of  the  glans  and  testes. 

In  women  sexual  disturbances  similar  to  those  observed  in  men  also  occur. 
Not  infrequently  it  happens  that  a  patient  complains  of  orgasms  occurring 
during  sleep,  and  fui'ther  states  that  these  are  accom^Danied  by  voluptuous  or 
unpleasant  dreams,  and  that  she  feels  very  much  prostrated  by  them.  If  she 
be  married  she  is  less  likely  to  complain  of  nocturnal  orgasms,  but  rather  of 
some  abnormality  of  the  sexual  act ;  the  orgasm  may  be  delayed,  deficient, 
or  absent.  The  genitals  are  in  these  cases  in  a  condition  in  which  they 
respond  less  readily.  Contact  or  friction  fails  to  produce  pleasurable  sensa- 
tions. Earlier  in  the  history,  on  the  other  hand,  we  occasionally  have  marked 
hypersesthesia.  Various  distressing  parsesthesias  resembling  those  occurring 
in  the  male  may  also  be  present.  It  need  hardly  be  stated  that  female  patients 
are  less  ready  in  their  admissions  in  regard  to  sexual  symptoms  than  men. 
Occasionally,  however,  they  evince  a  morbid  desire  to  dwell  upon  them,  the 
mental  condition  being  similar  to  that  existing  in  male  patients. 

Very  frequently  neurasthenic  women  complain  of  pelvic  pain,  and  this 
upon  investigation  proves  to  be  ovarian.  Associated  with  this  condition  there 
■  is  often  marked  ovarian  tenderness.  Here,  however,  we  must  be  upon  our 
guard  not  to  confound  actual  organic  disease  with  a  symptom  purely  indicative 
of  hypersesthesia  or  irritability.  In  this  connection,  too,  we  should  remem- 
ber that  large  numbers  of  neurasthenic  women  suffer  from  actual  pelvic 
disease.  In  these  cases  the  neurasthenia  is  almost  always  the  outcome  of  the 
local  affection,  and  must  therefore  be  regarded  as  a  neurasthenia  symptomatica. 

Symptomatology  in  General.  In  the  clinical  picture  presented  by  neu- 
rasthenia the  most  varied  symptoms  are  aggregated.  Because  of  this  appar- 
ent complexity,  it  has  sometimes  been  maintained  that  in  neurasthenia  we 
have  not  a  single  affection  to  deal  with,  but  really  a  great  variety  of  diseases. 
However,  it  is  evident  that  in  their  essentials  all  of  the  symptoms  are  the  same. 
They  are  simply  various  ways  of  expressing  the  two  cardinal  facts  of  the 
weakness  and  irritability  which  affect  the  nervous  system  as  a  whole.  It 
must  not  be  expected  that  every  case  should  present  all  of  the  sensory  and 
motor  disturbances,  or  all  of  the  other  anomalies  of  function  above  described. 
While  it  is  true  that  there  are  some  cases  in  which  fatigue  symptoms  appear 
to  be  distributed  evenly  over  the  entire  nervous  system,  there  are  others  in 
which  this  or  that  joarticular  group  of  symptoms  is  accentuated.  For  in- 
stance, the  form  in  which  the  symptoms  are  widely  diffiised,  that  is,  are  both 
cerebral  and  spinal,  has  been  called  cerebro-spinal  neurasthenia.  Again,  the 
form  in  which  cerebral  symptoms  predominate  has  been  termed  encephelas- 
thenia ;  the  form  in  which  cord  symptoms  predominate  (i.  e.,  spinal  irrita- 
tion, great  weakness  of  the  legs,  etc.)  has  been  called  myelasthenia.  Inas- 
much as  neurasthenia  is  an  affection  of  the  nervous  system  as  a  whole,  the 
predominance  of  this  or  that  group  of  symptoms  cannot  be  considered  as 
sufficient  ground  for  its  division  into  separate  forms.  In  its  essentials  the 
affection  is  always  the  same. 

Pathology.  Numerous  writers  have  indulged  in  more  or  less  vague  specu- 
lations regarding  the  pathology  of  neurasthenia.  These  it  would  be  useless 
to  consider.  Let  it  simj^ly  suffice  to  say  that  neurasthenia  does  not  stand 
in  any  relation  with  ansemia,  chlorosis,  or  other  affection  of  the  blood. 
Neither  does  it  bear  any  direct  relation  to  the  condition  of  the  other  tissues. 
That  it  has  a  pathology  of  its  own  involving  the  nervous  system  directly  is 
rendered  more  than  probable  by  the  remai^kable  researches  of  C.  F.  Hodge,^ 

1  Hodge,  C.  F. :  A  Microscopical  Study   of  Changes  Due  to  Functional  Activity  in  Nerve-cells. 
Journal  of  Morphology,  1892,  vol.  vii.  p.  95. 


74 


XEBVOrS  DISEASES  ASD  THEIR  TREATMENT. 


and  tlie  equally  remarkable  discoveries  of  A.  Mosso.  The  former  investiga- 
tor studied  the  nerve  cells  of  various  animals  both  before  and  after  fatigue. 
In  some  instances  he  exhausted  the  cells  by  prolonged  electrical  stimulation ; 
in  others  his  results  were  based  upon  fatigue  induced  by  the  normal  exercise 


Fig.  22. 


Portion  of  field  from  the  third  brachial  ganglion  of  an  English  sparrow  killed  at  7  a.  m.    (Hodge.) 

of  function.  Among  the  animals  studied  h\  him  were  the  frog,  the  cat,  the 
dog,  the  English  sparrow,  the  pigeon,  the  swallow,  and  the  honey-bee.  The 
spinal  ganglion  cells  of  the  cat,  for  instance,  were  studied  in  such  a  way  that 

Fig.  23. 


Field  from  the  conesponding  ganglion  of  an  English  sparrow  killed  on  the  same  day  (as  in  Fig.  22) 

at  7.30  P.  M.    (Hodge.) 

a  ganglion  which  had  been  subjected  to  prolonged  electrical  stimulation  was 
compared  with  the  normal  ganglion  on  the  corresponding  nen-e  root  of  the 
opposite  side.     Again,  the  spinal  ganglia  and  brain  cells  of  bu-ds  and  of  bees 


GENERAL  MORBID  STATES. 


75 


were  studied  by  securing  various  individuals  before  and  after  prolontfed 
flights,  the  examinations  being  in  each  instance  conducted  under  precisely 
the  same  conditions.  Thus,  for  instance,  the  nerve  cells  of  bees  that  had  worked 
all  day  were  compared  with  those  of  the  same  hive  that  had  been  at  rest  dur- 
ing the  same  period.  In  all  instances,  irrespective  of  the  animal  selected, 
changes  were  discovered  in  the  ner^"e  cells  ;  further,  these  changes  were  always 
the  same.  They  involved  the  nucleus,  the  cell  protoplasm,  and  even  the  cell 
capsule  when  present.     They  are  summarized  by  Hodge  as  follows : 

A.  For  nucleus:  1.  ^larked  decrease  in  size.  2.  Change  fi'om  smooth 
and  rounded  to  a  jagged,  irregular  outline.  3.  Loss  of  open  reticulate  ap- 
pearance, with  darker  stain. 

B.  For  cell-protojilasm :  1.  Slight  shrinkage  in  size,  with  vacuolation  for 
spinal  glanglia ;  considerable  shrinkage,  with  enlargement  of  pericellular 
lymph  space  for  cells  of  cerebrum  and  cerebellum.  2.  Lessened  power  to 
stain  or  to  reduce  osmic  acid. 

C  For  cell  capsule,  when  present :  Decrease  in  size  of  nuclei. 

D.  Individual  nerve  cells,  after  electrical  stimulation,  recover,  if  allowed 
to  rest  for  a  sufiicient  time.  The  process  of  recovery  is  slow  ;  from  five  hours' 
stimulation,  being  scarcely  complete  after  twenty-four  hours'  rest. 


Fig.  24. 


Fig.  25. 


Median  subdivision  of  the  antennary  lobe  of  the  brain  of  the  honey  bee.    Fig.  24,  morning,  6  o'clock 
Fig.  25,  evening,  7.30  o'clock.    Both  of  same  day.    (Hodge.) 


Certainly  these  experimental  results  are  more  than  suggestive,  and  are  of  the 
utmost  value.  Clearly,  we  have  here  facts  upon  which  a  rational  pathology  of 
neura.sthenia  can  be  based.  When  we  consider  that  the  primary  sym2:)tom  of 
neurasthenia  is  loss  of  power,  and  when  we  learn  that  the  lesion  of  fatigue  is 
loss  of  cell  substance,  it  remains  but  to  add  one  fact  to  the  other.  When  we 
learn  forther  that  the  process  of  recovery  of  the  exhausted  cell  is  slow  we 
can  readily  frame  a  hypothesis  to  account  for  the  persistence  of  the  average 
neurasthenic  symptom.  A^^e  must  also  reflect  that  in  the  neurasthenic  patient 
fatigue  has  exceeded  the  normal  limits,  and  further  that  the  proj^er  oppor- 
tunity for  repair  to  take  place  does  not  present  itself. 


76  NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 

Before,  however,  a  complete  conception  of  the  pathology  of  neurasthenia 
can  be  formed  another  factor  must  be  considered.  It  is  exceedingly  probable, 
where  there  is  such  an  excessive  waste  of  nerve  substance  as  we  have  reason 
to  infer  is  the  case  in  neurasthenia,  that  various  substances,  the  result  of  this 
metamorphosis,  are  circulating  in  the  blood — substances  some  of  which  may 
be  normal  to  the  blood  but  now  present  in  excess,  and  others  perhaps  entirely 
new  and  foreign.  At  any  rate,  some  of  the  phenomena  presented  by  ad- 
vanced and  chronic  cases  of  neurasthenia  suggest  the  presence  within  the 
blood  of  substances  having  a  toxic  action.  Mosso,"  on  observing  that  soldiers 
presented  in  the  evening,  after  a  day's  march,  fatigue  in  the  arm  muscles  as 
well  as  in  the  leg  muscles,  conceived  the  idea  that  fatigue  altered  the  consti- 
tution of  the  blood,  and  he  afterward  discovered  that  the  blood  of  a  fatigued 
animal  when  injected  into  an  animal  at  rest,  produced  in  the  latter  the  charac- 
teristic symptoms  of  fatigue.  That  in  purely  nervous  exhaustion  similar 
modifications  of  the  blood  ensue  seems  a  reasonable  conclusion.  Although 
pur  knowledge  of  the  substances  produced  in  the  blood  under  these  circum- 
stances is  exceedingly  limited,  such  evidence  as  we  possess  proves  that  they 
have  a  decidedly  toxic  action.  It  is  well  known  to  physiologists  that  if  a  frog 
muscle,  which  has  been  completely  exhausted  by  electrical  stimulation  and  re- 
fuses longer  to  respond,  is  washed  out  by  injecting  into  its  artery  normal  salt 
solution,  the  exhaustion  disappears  and  the  muscle  again  reacts  to  the  elec- 
trical current  almost  as  well  as  before.  Evidently  the  muscle  exhausted  by 
fatigue  suffers  not  only  from  loss  of  substance,  but  also  from  the  presence  of 
various  toxic  agents  which  strongly  inhibit  its  physiological  action.  While 
equal  exjaerimental  proof  is  not  at  hand  as  regards  the  nerve  centres,  there 
can  be  no  doubt  that  the  physiological  problem  j^resented  is  the  same.  The 
chemical  nature  of  the  various  fatigue  substances  is  still  a  matter  of  scientific 
inquiry,  but  whatever  their  nature  they  are  the  direct  result  of  tissue  metabol- 
ism, and  in  some  aspects  this  fact  is  exceedingly  interesting  and  suggestive. 
For  instance,  we  are  all  familiar  with  the  relation  existing  between  gout  and 
neurasthenia  and  with  the  fact  that  the  urine  of  neurasthenics  very  often  con- 
tains uric  acid  in  great  excess.  These  facts  must  have  a  special  significance. 
The  suggestion  acquires  additional  force  from  what  we  know  at  the  present 
day  of  the  relation  of  uric  acid  to  the  nucleins.  Uric  acid  is  not,  as  has  been 
so  long  taught,  a  substance  standing  in  a  complementary  relation  to  urea.  We 
have  reason  to  believe  from  the  researches  of  Horbaczewsky  that  it  represents 
the  chemical  disintegration  of  the  nuclein  constituent  of  cells,  and  if  this  be 
true  its  jDresence  in  excess  in  neurasthenics  and  the  relation  of  gout  to  neuras- 
thenia acquires  a  new  significance. 

In  addition  to  the  above  considerations,  other  factors  secondary  in  charac- 
ter, but  of  great  practical  importance,  present  themselves.  It  is  well  known 
that  prolonged  and  persistent  derangement  of  function  may  be  followed  by 
actual  tissue  changes.  Thus  a  heart  Avhich  is  constantly  overacting,  Avhich  is 
subject  to  frequently  repeated  and  violent  attacks  of  palpitation,  may  un- 
dergo hypertrophy ;  or  the  walls  of  the  bloodvessels  may  become  thickened, 
and,  if  the  case  persist  sufiiciently  long,  may  even  undergo  atheromatous 
change.  That  actual  organic  changes  may  supervene  in  the  digestive  tract 
is  more  than  probable.  That  such  changes  also  occur  in  other  structures,  such 
as  the  muscles  and  even  the  bones,  there  can  be  very  little  doubt.  When  oc- 
curring in  the  last  mentioned  structures  they  are  like  the  changes  in  the 
bloodvessels,  suggestive  of  senescence,  and  are  best  seen  in  cases  of  athletes  or 
persons  who  have  overtrained  physically  and  in  whom  neurasthenia  is  ex- 

1  Mosso",  A. :  Sulle  leggi  della  fatica.    Rendiconti  della  R.  Accademia  dei  Lincei,  1887.    Also,  Die 
Ermuedung  (German  translation).    Leipzig,  1892. 


GENERAL  MORBID  STATES.  77 

pressive  of  a  breakdown,  the  direct  result  of  physical  excesses.  These  second- 
ary changes  observed  in  neurasthenic  subjects  are  of  course  terminal  in  char- 
acter, and  their  recognition  is  of  the  utmost  importance  with  the  view  of 
prognosis.  When  they  are  present  the  symptoms  are  necessarily  persistent 
and  little  if  at  all  influenced  by  treatment.  The  picture  presented  is  that  of  a 
profound  and  practically  hopeless  nervous  exhaustion  to  which  the  name  ter- 
minal nexirasthenia  seems  to  be  especially  applicable.  Further,  the  presence 
of  toxic  substances  in  the  blood  as  an  outcome  of  simple  though  long-con- 
tinued and  profound  neurasthenia  furnishes  an  added  explanation  for  those 
cases  which  eventuate  in  terminal  forms,  and  renders  more  readily  comprehen- 
sible the  occurrence  of  such  changes  as  general  arterio-sclerosis  and  sclerotic 
changes  in  the  kidneys  and  other  viscera. 

Diagnosis.  The  simpler  and  milder  forms  of  neurasthenia  are  readily 
recognized.  The  same  symptoms  are  so  frequently  grouped  together  that  the 
recognition  of  the  affection  is  comparatively  easy.  However,  the  physician 
must  be  cautioned  to  eliminate  absolutely  all  evidences  of  organic  or  special 
functional  diseases.  This  is  especially  true  of  such  affections  as  are  accom- 
panied by  general  loss  of  strength,  as  beginning  phthisis,  the  various  diseases 
of  the  blood,  and  some  of  the  more  obscure  affections  presently  to  be  mentioned. 
At  times  we  have  associated  with  neurasthenia  hysteria,  and  it  therefore  be- 
comes important  in  many  cases  to  decide  whether  our  case  is  one  of  simple  neu- 
rasthenia or  pure  hysteria,  or  whether  we  have  neurasthenia  present  with  hys- 
terical complications.  The  differences  between  simple  neurasthenia  and 
hysteria  are  well  marked.  It  will  be  remembered,  for  instance,  that  in  the 
former  affection  we  have  no  true  paralysis.  On  the  other  hand,  paralysis  in 
various  forms  occurs  in  hysteria.  Again  we  have  seen  that  true  anaesthesia 
never  occurs  in  neurasthenia.  It  often  occurs  in  hysteria ;  for  example,  in  the 
form  of  hemiansesthesia.  Convulsions,  too,  are  not  symptoms  of  neurasthenia ; 
on  the  other  hand,  they  are  common  symptoms  of  hysteria.  Contractures  of  the 
muscles  never  occur  in  neurasthenia ;  they  frequently  occur  in  hysteria.  Fur- 
ther in  its  course  and  aspect  simple  neurasthenia  differs  markedly  from  hysteria. 
Its  beginning  is  very  gradual,  and  the  symptoms  become  steadily  more  and 
more  marked  with  time.  The  onset  of  hysteria,  however,  may  be  sudden, 
and  the  symptoms  presented  often  vary  greatly  from  day  to  day.  Again, 
such  hysterical  stigmata  as  the  globus  hystericus,  the  form  of  head  pain 
known  as  clavus,  and  the  reversal  of  the  color-fields,  are  never  present  in  neu- 
rasthenia. Other  points  of  minor  importance  might  also  be  cited,  but  enough 
has  been  given  to  indicate  the  line  of  thought  that  is  to  be  followed  in  differ- 
entiating between  the  two  affections.  We  must  not  forget,  however,  as  already 
hinted,  hysteria  is  every  now  and  then  engrafted  upon  neurasthenia.  Indeed 
it  may  be  said  that  under  certain  circumstances  neurasthenia  will  predispose 
the  patient  also  to  hysteria. 

We  have  already  pointed  out,  in  discussing  the  symptomatology,  the  differ- 
ences existing  between  the  pseudo-hypochondria  of  neurasthenia  and  true 
hypochondria.  In  the  former  condition  it  will  be  remembered  the  patient, 
who  for  the  time  being  believed  that  he  had  serious  disease  of  the  heart  on 
account  of  frequently  recurring  attacks  of  palpitation,  readily  permits  himself 
to  be  set  at  right.  The  ideas,  however,  formed  in  true  hypochondriasis  are 
fixed  and  amount  to  actual  delusions.  We  have  a  true  psychosis  to  deal  wath. 
It  will  hardly  be  necessary  in  this  chapter  to  point  out  the  differences  between 
the  depressed  mental  state  of  neurasthenia  and  melancholia.  Suffice  it  to  say, 
that  the  evident  psychic  pain  present  in  the  latter  affection,  together  with 
the  self-accusatory  ideas  or  the  delusion  of  the  unpardonable  sin,  at  once  set- 
tle the  question.  The  following,  however,  should  be  borne  in  mind  ;  that  is, 
that  every  now  and  then  the  patient  in  whom  the  diagnosis  of  neurasthenia 


78  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

has  been  made,  may  many  months  or  years  afterward  suffer  from  true  hjqDO- 
chondriasis  or  true  melancholia.  The  question  naturally  arises  whether  in 
these  cases  a  natural  transition  into  these  psychoses  has  taken  place.  It  can 
be  safely  said  that  this  transition,  if  it  occur  at  all,  is  exceedingly  rare. 
Almost  always,  if  such  transition  has  taken  place,  w^e  will  find  that  the  patient 
presents  a  history  pointing  clearly  to  a  neuropathic  ancestry,  or  we  have  symp- 
toms presented  by  the  patient  himself  which  are  incontrovertible  evidences  of 
a  neuropathic  constitution. 

Occasionally  there  is  danger  of  confounding  some  of  the  psychoses,  when 
in  their  earlier  stages,  with  neurasthenia.  At  times,  indeed,  it  is  a  matter  of 
difficulty  to  distinguish  between  a  profound  encephalasthenia  and  a  beginning 
paretic  dementia.  In  neurasthenia,  it  will  be  remembered,  we  may  have 
tremor,  alterations  of  speech,  of  handwriting,  and  there  may  even  be  transi- 
tory inequality  of  the  pu2:)ils.  As  regards  the  speech  and  handwriting,  we 
should  remember  that  it  is  always  possible  for  the  neurasthenic  to  speak  and 
write  correctly  and  legibly  when  his  attention  is  directed  to  it ;  and,  further, 
that  he  is  conscious  of  his  errors  as  he  makes  them.  There  is,  also,  this  im- 
portant point  of  distinction.  In  neurasthenia  the  change  in  the  mental  facul- 
ties is  one  of  quantity  and  not  of  quality.  We  must  remember  that  the  car- 
dinal feature  of  cerebral  neurasthenia  is  the  inability  for  sustained  intellectual 
efibrt.  The  patient  is  capable  of  appreciating  and  correctly  reasoning  about 
various  matters  that  are  brought  to  his  attention,  but  soon  becomes  exhausted. 
In  paresis,  however,  thei^e  is  a  distinct  blunting  of  the  mental  faculties.  We 
soon  realize,  on  studying  such  a  case,  that  the  intellectual  as  well  as  the  emo- 
tional faculties  are  distinctly  obtunded.  It  is  only  in  the  earlier  stages,  when 
the  change  is  still  very  slight,  that  difficulty  may  arise,  but  it  is  just  under 
these  circumstances  that  errors  have  occasionally  been  made  by  reputable  phy- 
sicians.    See  also  Chapter  XXIII. 

Prognosis.  Neurasthenia  is  essentially  chronic  in  its  course.  It  does  not 
immediately  threaten  life.  In  the  simple  and  uncomplicated  form  the  prog- 
nosis is  very  bright,  and  this  is  the  case  no  matter  how  profound  the  affection 
may  be.  It  is  truly  marvellous  how  much  can  be  accomplished.  As  we  will 
presently  see,  patients  presenting  the  symptoms  in  the  most  pronounced  degree, 
who  have  suffered  great  loss  of  weight,  and  who,  in  outward  appearance,  look 
as  though  their  hold  upon  life  Avas  extremely  small,  often  make,  under  favor- 
able conditions,  a  most  wonderful  recovery.  If  neglected,  however,  the  affec- 
tion is  apt  to  progress  steadily  from  bad  to  worse.  ComjDlication  with  hysteria 
offers  no  material  drawbacks.  Sometimes  the  difficulties  are  very  great,  but 
rarely  insurmountable. 

AVhile  the  above  sanguine  view  is  justified  by  a  large  number  of  cases  we 
should  always  be  guarded  in  our  statements  to  the  patient ;  we  should  remem- 
ber that  there  are  many  circumstances  which  make  a  complete  recovery  im- 
possible. A  number  of  important  factors  must  be  taken  into  consideration. 
They  are :  First,  a  history  of  neurasthenia,  or  general  nervousness  in  the 
ancestors  ;  secondly,  a  history  of  any  affection  in  the  ancestry  which  suggests 
the  existence  of  a  neurojDathic  constitution,  such  as  epilepsy,  insanity,  or 
organic  nervous  diseases  ;  thirdly,  any  trace  of  neuropathic  or  degenerate  con- 
stitution in  the  patient  himself;  fourthly,  the  age  at  which  the  neurasthenia 
begins ;  and,  lastly,  the  length  of  time  for  which  it  has  existed.  As  to  the 
age  at  which  neurasthenia  begins,  it  is  known  that  persons  in  Avhom  the 
affection  makes  its  appearance  in  childhood  are  with  difficulty  brought  to 
the  average  level  of  health,  and  even  then  are  prone  to  frequent  and  pro- 
longed relapses.  Again,  in  neurasthenia  making  its  appearance  toward  the 
close  of  the  middle  period  of  life,  or  in  old  age,  the  results  of  treatment  are 
only  partially  satisfactory,  and  often  disappointing.     The  reasons  are  obvi- 


OENEBAL  MORBID  STATES.  79 

ous.  The  tissues  in  general,  the  bloodvessels,  and  other  organs  exhibit  more 
or  less  the  effects  of  the  wear  and  tear  of  life.  As  to  the  length  of  time 
during  which  a  neurasthenia  has  lasted,  we  should  remember  that  long- 
standing cases  are  often  very  intractable.  In  discussing  the  symptomatology 
and  pathology  of  the  affection  we  have  pointed  out  how,  in  long-standing 
cases,  secondary  and  terminal  organic  changes  in  the  tissues  arise. 

If  a  temporizing  treatment  be  employed  in  a  given  case,  and  the  original 
etiological  factors  allowed  to  remain  at  work,  several  possibilities  as  to  the 
future  present  themselves.  First,  the  patient  may  suffer  day  in  and  day  out 
from  the  various  distressing  symptoms  of  the  affection ;  and,  finally,  if  the 
case  persist  long  enough,  and  if  it  be  of  sufficient  severity,  terminal  neuras- 
thenia supervenes.  A  second  possibility  is  the  formation  sooner  or  later  of 
some  toxic  habit.  Among  men  the  alcoholic  habit  especially  in  that  form 
known  as  periodic  inebriety,  may  sooner  or  later  be  established.  In  women 
the  morphia  or  chloral  habit  may  be  formed.  A  third  possibility  is  the  transi- 
tion of  the  neurasthenia  into  one  of  the  psychoses.  In  persons  of  a  non- 
neuropathic  heredity  this  outcome  is  very  improbable.  The  remarks  that  have 
been  already  made  in  this  connection  in  reference  to  hypochondriasis  and  mel- 
ancholia apply  also  to  paretic  dementia,  paranoia,  mania,  moral  insanity,  etc. 

Treatment.  When  we  consider  the  etiology  and  pathology  of  neurasthenia 
the  indications  for  treatment  become  very  clear.  It  is  evident,  first  of  all, 
that  rest  is  an  imperative  factor.  Certainly,  if  the  waste  be  rapid  and  repair 
be  slow,  the  diminution  of  function — the  securing  of  as  complete  a  rest  as 
possible — is  the  object  to  be  aimed  at.  We  all  know  that  absolute  rest, 
physiologically  speaking,  is  an  impossibility ;  but,  at  the  same  time,  that 
the  degree  of  relative  rest  which  is  practicable  is  very  great.  The  first 
question  in  a  given  case  is  naturally.  How  much  rest  does  this  patient  re- 
quire ?  It  is  frequently  impossible  for  persons  actively  engaged  in  the  pur- 
suits of  life  to  take  absolute  rest ;  nor,  in  fact,  is  absolute  rest  always  a  necessity. 
Very  frequently  the  most  astounding  changes  can  be  brought  about  by  rela- 
tive rest.  In  the  high  pressure  of  modern  civilization,  especially  as  it  exists 
in  this  country,  the  temptation  to  overwork  is  extreme,  and  in  very  many 
cases  of  neurasthenia,  if  the  excess  of  work  be  stopped,  recovery  will  ensue. 
In  many  cases  we  need  only  adopt  the  scheme  of  "  partial "  rest,  instituted  by 
Dr.  Weir  Mitchell,  in  which  the  patient,  often  an  active  business  man,  is 
directed  to  prolong  the  hours  of  rest  in  bed,  to  rise  not  earlier  than  nine  or 
ten  o'clock  in  the  morning,  and  to  retire  with  the  onset  of  evening.  A  man 
following  these  directions  must  necessarily  curtail  the  hours  devoted  to  work, 
and  very  often  this  simple  expedient  is  sufficient  to  bring  about  a  most  favor- 
able result.  Let  us  remember  that  if  our  case  of  neurasthenia  be  profound 
and  of  long  duration,  that  the  rest  must  be  as  nearly  absolute  as  it  is  possible 
for  us  to  make  it.  Dr.  Weir  Mitchell  has  already  pointed  out  how  this  is  to 
be  accomplished ;  how  in  very  bad  cases  the  patient  is  not  even  allowed  to 
feed  herself,  to  turn  in  bed  without  the  assistance  of  the  nurse,  nor  to  leave  the 
bed  to  void  the  bowels  or  urine.  Now,  while  rest  is  undoubtedly  a  factor  of 
prime  importance,  rest  of  itself,  as  Dr.  Mitchell  has  shown,  is  not  without  its 
attendant  evils.  (See  Seguin  Lecture  and  "Fat  and  Blood.")  It  is  well 
known  that  a  joint,  if  not  moved,  will  stiffen  and  finally  become  ankylosed ; 
it  is  well  known  that  a  muscle  which  is  not  exercised  will  waste  away,  and  it 
is  probable  that  analogous  changes  take  place  in  other  tissues.  How  to 
combat  these  evils  is  the  problem  which  presents  itself.  If  we  exercise  our 
patient  we  expend  his  strength.  Evidently  the  solution  of  the  problem  is  to 
obtain  the  effects  of  exercise  without  this  expenditure.  Ordinarily  we  obtain 
these  effects  by  massage  and  by  electricity.  To  Dr.  Weir  Mitchell  we  owe 
the  introduction  of  these  expedients  into  the  treatment  of  neurasthenia  com- 


80  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

billed  with  rest,  and  it  is  the  combination  of  these  forms  of  "  passive  exercise  " 
with  prolonged  rest  in  bed  that  constitutes  the  "  rest  cure."  To  the  details  of 
massage  and  electricity  we  will  presently  return. 

The  diet  in  neurasthenia  next  claims  our  attention.  The  indication  is  to 
raise  the  nutrition  of  the  patient  to  as  high  a  level  as  possible,  and  with  this 
end  in  view,  first,  to  administer  the  most  readily  digested  foods,  and,  secondly, 
to  administer  them  in  as  large  a  quantity  as  possible.  These  points  can  be 
best  illustrated  by  the  methods  pursued  in  severe  cases,  such  as  require  system- 
atic rest  treatment.  Almost  of  necessity  milk  constitutes  a  large  portion  of 
the  diet ;  the  patient  is  placed  almost  habitually  upon  milk  at  first,  and  later 
on  other  food  is  added.  The  neurasthenic  is,  as  we  know%  almost  of  necessity 
a  dyspeptic ;  he  lacks  both  the  desire  to  eat  and  the  ability  to  digest  food 
properly.  He  presents  the  train  of  symptoms  so  familiar  under  the  name 
"  nervous  dyspepsia."  Frequently  he  objects  strenuously  to  the  milk,  assert- 
ing over  and  over  again  that  he  cannot  digest  it,  that  the  milk  will  be  vomited, 
or  that  it  gives  rise  to  pain.  The  custom  under  these  circumstances  is  to  in 
some  way  modify  the  milk,  either  by  the  addition  of  some  diluent,  as  weak 
tea  or  one  of  the  carbonated  waters ;  or  peptonized  milk  or  koumis  is  ad- 
ministered. Most  often,  however,  it  is  found  that  the  inability  to  take  milk 
is  very  much  exaggerated,  and  it  is  best  never  to  ask  a  patient  the  question, 
"  Does  milk  agree  with  you?  "  but  simply  to  order  it.  AVe  should  be  careful, 
however,  to  order  it  in  small  quantities,  beginning  with  about  four  ounces 
every  two  hours,  and  excluding  absolutely  all  other  food.  This  amount  is,  of 
course,  insufiicient  for  the  needs  of  the  body,  but  we  find  that,  even  if  a  dis- 
gust for  milk  is  present,  the  patient  being  placed  upon  a  very  small  amount 
of  food,  and  becoming  in  a  day  or  two  very  hungry,  becomes  extremely 
grateful  for  the  milk,  and  takes  it  eagerly.  We  should  next  increase  the 
milk  very  slowly,  being  careful  at  first  to  keep  the  patient  a  little  hungry 
all  of  the  time.  Finally,  in  the  course  of  a  week  or  ten  days,  we  should 
increase  the  amount  to  eight,  ten,  or  even  twelve  ounces  every  two  hours,  as 
the  case  may  be.  If  we  find  that  the  patient  is  quite  hungry  by  the  fourth 
or  fifth  day,'  it  is  well  to  add  a  small  slice  of  stale  bread  with  butter  once 
or  twice  a  day,  and  later  on  three  times  daily.  The  diet  is  then  ftirther  in- 
creased by  a  soft-boiled  egg,  or  perhaps  by  a  mere  fraction  thereof  at  breakfast. 
Finally,  a  small  chop  or  steak  is  given  at  noon,  and  a  small  quantity  of 
thoroughly  boiled  rice  may  be  given  at  supper.  Upon  these  beginnings  a 
substantial  diet  is  finally  built  up,  until  the  patient  eats  three  large  meals  a 
day  ;  such,  for  instance,  as  a  breakfast  of  fruit,  cracked  wheat,  one  or  two  soft- 
boiled  eggs,  or  a  good-sized  steak  or  several  chops,  bread  and  butter,  and  milk ; 
a  dinner  of  a  good  slice  of  roast  beef,  with  vegetables  and  boiled  rice  (in  place 
of  potatoes).  The  supper  should  remain  as  a  light  meal  of  bread,  butter, 
fruits,  light  pudding,  and  milk.  It  will  be  noticed  that  in  this  dietary  coffee, 
chocolate,  tea,  and  cocoa  are  absolutely  omitted. 

Soups,  beef-tea,  and  broths  possess  relatively  little  value ;  they  simply  oc- 
cupy space  which  can  otherwise  be  given  to  milk.  Certainly  the  latter  has 
a  far  higher  nutritive  power.  The  same  holds  true  of  tea,  chocolate,  and 
cocoa,  while  coffee  is  exceedingly  objectionable,  inasmuch  as  the  neurasthenic 
is  an  individual  who  has,  in  the  vast  majority  of  cases,  abeady  exhausted  stimu- 
lants— not  only  coffee,  tea,  and  alcohol,  but  also  the  various  narcotics — in  the 
vain  hope  of  finding  relief.  The  waiter  believes  that  coffee  and  alcohol,  even 
in  moderate  use,  should  be  avoided. 

Another  element  of  importance  in  the  treatment  is,  as  Mitchell  and  Play- 
fair  have  both  pointed  out,  the  isolation  of  the  patient.  Not  only  is  the 
patient  -the  victim  of  a  neurasthenia,  but  in  very  many  instances  also  of  hys- 
teria.    Neurasthenia  and  hysteria  are,  as  we  have  seen,  often  inextricably 


GENERAL  MORBID  STATES.  81 

intertwined.  Under  these  circumstances  isolation,  the  withdrawal  of  the 
patient  from  the  influences  of  relatives  and  friends  is  of  the  utmost  impor- 
tance. How  deleterious  home  surroundings  are  under  these  circumsances  need 
not  be  dwelt  upon.  In  cases  of  nervous  prostration  which  are  sufficiently  pro- 
nounced to  require  rest  in  bed,  isolation  is  imperative,  and  it  should  be  abso- 
lute. No  exceptions  should  be  made  in  favor  of  any  relative,  nor  should  any 
communication  ever  reach  the  sick-room,  except  through  the  mouth  of  the 
doctor,  and  then  even  should  be  most  guarded  and  most  general  in  character. 
The  writer's  experience  accords  with  that  of  Drs.  Mitchell  and  Playfair,  that 
even  slight  infringements  upon  this  rule  are  sometimes  followed  by  the  most 
unfavorable  results. 

We  find,  then,  that  our  resources  for  combating  profound  neurasthenia  com- 
prise rest,  artificial  exercise  (namely,  massage  and  electricity),  a  special  diet, 
and  isolation. 

The  success  which  attends  our  efibrts  in  a  given  case  depends  largely 
upon  the  way  with  which  the  various  means  at  our  disposal  are  utilized.  No 
doubt  every  one  who  has  essayed  the  rest-cure  has  developed  certain  methods 
of  his  own  which  he  finds  give  him  the  best  results.  The  writer's  experience 
has  led  him  to  adopt  the  following :  The  patient  is  placed  in  bed.  Most  often 
it  is  a  woman,  and  as  a  rule  she  is  extremely  nervous,  and  perhaps  hysterical. 
Frequently  she  is  a  stranger  amid  strange  surroundings.  She  is  left  by  her 
friends  in  the  care  of  a  physician  whom  she  knows  only  by  reputation,  and 
of  a  nurse  of  whom  she  knows  less.  It  is  my  custom,  therefore,  to  begin 
treatment  in  the  most  gradual  manner.  It  requires  time,  in  the  first  place, 
for  the  patient  to  become  accustomed  to  her  bed,  for  lying  in  bed  is  in  the 
beginning  quite  a  task  to  even  neurasthenic  people,  and,  in  the  second  place, 
it  requires  time  to  become  acquainted  with  and  acquire  confidence  in  her 
nurse.  The  writer,  therefore,  at  the  first  visit  is  in  the  habit  of  examining  the 
patient  thoroughly,  if  he  finds  that  the  examination  is  well  borne  and  causes 
no  excitement,  but  only  in  part  if  she  be  very  nervous.  Frequently  he  does 
not  finish  the  examination  until  the  next  or  even  the  third  visit.  He  simply 
orders  a  small  quantity  of  milk,  as  already  explained,  and  instructs  the  nurse 
that  she  give  the  patient  that  evening  a  light  and  rapid  sponge  bath.  Gener- 
ally massage  should  not  begin  until  the  second  or  third  day,  and  then  should 
only  continue  for  a  short  time,  and  should  |be  very  gentle  and  superficial  in 
character.  The  reasons  for  beginning  the  massage  in  so  gradual  a  manner 
are  :  first,  that  the  patient  may  become  accustomed  to  the  touch  of  the  nurse, 
and,  secondly,  because  the  gentle,  superficial  stroking  soothes  the  patient.  We 
should  take  advantage  of  this  quieting  effect  and  direct  that  the  massage  be 
given  in  the  evening,  At  this  time  it  strongly  favors  sleep,  and  is  indeed  one 
of  the  most  powerful  agents  for  combating  insomnia  at  our  command.  Just 
as  the  diet  is  very  gradually  increased  so  should  the  massage  be  very  gradually 
increased,  both  in  depth  and  vigor ;  finally,  the  duration  of  the  ma.ssage  should 
be  increased  to  at  least  an  hour.  Dr.  Playfair  recommends  that  the  patient 
be  masseed  for  even  three  hours.  It  is  doubtful,  however,  whether  anything 
is  gained,  if  indeed  something  be  not  lost,  by  this  prolonged  rubbing. 

Another  point  which  the  writer  regards  as  important  is  that  the  massage 
be  performed  by  the  nurse ;  this  of  course  makes  it  necessary  that  the  nurse 
be  also  a  masseuse.  If  the  patient  be  treated  by  a  regular  masseuse  at  cer- 
tain intervals  in  the  day,  the  visit  of  this  third  person,  with  whom  the  patient 
has  also  to  become  acquainted,  acts  as  a  disturbing  factor ;  to  use  an  every- 
day expression,  the  patients  are  apt  to  be  "  upset "  by  it. 

Electricity  is  not  of  the  same  value  or  importance  as  massage.  However, 
it  is  a  remedy  which  the  Avriter  almost  invariably  utilizes,  but  generally  as 
follows :     In  the  first  place,  almost  all  that  can  be  gained  by  artificial  exer- 

6 


82  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

cise  can  be  gained  by  massage,  and  we  must  remember  that  most  patients  are 
excessively  afraid  of  the  battery.  However,  as  in  the  case  of  massage,  its 
application  must  be  begun  in  a  very  gradual  manner.  A  scarcely  percept- 
ible current  is  at  first  used,  and  the  nurse,  who  has  been  previously  instructed 
in  the  points  of  Ziemssen  (see  Chapter  XXXIV.),  is  made  to  use  the  slowly  in- 
terrupted current  in  such  a  way  that  each  group  of  muscles  contracts  a  given 
number  of  times.  Until  the  patient  becomes  accustomed  to  this  often  unpleas- 
ant sensation  the  application  may  be  limited  to  the  forearms  and  legs.  Later 
it  may  be  applied  to  the  thighs,  arms,  and  trunk.  Electricity  is  doubtless  a 
useful  adjuvant  to  the  rest-cure,  but  it  is  only  an  adjuvant.  At  the  same  time 
its  utility  cannot  be  questioned.  The  writer  never  uses  it  early  or  in  the  begin- 
ning of  a  case.  He  is  fearful,  and  in  fact  such  has  frequently  been  his  experi- 
ence, that  the  excitement  and  the  irritation  consequent  upon  its  use  act  deleteri- 
ously  upon  the  patient.  Moreover,  the  exercise  that  it  gives  the  muscles 
frequently  tires  and  exhausts,  and  it  occasionally  retards  the  increase  in  weight 
which  otherwise  takes  place.  We  should  begin  with  it  only  several  weeks  after 
the  treatment  has  been  well  under  way,  and  sometimes  in  the  latter  part  of  a 
case,  preparatory  to  getting  the  patient  out  of  bed. 

After  our  treatment  has  been  continued  for  some  time  the  question  arises. 
How  shall  we  determine  whether  we  are  making  satisfactory  progress  ?  In 
the  first  place,  if  the  patient  is  taking  a  large  amount  of  food,  and  massage 
is  having  its  proper  effect,  the  color  of  the  patient  should  improve.  The 
patient  should,  as  the  masseuse  expresses  it,  "  pink  "  readily  under  her  touch. 
The  muscles  should  gradually  become  firmer  to  pressure.  However,  another 
and  more  important  guide  than  this  is  the  change  in  weight  shown  by  the 
patient.  Occasionally  it  is  noticed  that  in  the  first  few  days  there  is  a  pro- 
gressive loss  of  weight,  but  soon  the  patient  begins  to  gain,  and,  in  the 
average  case,  gains  rapidly  ;  sometimes  in  the  course  of  from  eight  to  twelve 
weeks  as  much  as  twenty-five,  or  even  thirty-five,  pounds.  The  writer  can 
confirm  from  personal  observation  and  personal  experience  much  that  has 
been  said  upon  this  subject  by  Drs.  Mitchell  and  Playfair,  and  he  has  learned 
to  regard  the  progressive  increase  in  weight  as  the  most  valuable  index 
attainable  regarding  the  progress  of  a  case.  It  is  far  more  valuable  than 
the  persistence  or  non-persistence  of  such  symptoms  as  backache  or  headache, 
or  general  nervous  feeling.  Some  of  the  subjective  symptoms  disappear  rela- 
tively early,  others  persist ;  but  even  the  latter,  in  the  majority  of  cases,  grow 
fainter  and  fainter,  until  at  last  they  no  longer  impress  themselves  upon  the 
consciousness  of  the  patient.  In  those  instances  in  which  obscure  subjective 
sensations  seem  to  be  permanent,  it  is  not  improbable  that  more  or  less  defi- 
nite changes,  "the  terminal  changes,"  have  taken  place,  and  that  these 
persistent  symptoms  are  due  to  the  latter. 

It  will  be  noticed  that  in  the  above  plan  of  treatment  drugs  find  no  place. 
However,  it  is  occasionally  judicious  to  use  a  few  remedies.  Not  infrequently, 
as  we  have  seen,  the  indigestion  of  our  patients  is  complicated  by  a  veritable 
gastric  catarrh.  Indeed,  this  is  more  frequently  the  case  than  not.  The 
writer  is  in  the  habit  of  prescribing  nitrate  of  silver,  say  one-fourth  of  a  grain, 
combined  with  a  fourth  of  a  grain  of  extract  of  hyoscyamus,  to  be  taken 
half  an  hour  before  meals.  Sometimes,  also,  at  the  beginning  of  the  treat- 
ment we  find  that  the  patient's  tongue  is  coated  and  that  the  bowels  are 
loaded.  In  such  cases  it  is  well  to  prescribe  small  doses  of  calomel  and 
bicarbonate  of  soda  until  the  desired  effect  is  obtained.  _  In  other  words,  gen- 
eral principles  must  guide  us  in  the  use  of  medicines  in  these  cases,  though, 
as  far  as  possilole,  medicines  are  to  be  avoided.  1\\  a  number  of  cases  a  laxa- 
tive of  some  sort  becomes  necessary.  The  choice  of  this  is  largely  a  matter 
of  personal  judgment ;  the  simpler  the  remedy  the  better.     The  writer  is  in 


GENERAL  MORBID  STATES.  83 

the  habit  of  using  the  fluid  extract  of  cascara,  given  at  night,  and,  if  possi- 
ble, in  gradually  diminishing  doses. 

Occasionally  special  symptoms  require  special  interference.  It  may  be 
that  the  headache  is  so  intense  as  to  demand  active  medication.  In  this  case 
phenacetin  or  antipyrin  may  be  used,  and  sometimes  moderate  doses  of 
bromide  of  ammonium  may  be  given  at  the  same  time.  Frequently,  too, 
the  insomnia  is  so  profound  that  it  does  not  yield  to  the  general  treatment. 
We  find,  however,  as  a  rule,  that  patients  who  are  taking  a  large  amount  of 
milk  sleep  a  great  deal.  The  excess  of  food  seems  to  have  a  soporific  or 
sedative  influence ;  and,  therefore,  narcotics  are  rarely  indicated.  The  mas- 
sage, too,  if  given  in  the  latter  part  of  the  day,  favors  sleep.  Sometimes, 
though  not  always,  a  wet  sheet,  followed  by  a  gentle  rubbing,  or  a  hot  sponge 
bath,  rapidly  given,  act  as  sedatives.  Occasionally,  however,  the  insomnia  is 
so  profound  that  we  are  driven  to  the  use,  for  a  time  at  least,  of  drugs.  The 
milder  drugs,  small  doses  of  sulphonal  or  trional,  or  possibly  of  bromide, 
should  be  given  (see  also  p.  85).  The  stronger  narcotics  should  practically 
never  be  used.  Fortunately,  in  the  average  case  we  can  get  along  without 
them. 

Strychnin,  so  much  vaunted  in  neurasthenia,  is  a  drug  rarely  used  by  the 
Avriter.  In  a  large  number,  perhaps  the  majority,  of  cases  the  treatment  can 
be  conducted  successfully  from  beginning  to  end  without  the  use  of  any 
other  medium  than  an  occasional  laxative.  However,  in  those  cases  in  which 
the  neurasthenia  is  complicated  by  anaemia,  iron  or  arsenic  may  be  used  with 
advantage.  If  the  analysis  of  the  urine  has  revealed  an  excess  of  uric  acid, 
as  is  so  frequently  the  case,  special  remedies  applicable  to  the  condition  may 
be  given.  The  alkalies  are  indicated,  and  the  urine  often  clears  up  rapidly 
under  their  use.  However,  the  writer  has  been  especially  successful  with  the 
administration  of  piperazin.  About  one  gramme  should  be  given  daily  for  a 
time.  It  should  be  administered  largely  diluted.  One  gramme  having  been 
dissolved  in  about  a  pint  of  water,  the  solution  should  be  given  in  divided 
doses  at  intervals  throughout  the  day  until  the  entire  amount  is  consumed. 
If,  on  the  other  hand,  oxaluria  be  present  nitro-hydrochloric  acid  is  indi- 
cated. 

Let  us  suppose  now  that  the  patient  is  progressing  favorably,  when  is  the 
rest  in  bed  to  terminate?  How  are  we  to  know  when  the  maximum  amount 
of  good  has  been  obtained  ?  In  neurasthenic  cases  of  long  standing  it  is 
probable  that  our  best  guide  is  the  change  shown  by  the  body-weight.  If  a 
decided  increase  has  taken  place,  and  it  then  ceases,  it  is  probable  that  the 
maximum  increase  has  been  reached — i.  e.,  the  maximum  increase  possible 
under  the  treatment.  If,  at  the  same  time,  the  patient's  symptoms  have 
become  progressively  less  marked,  we  have  probably  reached  a  period  when 
the  patient  should  be  gotten  out  of  bed.  In  young  neurasthenics,  however, 
and  in  others  in  whom  the  neurasthenia  has  not  been  so  profound,  the  in- 
crease in  weight  is  not  of  itself  a  sufRcient  guide,  inasmuch  as  these  patients 
will  sometimes  grow  needlessly  fat.  In  such  cases  we  are  to  consider  whether 
the  weight  is  about  normal  to  the  height  and  age  of  the  individual.  In  get- 
ting the  patient  out  of  bed  we  must  remember  that,  though  well  nourished, 
she  (or  he)  is  weak.  We  must  remember  that,  though  the  muscles  have  been 
thoroughly  rubbed,  and  though  they  have  been  toned  up  by  the  battery,  the 
patient  has  not  exercised  for  weeks  and  months.  She  is  in  the  condition  of 
having  accumulated  an  enormous  amount  of  latent  energy.  This  energy  must 
now  be  mobilized — made  potent  by  gradual  exercise.  She  is  allowed,  there- 
fore, to  sit  up  for  five  or  ten  minutes  in  a  day.  While  in  bed  passive  move- 
ments of  the  legs  and  arms  are  made.  Gradually  the  length  of  time  for  sit- 
ting up  is  increased,  so  that  the  patient  sits  up  twenty  minutes  to  forty-five 


S4  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

minutes  or  an  hour  a  day.  Little  by  little  the  time  is  increased,  until  at  the 
end  of  ten  days  the  patient  is  up  from  four  to  six  hours. 

Passive  movements,  which  until  now  have  been  practised,  are  dispensed  with. 
For  them  Swedish  movements  and  light  calisthenics  are  substituted.  The 
patient  is  also  made  to  walk  about  the  room  a  little.  Finally,  a  short  walk  out 
of  the  house  or  a  carriage  ride  follows.  Next  comes  a  trip  to  the  seashore  for 
some  ten  days  or  three  weeks.  During  this  time  the  patient  is  made  to  exercise 
in  the  open  air.  As  a  rule,  she  walks  little  at  first,but  gradually  increases  the 
amount  until  two  or  three  miles  at  a  brisk  gait  is  attained.  The  massage  is, 
little  by  little,  discontinued,  and  during  the  stay  at  the  seashore  occasional 
immersion  in  a  hot  salt-water  bath,  say  twice  weekly,  is  ordered.  This  im- 
mersion should  be  very  brief,  because  a  prolonged  bath  in  some  patients  will 
be  followed  by  a  sense  of  fatigue  rather  than  exhilaration. 

Gradually  the  patient  is  permitted  to  renew  her  relations  with  her  relatives 
and  friends.  Finally  she  is  returned  home,  and,  in  order  to  insure  against  a 
relapse,  which  under  proper  precautions  rarely  occurs,  she  is  told  to  spend 
some  ten  hours  in  bed  out  of  the  twenty-four,  to  still  take  her  breakfast  in 
bed,  and  to  still  keep  up  a  moderate  quantity  of  milk  in  addition  to  her 
regular  diet.  Daily  exercise  is  also  insisted  upon.  Little  by  little  the  patients 
break  in  upon  the  rules  laid  down  by  the  physician  at  parting,  and  in  the 
course  of  a  number  of  weeks  adopt  the  lives  of  the  people  about  them. 

In  the  rest  cure  time  is  a  necessary  element  in  achieving  a  durable  result. 
The  patient  should  have  the  benefit  of  from  six  to  twelve  weeks  of  treat- 
ment, and  in  some  cases  even  more. 

One  of  the  most  powerftil  therapeutic  adjuvants  in  the  treatment  of  neuras- 
thenia, and  one  that  is  much  neglected  in  this  country,  is  hydrotherapy. 
This  implies  both  the  internal  and  external  use  of  water.  We  have  already 
pointed  out  that  the  large  majority  of  neurasthenics  have  deficient  thirst, 
and,  in  consequence,  consume  too  little  liquid.  There  can  be  no  doubt  that 
some  of  the  benefit  derived  from  a  prolonged  course  of  milk  diet,  such  as  is 
ordinarily  used  in  conjunction  with  the  rest-cure,  is  to  be  attributed  to  the 
increased  ingestion  of  liquid  thus  necessitated.  In  most  cases,  in  addition  to 
the  milk  that  is  added  to  the  diet,  it  is  necessary  to  urge  the  patient  to  drink 
freely  of  water,  and,  in  order  to  secure  compliance  with  this  advice,  it  is  well 
to  prescribe  a  certain  amount  of  some  special  water  daily — for  example, 
Poland  Spring  water,  or  a  carbonated  water,  as  apollinaris  or  seltzer.  If,  as 
we  have  pointed  out  in  discussing  the  pathology  of  neurasthenia,  there  are 
toxic  substances  circulating  in  the  blood,  the  free  ingestion  of  water  is 
urgently  indicated,  and  we  need  only  recall  the  experiment  of  the  ex- 
hausted frog-muscle,  in  which  washing  out  the  fatigue  substances  almost 
completely  restores  the  electrical  excitability,  to  realize  the  value  of  such  a 
measure. 

Water,  when  applied  in  the  form  of  douches,  showers,  or  sprays,  to  the 
surface  of  the  body,  acts  in  two  ways :  first,  by  the  impact  of  the  water  upon 
the  surface  of  the  body ;  and,  secondly,  by  the  stimulating  effect  of  the  tem- 
perature of  the  water.  Cold  water  applied  suddenly  and  for  short  intervals 
acts  as  a- powerful  stimulant.  It  is  at  once  followed  by  a  reaction  in  the  cir- 
culation of  the  part.  This  reaction,  after  the  shower-bath  or  after  the  sheet- 
bath,  may  be  enhanced  by  vigorous  rubbing  with  a  towel.  It  is  an  easy  mat- 
ter to  attach  to  the  water-pipe  in  a  bath-room  a  section  of  an  ordinary 
garden-hose  with  a  sprinkler,  and  this,  for  practical  purposes,  answers  very 
well.  Elaborate  apparatus  can  be  found  in  only  few  public  institutions,  and 
is  rarely  at  the  disposal  of  the  practitioner.  The  manifold  uses  of  hydrothe- 
rapy in  neurasthenia  at  once  becomes  evident  when  we  learn  that  many  cases 
of  "tender  spine"  yield  more  rapidly  to  vigorous  douching  than  to  massage. 


GENERAL  MORBID  STATES  85 

Care,  however,  should  be  exercised  in  the  use  of  this  agent,  and  Ave  should  be 
careful  to  introduce  the  patient  to  the  method  very  gradually. 

A  large  number  of  the  milder  cases  of  neurasthenia  can  be  treated  without 
the  aid  of  a  nurse  by  the  system  of  partial  rest.  This  should  inchide  not  only  a 
prolongation  of  the  hours  devoted  to  rest  in  bed,  but  also  a  certain  amount 
of  physical  exercise.  A  case  under  partial  rest-treatment  should  be  instructed 
to  retire  at  an  early  hour  and  to  rise  late.  Breakfast  should  be  served  in 
bed.  The  diet  should  consist  of  plain  but  nutritious  food,  of  which  milk 
should  be  a  part.  As  before,  tea,  coffee,  tobacco,  and  alcohol  should  be 
excluded.  The  exercise  should  consist  of  walking  in  the  open  air  and  of 
light  gymnastics  performed  under  the  eye  of  a  physical  instructor.  Little 
by  little,  as  the  case  progresses,  the  amount  of  exercise  and  also  its  character 
may  be  modified.  Whenever  practicable,  out-door  exercise,  such  as  horse- 
back riding,  should  be  substituted  for  in-door  work.  Running  and  swim- 
ming ought  not  to  be  indulged  in,  unless  the  patient  has  made  very  marked 
jDrogress  toward  the  goal  of  health.  Running  is  very  apt  to  tax  the  heart, 
while  swimming  is  often  followed  by  depression  and  exhaustion  instead  of 
exhilaration.  These  remarks  apply  to  the  after-bed  treatment  of  profound 
neurasthenia  as  well  as  to  the  milder  cases.  Great  judgment  is  required  to 
prescribe  the  amount  and  character  of  the  exercise  for  each  individual  case, 
and  upon  it  the  success  of  the  treatment  often  largely  depends. 

It  is  often  advisable  to  send  our  patients  away  from  home.  Some  small 
hotel  or  cottage  at  the  seashore  at  which  the  life  is  quiet  and  tranquil  should 
be  selected.  Here,  with  a  certain  amount  of  exercise,  such  as  walking,  appe- 
tite and  digestion  rapidly  improve.  One  of  the  principal  advantages  of 
a  stay  at  the  seashore  is  the  securing  of  a  wholesome  sleep.  Indeed,  it  con- 
stitutes one  of  our  most  effective  means  of  combating  insomnia.  After  awhile 
the  patient  may  bathe  in  the  surf,  and,  with  a  view  to  this,  the  place  selected 
should  have  a  beach  with  a  very  gentle  slope.  A  steep  beach  with  a  rough 
surf  may  be  followed  by  unfavorable  results.  The  bath,  of  course,  should  last 
for  a  few  minutes  only. 

Occasionally  it  is  of  advantage  to  send  the  patient  on  a  sea-voyage.  As  a 
rule,  the  longer  the  voyage  the  better.  After  the  first  few  days  of  seasickness 
have  passed  away  an  increased  appetite  follows,  and  there  is  the  same  soporific 
influence  of  the  sea-air  as  before.  Further,  on  board  of  a  vessel  the  patient 
experiences  all  of  the  beneficial  effects  of  isolation.  The  monotony  of  the 
daily  life  also  predisposes  to  a  calm  and  even  frame  of  mind. 

In  sending  out  patients  other  than  to  the  seashore  we  should  remember,  in 
our  choice  of  climate,  to  be  especially  carefiil  not  to  send  them  to  high  alti- 
tudes. The  air  of  high  plateaus  and  of  mountains  may  increase  many  of  the 
nervous  symptoms.  It  is  apt  to  increase  the  headache,  and  especially  to 
produce  insomnia,  or  to  make  it  worse  if  already  present.  As  patients  im- 
prove, however,  a  gradual  change  from  a  low  to  a  high  sea-level  is  often 
followed  by  benefit. 

In  numerous  cases  of  neurasthenia,  in  which  circumstances  prevent  the 
adoption  of  the  rest-treatment,  we  find  that  the  "  nervousness  "  of  the  patient 
is  so  pronounced  as  to  necessitate  the  administration  of  medicines.  The  bro- 
mides are  of  undoubted  value  in  enabling  us  to  allay  some  of  the  symptoms. 
They  should,  however,  in  no  case  be  continued  for  a  very  long  period.  In 
the  W'riter's  experience  their  efficacy  is  much  increased  if  a  small  dose  of  anti- 
pja'in  be  added.  Indeed  antipyrin  has  a  distinct  action  in  calming  the  patient, 
and  it  may  even  be  given  alone.  Doses  of  10  grains,  three  times  daily,  are 
often  very  beneficial.  Further,  in  many  cases  of  nervous  exhaustion,  anti- 
pyrin given  at  night  also  favors  sleep.  The  writer's  experience  in  the  vise  of 
this  drug  is  borne  out  by  the  statements  made  by  Batty  Tuke  in  his  lectures 


86  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

on  the  lusanity  of  Overexertion  of  the  Brain.  Tuke,  among  other  measui-es 
for  combating  the  insomnia  of  grave  brain  exhaustion,  has  used  antipyrin 
freely  for  the  last  three  years.  He  states  that  in  closes  of  15  grains  every  two 
hours  it  usually  produces  sleep,  and  that  the  general  condition  usually  im- 
proves, and  also  that  he  has  "  frequently  given  antipyrin  to  the  amount  of  60 
to  100  grains  per  diem  for  a  fortnight  at  a  time,"  and  that  he  has  "never 
noticed  any  of  the  ill-effects  ascribed  to  it,  except  occasionally  nausea  and  vomit- 
ing. It  may  be  that  patients  in  the  condition  we  are  speaking  of  (the  insan- 
ity of  overexertion  of  the  brain)  may  be  more  tolerant  of  the  poison  than 
those  in  whom  temperature  runs  high.  As  in  all  nervous  cases,  the  dosage  is 
at  first  a  matter  of  experiment ;  but  it  is  quite  safe  to  begin  with  the  dose 
above  indicated,  raising  it  somewhat,  and  administering  it  more  frequently, 
according  as  the  patient's  condition  improves."  Of  course  the  writer  does  not 
urge  the  use  of  such  large  doses  of  antipyrin  in  every-day  forms  of  neuras- 
thenia. In  his  experience  much  smaller  doses  suffice.  However,  the  results 
of  Batty  Tuke  in  the  use  of  antipyrin  in  the  insanities  of  overexertion  are 
exceedingly  important  as  demonstrating  that  we  have  here  a  drug  of  great 
value.  The  writer,  however,  wishes  here  to  repeat  the  statement  already 
made,  that  whenever  possible  the  use  of  medicines  is  to  be  avoided. 

In  the  foregoing  remarks  upon  the  treatment  the  writer  has  indicated 
merely  general  principles.  Of  course  special  forms  of  neurasthenia  demand 
special  methods.  This  is  particularly  true  of  that  form  in  which  sexual 
symptoms  predominate,  namely,  "  sexual  neurasthenia."  Here  it  is  necessary- 
first  to  correct  the  sexual  life  of  the  individual.  Abstinence  should  if  possi- 
ble be  enforced.  At  the  same  time,  advantage  should  be  taken  of  all  meas- 
ures at  our  command  for  raising  the  general  level  of  the  patient's  health. 
Among  these,  active  exercise  in  the  open  air,  outdoor  sports,  the  companion- 
ship of  healthy  comrades,  together  with  Avholesome  reading,  are  the  most 
important.  The  special  symptoms,  however,  usually  compel  us  to  resort  to 
various  forms  of  medication.  The  sexual  apparatus,  as  we  have  pointed  out, 
is  in  a  condition  of  irritable  weakness,  and  one  of  the  most  distressing  symp- 
toms to  the  patient  is  the  frequency  of  the  nocturnal  emissions.  Here  bro- 
mides are  again  of  value,  but  their  usefulness  is  secondary  to  that  of  hyoscin 
hydrobromate,  which  should  be  given  in  doses  varying  from  1-80  to  1-100  of 
a  grain  at  bedtime.  In  some  cases  it  is  expedient  to  administer  bromide  and 
hyoscin  together.  If  the  weakness  of  sexual  power  be  accompanied  by 
markedly  diminished  cutaneous  sensibility,  the  use  of  urethral  electrodes, 
together  with  a  dry  Avire-brush,  may  be  resorted  to.  Hot  and  cold  douches 
to  the  spine  may  also  be  employed. 

In  many  patients  who  complain  of  sexual  weakness,  the  afiection  is  psychic 
rather  than  physical.  In  such  instances,  true  sexual  neurasthenia  does  not 
exist.  Many  such  cases  require  only  a  few  words  of  good  advice.  In  others, 
however,  the  condition  amounts  to  one  of  actual  hypochondria.  It  is  this 
class  Avhich  taxes  our  resources  to  the  utmost. 

Before  closing  it  is  necessary  to  speak  briefly  of  the  animal  extracts,  the 
efficacy  of  which  has  been  so  much  vaunted.  The  results  do  not,  in  the  Avriter's 
opinion,  justify  the  claims.  Distinct  exception  must,  however,  be  made  to  this 
statement  as  regards  extract  of  the  testicle.  There  can  be  no  doubt  that,  even 
when  the  possibility  of  suggestion  is  excluded,  the  use  of  this  remedy  is  of 
benefit.  It  appears  to  act  as  a  stimulant,  and  will  occasionally  enable  us  to 
make  an  impression  upon  a  case  otherwise  intractable.  The  nucleins  now 
being  introduced  to  the  profession  apparently  have  a  similar  action. 


CHAPTER  III. 
GENERAL  MORBID  STATES  OF  THE  NERYOUS  SYSTEM. 

(Continued.) 
By  JAMES  HENDRIE  LLOYD,  M.D. 

HYSTERIA. 

In  the  vast  literature  of  the  affection  we  are  about  to  consider  a  few  names 
only  rise  conspicuously  above  the  general  level.  These  are  the  names,  first, 
of  those  who  by  reason  of  their  authority  in  medicine  did  little  more  than 
establish  definitions  and  terms,  often  erroneous,  which  for  long  periods  have 
encumbered  the  science,  and,  secondly,  of  those  who  have  corrected  these 
errors  and  have  advanced  our  knowledge  of  this  remarkable  disease  by  the 
accuracy  of  their  description  of  its  symptoms.  To  the  right  comprehension 
of  hysteria  a  brief  historical  study  is  more  essential  than  in  the  case  of  almost 
any  other  affection,  because,  more  than  in  the  cases  of  most  others,  the  knowl- 
edge of  it  has  been  obscured  by  definitions  which  are  of  great  antiquity. 
Some  of  these  venerable  traditions  still  confuse  the  subject  in  spite  of  the 
progress  of  recent  scientific  criticism,  and  their  influence  in  various  ways  is 
still  wholly  pernicious. 

In  tracing  the  history  of  hysteria  it  is  almost  sufficient  to  trace  merely  the 
history  of  one  dominant  idea.  This  is  the  idea  that  the  womb  is  the  seat  of  the 
affection.  From  this  one  central  thought  all  others  rose  and  radiated  for  two 
thousand  years.  With  slight  variations  of  expression  this  uterine  pathology 
served  the  purposes  of  science,  and  even  until  to-day  has  satisfied  the  require- 
ments of  the  people  and  of  a  portion  of  the  profession.  This  tradition,  prob- 
ably the  most  ancient  in  medicine,  has  held  an  ascendency  which  is  not  often 
acquired  except  by  some  mystic  creed,  and  unfortunately  it  has  been  one  of 
the  last  of  the  primitive  errors  to  lose  ground.  It  gave  origin  to  many 
grotesque  and  not  a  few  obscene  conceptions  ;  and  created  a  prejudice  against 
and  a  scandal  about  the  very  term  hysteria,  that  still  adhere  to  it  with  the 
persistency  of  an  evil  reputation. 

Among  the  earliest  writers  Hippocrates,  and,  later,  Plato  held  the  fanciful 
doctrine  of  the  wandering  womb.  Hippocrates  taught  that  the  hysterical 
globus  was  caused  by  the  ascent  of  the  womb  against  the  liver  and  diaphragm. 
Plato^  said  that  the  womb  is  an  animal  that  desires  ardently  to  engender 
children ;  when  it  remains  sterile  it  controls  itself  with  difficulty ;  it  is  in- 
dignant ;  it  wanders  about  the  body,  obstructing  the  air-passages,  arresting 
respiration,  throwing  the  body  into  extreme  dangers,  and  causing  diverse 
maladies.  Aretseus  accepted  this  incredible  doctrine ;  for  him  the  womb  was 
an  animal  within  an  animal,  enjoying  delicate  odors.  He  said  that  it  was 
possible  to  drive  it  down  by  presenting  fetid  odors  to  the  nose,  and  to  drive 
it  up  by  presenting  the  same  odors  to  the  vulva.  This  opinion,  unworthy  of 
an  untutored  savage,  controlled  practice  down  to  the  middle  ages.     He  was 

1  Timffius,  p.  568.    Works  of  Plato.    Translated  by  Taylor,  London,  1804. 


88  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

responsible  for  the  opinions  that  young  girls  alone  are  subject  to  the  disease ; 
that  elder,  married  women  escape  it — an  opinion  not  altogether  banished  to 
this  day. 

Galen  taught  that  hysteria  was  caused  either  by  the  suppression  of  the 
menses  or  the  retention  of  the  semen  (meaning  by  this  the  female  principle). 
Henceforth  this  latter  idea  has  great  prominence.  The  retained  semen,  under- 
going putrefaction,  became  a  violent  poison,  and  had  especially  injurious  effects 
in  women  who,  having  been  habituated  to  sexual  indulgence,  were  deprived 
of  it  suddenly.  To  effect  the  discharge  of  this  semen  Galen  recommended 
an  indecent  practice.  Thus  the  subject  became  identified  gradually  with  the 
idea  of  sexual  excesses  and  perversions. 

Aetius  and  Paul,  of  Aegina,  wrote  that  hysteria  attacked  preferably  young 
girls  who  were  lascivious  and  sterile. 

From  these  authors  there  is  a  wide  gap  down  to  the  early  part  of  the  seven- 
teenth century. 

The  earlier  of  the  modern  writers  merely  repeat  the  ancient  pathology. 
For  them,  as  for  the  ancients,  the  disease  was  confined  entirely  to  females  past 
puberty.  Forestus  was  the  first  who  attempted  to  distinguish  hysteria  from 
syncope,  apoplexy,  epilepsy,  and  lethargy,  and  described  well  the  phenomena 
of  the  disease ;  and  yet,  like  his  predecessors,  he  exaggerated  the  sexual  and 
libidinous  character  of  these  patients.  He  even  pretended  that  hysterical 
women  conceived  more  easily  than  others,  implying  that  this  fact  was  due  to 
their  greater  sexual  passion.  Sennertus  apparently  believed  in  the  infec- 
tiousness of  hysteria,  for  he  speaks  of  the  danger  to  which  one  is  exposed 
from  those  dead  of  the  disease. 

The  first  writer  to  recognize  hysteria  as  a  disease  not  confined  to  the  female 
sex,  and  hence  not  dependent  upon  affections  of  the  womb,  was  undoubtedly 
Carolus  Piso.  His  name  ought  to  take  high  rank  among  those  who  have  con- 
tributed to  the  knowledge  of  the  disease.  His  work  should  have  constituted 
an  epoch.  Yet  it  was  not  to  be  so.  The  old  ideas  were  too  deeply  rooted  to 
be  eradicated  by  one  man.  Piso,  or  Le  Pois,  was  the  first  who  distinctly  gave 
to  hysteria  a  cerebral  origin.  For  him  the  disease  was  caused  by  a  serous 
exudation  which  compressed  the  brain. 

Willis  elaborated  this  idea.  The  origin  of  hysteria  is  frequently  remote 
from  the  womb,  and  is  in  other  organs.  He  recognized  sudden  terror  as  a 
cause,  and  thus  anticipated  the  ideas  of  the  present  time,  especially  on 
trauma. 

From  this  point  begins  the  modern  epoch  of  hysteria,  which  is  characterized 
by  a  steady  departure  from  the  ancient  pathology  of  the  uterine  origin  of 
the  disease.  This  has  been,  however,  an  extremely  slow  j)i"0cess,  marked  by 
periodic  reactions.     Even  yet  it  is  not  complete. 

Sydenham's  was  the  first  great  name  of  this  period,  as  Charcot's  has  been 
the  last.  Sydenham  taught  that  hysteria  and  hypochondria  were  identical, 
being  distinguished  by  the  fact  alone  that  the  former  occurs  in  the  female,  the 
latter  in  the  male  sex.  He  believed  it  to  be  the  most  frequent  of  chronic 
maladies,  and  explained  it  by  a  humoral  pathology. 

Astruc  insisted  upon  marriage  as  a  remedy  for  hysteria — a  fallacy  which 
exercises  an  influence  to  this  day.  It  is  based,  of  course,  upon  the  primitive 
idea  of  a  predominant  sexual  element  in  this  disease. 

Whyte  was  the  first  who  approached  the  subject  in  the  modern  scientific 
spirit.  With  him  the  sexual  idea  falls  into  the  background.  He  finds  a 
number  of  causes  for  hysteria,  among  which  are  the  neurotic  temperament, 
prolonged  illness,  as  fever,  and  gout. 

Tissot  believed  that  the  ancients  were  wrong  in  regarding  the  womb  as  the 
sole  cause  of  hysteria. 


GENERAL  MORBID  STATES.  89 

Dr.  Rush'  placed  the  seat  of  the  disease  in  the  nervous  and  muscular  sys- 
tems. 

In  1816  Louyer  Villermay^  wrote  a  treatise  which  marked  the  height  of  the 
last  reaction  toward  the  ancient  pathology — a  book,  of  which  Briquet  said, 
that  it  ought  to  date  from  1500  rather  than  from  1816.  This  author  admits, 
like  the  ancients,  the  existence  of  a  sperm  or  semen  in  the  female ;  he  reverts 
to  the  belief  in  the  peregrinations  of  the  uterus,  and  consecrates  his  work  to 
making  of  hysteria  a  disease  of  lubricity,  a  shameful  affection,  the  victims  of 
which  are  objects  of  disgust  or  pity.  It  is  not  too  much,  perhaps,  to  say  that 
Louyer  Villermay  is  responsible  for  not  a  few  of  the  reactionary  ideas  that 
have  characterized  the  treatment  of  hysteria  in  the  present  century.  He  was 
refuted  by  Georget,  whose  observations  were  made  at  la  Salp^triere,  in  which 
hospital  at  a  later  date  it  was  reserved  for  Charcot  to  establish  this  subject  of 
hysteria  upon  a  basis  at  once  scientific  and  enduring. 

Before  him,  however,  Brodie,^  in  England,  w^rote  his  short  essay  on  local 
hysterical  affections,  a  work  that  has  no  superiors  for  originality.  It  forecast 
the  whole  vastly  important  subject  of  traumatic  hysteria. 

The  masterly  treatise  of  Briquet,  which  may  be  said  to  have  been  the  fore- 
runner of  the  school  of  Charcot,  appeared  in  1859.  To  the  latter  and  his 
pupils  we  can  refer  here  but  by  name.  The  chapter  which  follows  is  based 
largely  in  method  and  spirit  upon  the  scientific  foundations  which  they  laid 
both  broad  and  deep,  although  for  clinical  material  and  illustrations  it  draws 
almost  entirely  from  original  sources.  We  are  indebted  especially  to  the  trea- 
tise of  Gilles  cle  la  Tourette  for  much  assistance  in  literary  reference. 

Definition.  Hysteria  is  a  psycho-neurosis,  of  which  the  physical  symp- 
toms are  the  most  conspicuous,  tending  to  disguise  the  mental  phenomena  and 
to  simulate  superficially,  the  effects  of  various  organic  diseases.  It  is  not  a 
simulated  disease,  although  occasionally,  like  all  diseases,  it  may  be  feigned ; 
but  it  is  a  genuine  and  profound  affection  of  the  cerebral  centres,  which  pre- 
sents many  clinical  and  physiological  questions  of  great  interest. 

Hysteria  is  not,  as  so  many  authors  have  claimed,  a  protean  affection,  aj)ing 
all  other  diseases  and  having  no  identity  of  its  own.  On  the  contrary,  it  is  a 
distinct  morbid  entity,  with  a  natural  history,  and  with  a  train  of  symptoms 
that  are  subject  to  well-defined  laws  and  may  be  submitted  to  a  methodical 
study.  It  is  the  object  in  this  chapter  to  make  such  a  systematic  presentation 
of  hysteria. 

It  Mas  been  too  much  the  custom  to  regard  hysteria  as  a  conglomorate  affec- 
tion made  up  mostly  of  fantastic,  assumed  and  purposive  symptoms,  which 
are  the  evidences  either  of  foolish  or  of  designing  women.  Hence  hysteria 
is  still  confused  by  some  authors  with  folly,  mendacity  and  malingering.  In 
this  chapter  the  disease  will  be  demonstrated  to  be  something  far  other  than 
these. 

Finally,  hysteria  in  its  major  stages  has  some  manifestations  that  appear 
to  ally  it  with  other  grave  nervous  diseases,  such  especially  as  epilepsy, 
chorea  and  insanity,  and  it  has  received  names,  such  as  "  hystero-epilepsy," 
"chorea  major"  and  "hysterical  insanity,"  which  have  the  sanction  of  very 
respectable  authorities  and  which  are  intended  to  indicate  such  alliances. 
Nevertheless  it  will  be  maintained  in  this  chapter  that  such  terms  are  erron- 
eous, because  hysteria  is  a  distinct  affection,  and  that  where  it  seems  to  have 
such  alliances  the  aj^pearance  is  delusive  and  that  in  reality  the  symptoms 
are  purely  hysterical.     By  this,  however,  it  is  not  meant  that  two  or  more 

1  Diseases  of  the  Mind,  p.  259. 

-  Traite  des  Vapeurs,  ou  Maladies  Nerveuses,  et  partieulierement  de  I'Hysterie  et  de  L'Hypochon- 
drie.    Nouvelle  Edition,  Paris,  1832. 
^  Lectures  Illustrative  of  Certain  Local  Nervous  Aflections.    1837. 


90  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

distinct  neuroses,  such  as  epilepsy  and  hysteria  or  hysteria  and  insanity,  may 
not  coexist  in  the  same  person,  but  only  that,  even  if  co-existent,  they  are 
distinct.  Hence  the  error  of  attaching  to  some  of  the  phenomena  of  grand 
hysteria  terms  derived  from  other  diseases  will  be  avoided  in  these  pages. 

Etiology.  The  causes  of  hysteria  have  been  investigated  systematically 
and  classified  by  Guinon.^  He  shows  from  the  ancient  authors  that  hysteria 
developed  not  infrequently  in  former  times  under  the  influence  of  agents 
which  were  not  recognized.  The  conclusion  is  forced  upon  us  by  his  histor- 
ical study  that  hysteria  has  existed  as  at  present  at  all  times,  and  that  only 
an  error  of  doctrine  has  prevented  it  from  being  judged  at  its  true  value. 
Some  causes  of  hysteria  have  been  recognized,  nevertheless,  only  in  very 
modern  times,  and  it  is  probable  that  even  they  do  not  complete  the  list. 
This  is  to  be  explained  by  varying  conditions  of  life  and  environment,  such 
as  changes  and  developments  in  social  and  industrial  elements.  These  changes 
bring  some  causes  more  conspicuously  forward,  as,  for  instance,  trauma  in 
modern  life ;  or  create  others,  as  surgical  anaesthesia ;  or  allow  others  to  lapse 
into  insignificance  for  long  periods,  as  political  revolution  and  war.  Some 
causes  again  are  peculiar  to  locality,  as  earthquakes ;  others  to  certain  trades, 
as  poisoning  by  mercury. 

The  causes  of  hysteria  may  be  divided  into  six  classes  as  follows : 

Heredity.  This  is  the  most  important  and  extensive  cause  of  hysteria.  It 
is  in  fact  the  only  one  that  can  be  said  to  be  almost  universal.  It  is  the 
one  great  predisposing  cause,  all  others  are  only  exciting  causes,  according  to 
the  circumstances  of  time,  place  and  person.  So  uniformly  has  this  been 
recognized  that  it  did  not  escape  even  the  ancients.  Hijopocrates  recognized 
heredity  in  most  diseases,  as  when  he  said  that  phlegmatic  persons  engendered 
phlegmatic,  bilious  persons  bilious,  and  j)hthisical  persons  phthisical.  Hys- 
teria, in  fact,  may  be  included  in  the  class  of  constitutional  or  hereditary 
psychoses,  which  class  includes  at  its  other  extreme  the  types  of  e23ilepsy  and 
insanity.  Statistics,  as  well  as  common  observation,  prove  the  truth  of  this 
assertion.  Thus  hysteria  has  been  observed  to  be  transmitted  not  only  directly 
from  an  hysterical  parent,  but  indirectly,  or  by  transformation,  from  a  parent 
afilicted  with  one  of  the  more  grave  psychoses,  such  as  epilepsy  or  paranoia. 
This  is  an  indication  that  the  neurotic  constitution  is  developmental,  i.  e.,  the 
result  of  evolution  acting  thi'ough  innumerable  generations.  Georget  observed 
many  years  since  in  the  Salpetriere  that  hysterical  women  had,  among  their 
near  kindred,  hysterics,  epileptics,  hypochondriacs,  lunatics,  and  the  deaf  and 
blind.     Briquet^  demonstrated  the  truth  of  this  fact  by  a  statistical  study. 

His  first  table  shows  that  351  hysterics  had  1103  near  relatives  whose  his- 
tories could  be  traced.  Of  these  relatives  there  were  214  hysterics,  13  epilep- 
tics, 16  insane,  14  with  convulsive  diseases,  3  somnambulists,  and  12  with 
other  nervous  affections — a  result  of  25  per  cent.  His  other  tables  shoAV  that 
healthy  non- hysterical  women  had  but  2^-  per  cent,  of  neurotic  relatives ;  that 
subjects  whose  hysterical  careers  began  with  convulsions  had  28  per  cent,  of 
neurotic  relatives,  which  rate  was  shown  also  by  relatives  of  those  whose  hys- 
teria had  begun  before  puberty.  On  the  other  hand,  those  patients  whose 
attacks  had  come  on  gradually  had  but  19  per  cent,  of  kindred  with  grave 
neuroses.  From  all  this  it  appears  very  clearly  that  the  hereditary  element 
is  in  direct  proportion  to  the  severity  of  the  hysteria,  and  that  non-hysterics 
have  only  about  one-eighth  as  much  of  a  neurotic  element  in  their  heredity 
as  have  the  hysterics. 

Striking  instances  are  given  of  the  prevalence  of  hysteria  in  one  and  the 

1  Les  Agents  Provocateurs  de  I'Hysterie.     Paris,  1889.  -  Briquet:  Op.  cit.,  p.  79. 


GENERAL  MORBID  STATES.  91 

same  family.  Laudouzy'  saw  five  sisters  attacked  with  hysteria,  and  says 
that  Bernutz  saw  six  daughters,  born  of  an  epileptic  father,  the  victims  of 
hysteria.  I  have  seen  recently  an  only  daughter  with  hysterical  paraplegia, 
whose  only  brother  is  epileptic,  whose  father  is  a  confirmed  inebriate,  and 
whose  mother  has  the  marked  eccentricities  of  a  mild  grade  of  paranoia. 

Reynolds'^  on  the  other  hand  thinks  that  association  and  the  bad  influence 
of  an  hysterical  mother  explain  the  transmission,  which,  therefore,  is  not  by 
heredity  proper,  but  rather  by  example.  When  this  author  states,  however, 
that  "  hereditary  taint  has  not  been  shown  to  exert  any  marked  influence  in  the 
development  of  hysteria "  he  exhibits  the  lack  of  the  faculty  for  judicial 
criticism  and  the  disregard  for  literary  and  clinical  evidences  which  unfortun- 
ately characterize  many  British  writers  on  hysteria. 

Trauma.  Next  to  heredity,  trauma  ranks  in  importance  as  a  cause  of 
hysteria ;  not  that  it  is  so  frequent  as  some  others,  but  that  it  gives  rise  to 
grave  consequences  and  medico-legal  complications.  It  may  cause  most  or  all 
of  the  symptoms  of  hysteria,  both  paroxysmal  and  permanent ;  but  it  is  prone 
to  cause  some  of  the  latter  class  esj)ecially.  Among  these  are  localized  pal- 
sies, ansesthesias,  hy]3ersesthesias,  tremor,  and  contraction  of  the  visual  fields. 
These  efiects  are  confined  by  no  means  to  the  female  sex,  but  some  of  them,  as 
tremor  and  paralysis,  are  observed  especially  in  men.  From  the  practical 
standpoint  the  recognition  of  traumatic  hysteria  is  of  the  utmost  importance. 
This  is  so  for  two  reasons :  first,  because  of  the  prevalence  now  of  accidents 
by  railroad  and  by  machinery,  leading  to  litigation  for  damages ;  second, 
because  recently  the  subject  has  been  obscured  not  a  little  by  controversy 
and  by  the  use  of  euphemistic  terms. 

Of  all  the  forms  of  hysteria  this  hystero-traumatism  has  the  most  modern 
aspect.  This  is  due  to  the  fact  that  the  vast  extension  of  railroads  has  greatly 
increased  the  frequency  of  the  peculiar  morbid  entity  to  which  the  name  applies. 
It  would  be  a  mistake,  however,  to  suj)pose  that  cases  caused  by  railroad 
accidents,  or  cases  that  lead  to  litigation,  alone  display  these  symptoms.  Any 
form  of  traumatism,  even  the  slightest,  may  give  rise  to  the  most  obdurate 
symptoms.  Hence,  it  is  not  probable  that  this  class  of  cases  is  of  strictly 
modern  origin  ;  in  fact,  traces  of  such  cases  can  be  found  in  medical  litera- 
ture before  the  present  era,  but  they  were  not  recognized  at  their  fall  value, 
because  both  of  their  rarity  and  of  the  imperfect  knowledge  of  hysteria  which 
formerly  prevailed.  Brodie's^  monograph  on  this  subject  was  far  ahead  of 
his  time ;  it  is  remarkable  that  it  exerted  so  little  permanent  influence  and 
seems  to  be  so  completely  forgotten  or  overlooked  by  the  followers  now  of  the 
German  school.  Brodie,  in  the  simplest  and  plainest  way,  described  many 
of  the  interparoxysmal  symptoms  of  traumatic  hysteria,  and  illustrated  the 
subject  with  records  of  many  typical  cases.  Among  symptoms  observed  by 
him  were  hysterical  contracture,  astasia-abasia,  paralysis,  hysterogenous  zones, 
neuralgias,  aphonia,  anuria,  and  characteristic  mental  stigmata.  The  works 
of  Ericlisen  and  of  Page  mark  the  beginning  of  the  modern  interest  in  this 
subject ;  the  former  explained  these  cases  by  the  theory  of  a  spinal  concus- 
sion, the  latter  gave  them  a  psychical  origin.  From  the  time  of  the  appear- 
ance of  these  books  the  subject  has  been  discussed  with  acrimony.  Various 
terms  have  been  used  to  avoid  the  use  of  the  dreaded  term  hysteria,  among 
the  most  common  of  which  are  "railroad  spine,"  "traumatic  neurosis,"  and 
*'  traumatic  neurasthenia."  In  Germany,  and  later  in  England  and  America, 
under  the  influence  of  Op^^enheim,  the  tendency  has  been  to  differentiate  a 
special  form  of  neurosis,  the  result  of  accident,  to  which  the  name  of  hys- 

1  Quoted  by  Gilles  de  la  Tourette.  -  Art.,  Hysteria.    Reynolds'  System  of  Medicine. 

8  Op.  cit. 


92  NERVOUS  niSUASES  AND  THEIR  TREATMENT. 

teria  is  denied,  but  which  is  based,  nevertheless,  upon  many  or  most  of  the 
well-recognized  stigmata  of  hysteria  ;  while  in  France,  under  the  lead  of  the 
school  of  la  Salpetriere,  a  more  strict  and  consistent  nomenclature  has  been 
adopted,  and,  in  consequence,  a  more  scientific  presentation  of  this  subject 
has  prevailed.  It  seems  probable  that  a  more  scientific  criticism  will  yet 
prevail  in  America,  for  until  more  interest  and  care  are  shown  to  eliminate 
the  stigmata  of  hysteria  the  followers  of  the  German  method  must  be  on  the 
defensive.  Their  "  traumatic  neurosis  "  appears  to  be  hypothetical,  for  of  it 
Moebius^  says  that  it  is  a  form  of  hysteria,  and  Jolly  that  it  is  hysteria  pro- 
voked by  trauma. 

Apart  from  litigants  it  is  not  denied  that  trauma  causes  hysteria.^  The 
predisposition  of  the  patient  is  a  more  important  element  than  the  nature  of 
the  accident.  Accidents,  accompanied  with  shock,  and  especially  with  fright,, 
are  potent  causes,  hence  the  degree  of  actual  physical  injury  need  not  be 
great.  Hence  it  is,  also,  that  railroad  accidents,  which  excite  great  alarm, 
cause  so  many  of  these  cases.  Earthquakes  have  caused  inveterate  forms  of 
traumatic  hysteria ;  one  such  case  was  seen  by  the  writer  in  a  man  who  had 
persistent  hysterical  tremor  for  years  following  an  earthquake  and  great  tidal 
wave,  to  which  he  had  been  exposed  in  a  South  American  port.  Another 
case  of  tremor  has  been  seen  recently  in  a  young  woman  following  a  slight 
surgical  operation  under  ether.  Other  causes  are  dog-bites,  lightning,  and 
tornadoes.  This  class  of  causes  is  closely  allied,  therefore,  to  moral  and 
emotional  shocks  in  non-traumatic  cases,  which  will  be  considered  later.  No 
age,  sex,  or  condition  is  exempt  from  this  form  of  hysteria.  Some  of  the 
w^orst  cases  occur  in  men. 

Still  another  groujD  of  cases  is  ascribed  to  so-called  internal  traumata,* 
such  as  severe  visceral  disorders,  painful  colic,  etc.  These  cases  belong  prop- 
erly to  the  class  of  hysterics  caused  by  disease,  which  will  be  discussed  below. 
To  these  belong  also  the  cases  occurring  after  childbirth. 

Acute  and  Chronic  Disease.  In  persons  predisposed  any  protracted  dis- 
ease, or  even  an  acute  illness,  when  accompanied  with  suffering,  discourage- 
ment, depletion,  and  too  much  introspection,  may  cause  one  or  more  of  the 
symptoms  of  hysteria.  I  have  seen,  and  shall  report  briefly  later,  some  remark- 
able instances  of  this.  One  was  in  the  case  of  a  young  lady  who  had  under- 
gone an  arthrectomy  of  the  knee-joint,  followed  by  protracted  convalescence  * 
she  developed  hysterical  rajDid  respiration  to  what  appeared  to  be  an  alarm- 
ing extent.  I  have  seen  a  typical  hysterical  aphonia,  with  other  stigmata, 
develop  in  a  girl  who  was  bed-ridden  with  a  chronic  disease.  It  is  probable 
that  some  of  the  older  cases  of  so-called  aphasia  occurring  in  the  j)uerperium 
were  similar  to  this  one.  Churchill'  collected  reports  of  cases  of  paralysis 
after  childbirth,  as  did  also  Imbert-Gourbeyre'^  and  Poupon,®  among  Avhich 
hysterical  aphasia  (aphonia?)  and  hemiplegia  are  plainly  discernible.  AVhen 
occurring  after  infectious  diseases,  such  as  typhoid  fever,  scarlatina,  diphtheria, 
and  influenza,  the  diagnosis  may  remain  for  a  while  uncertain  as  between 
some  form  of  hysterical  paralysis  and  one  of  the  infectious  forms  of  neuritis. 

Brodie  describes  a  typical  case  of  hysteria  in  a  woman  following  tyj^hus 
fever. 

Diabetes   has  produced  hysterical  symptoms,  and  we  have  the  high  au- 

1  Quoted  by  Gillesde  la  Tourette,  whose  discussion  of  this  subject,  both  historical  and  clinical,  is 
complete  and  convincing.  The  literature  of  traumatic  hysteria  in  France  has  grown  to  large 
proportions,  and  must  be  consulted  by  all  who  wish  to  obtain  a  thorough  knowledge  of  the  subject. 

■-  Guinon  has  presented  this  aspect  of  the  subject  with  clearness  and  force  in  his  recent  work, 
"  Les  Agents  provocateurs  de  I'Hysterie,"  Paris,  1889. 

3  See  Rev.  Neurologique,  October,  1893. 

*  Dublin  Quart.  Journ.  Med.  Sci.,  vol.  xvii. 

^  "  Pes  Paralvsies  puerperales,"  Mem.  de  I'Acad.  Imp.  de  Med.  Tome  xxv. 

6  L'Enc6phale,  1865,  p.  393. 


GENERAL  MORBID  STATES.  93 

thority  of  Fournier^  for  the  statement  that  secondary  syphilis  has  excited  the 
crises  of  hysteria  in  women  previously  subject  to  it.  Raymond  and  others 
have  also  written  on  this  subject.  This  potency  of  syphilis  to  excite  hysteria 
may  be  ascribed  to  the  rather  sensational  character  of  the  disease  and  to  the 
profound  imj)ress  that  it  makes  ujjon  the  imagination. 

Emotions  and  Moral  Shock.  Closely  akin  to  the  mental  states  accom- 
panying traumata  are  emotions  of  various  kinds  acting  as  causes  of  hysteria. 
The  depressing  emotions,  although  not  exclusively,  act  thus.  The  most  com- 
mon are  fright,  chagrin,  disappointment,  grief.  As  said  already,  fright  is 
an  especially  active  cause  in  traumatic  cases,  but  it  may  act  with  equal 
force  in  non-traumatic  cases.  Chagrin  and  disappointment  are  active  causes 
in  the  young,  and  in  doubtful  cases,  in  which  hysteria  is  suspected,  such 
moral  causes  ought  always  to  be  sought  for.  Grief  probably  plays  a  sub- 
ordinate part  in  causing  the  disease,  unless  it  be  accompanied  with  other 
emotion,  such  as  sudden  shock.  It  is  common  to  ascribe  to  love  affairs  great 
j)otency  in  causing  hysteria,  and  this  probably  because  of  the  ancient  idea  of 
a  sexual  element  in  hysteria ;  but  this  asserted  tendency  is  probably  much 
exaggerated.  Mere  sentimentalism  and  emotionalism  do  not  fall  necessarily 
within  the  bounds  of  the  modern  strictly  defined  hysteria.  Genuine  grief 
or  disappointment  in  love  may  act  as  a  cause. 

A  common  cause  of  hysteria  in  all  ages  has  been  religious  excitement  or 
emotion.  This  is  seen  in  this  country  among  the  devotees  of  the  more  emo- 
tional sects.  It  is  not  uncommon  to  observe  this  cause  among  negroes  in 
their  camp-meetings  or  revival  services.  These  epidemics  of  hysteria  as- 
.sumed  immense  importance  and  great  proportions  during  the  middle  ages ; 
their  history  has  been  written  completely  by  Charcot  and  Paul  Richer.  They 
dejDended  always  upon  one  principle,  which  ought  never  to  be  forgotten, 
and  which  still  has  importance  every  day— the  principle  of  imitation.  This 
acts  with  equal  potency  sometimes  in  non-religious  epidemics,  as  in  schools, 
and  even  in  hospitals.  Thus,  recently  in  a  general  hospital  ward  in  Phila- 
delphia, in  which  several  cases  of  hysteria  of  severe  grade  were  being  treated, 
the  affection  threatened  to  spread  to  other  patients,  and  required  that  the 
hysterics  be  removed  and  isolated.  Of  historic  instances,  one  of  the  most 
important  was  the  epidemic  of  Salem  witchcraft,  which  owed  its  origin  to 
some  hysterical  children,  and  was  supported  in  the  perpetration  of  some  of  its 
greatest  atrocities  by  the  testimony  of  the  same  hysterical  perverts. 

Defective  Education.  As  said  already,  it  is  claimed  by  some  that  the 
effects  ascribed  to  heredity  as  a  cause  of  hysteria  are  the  efifects  rather  of 
evil  example,  and,  presumably,  of  bad  or  defective  education.  It  cannot  be 
doubted  that  the  two  classes  of  causes  are  closely  allied,  but  it  is  a  grave 
error  to  confuse  the  two  or  to  identify  the  one  with  the  other.  On  the  other 
hand,  it  is  extremely  difficult  to  distinguish  the  actions  of  these  causes  from 
one  another.  In  general  terms  it  may  be  said  that  the  training  or  environ- 
ment that  leaves  undeveloped  or  undisciplined  the  will-power  and  the  reason, 
and  that  permits  habits  of  self-indulgence  and  the  excesses  of  the  emotions 
and  the  imagination  to  go  uncurbed,  is  the  one  best  adajoted  to  foster  the 
hysterical  predisposition.  This  is  perhaps  a  somewhat  scholastic  statement  of 
a  most  practical  subject,  yet  even  such  a  practical  observer  as  Brodie  ascribed 
hysteria  to  a  defective  volition.  Perhaps  it  is  best  to  permit  the  mind,  after 
its  own  laws,  to  adjust  the  natural  and  wholesome  mutual  play  of  its  own 
faculties,  and  not  to  attempt  to  analyze  them  too  closely  in  the  hope  to  find  in 
psychological  terms  a  statement  and  a  remedy  for  this  disease.  A  wise  edu- 
cation, under  proper  instructors,  supplies  the  l:)est  environment  for  the  proper 

1  Lemons  cliniques  sur  la  sj'philis,  1873,  p.  816. 


94  NEEVOUS  DISEASES  AND  THEIR  TREAT2IENT. 

development  and  mutual  adjustment  of  all  the  faculties,  and  the  best  fruits 
of  it  are  discipKne,  self-control,  and  the  exercise  of  the  mind  in  useful  and 
rational  pursuits.  But  the  scope  of  such  an  education  cannot  be  outKned 
here.  On  the  other  hand,  it  is  a  grave  question  Avhether  even  the  wisest 
education,  even  universally  applied,  could  eradicate  or  suppress  entirely  the 
grand  neurosis.  Its  roots  are  too  deeply  fixed  in  the  constitution  of  patients 
to  render  it  probable  that  it  could  be  controlled  by  education  in  the  face  of 
some  of  the  existing  causes  ah-eady  named.  AYe  must  be  content  with  the 
general  statement  that  defective  training  permits  a  more  free  activity  of  these 
causes  which  a  wise  education  would  do  something  to  hold  in  abeyance. 

Toxmmia.  The  relation  of  toxic  states  to  hysteria  presents  a  somewhat 
novel,  and  a  most  important,  question.  The  subject  is  not  entirely  new,  yet 
the  complete  recognition  of  it  in  all  its  aspects  remains  still  to  be  recorded, 
esj)ecially  by  writers  in  the  English  language.  The  most  that  we  are  likely 
to  hear  in  this  country  is  that  confirmed  alcoholic  topers  may  present  some  of 
the  hysterical  stigmata.  This,  in  fact,  is  a  matter  of  common  observation, 
because  alcoholic  intoxication  is  a  common  vice.  Drunkenness  is  so  prev- 
alent that  all  its  effects  are  sooner  or  later  recognized.  Hence  alcohol  has 
long  been  regarded  as  an  hysterogenous  poison.  But  what  is  true  of  the 
familiar  alcohol  is  also  true  of  the  less  familiar  poisons,  such  as  lead,  mer- 
cury, and  sulphide  of  carbon.  Another  reason  for  the  confusion  existing 
about  the  hysterogenous  effects  of  these  poisons  is  the  fact  that  all  of  them 
produce  grave  organic  lesions,  especially  in  the  peripheral  nervous  system. 
Hence  the  tendency  is  to  attribute  all  nerve-involvement  to  organic  changes 
produced  by  the  particular  poison,  and  to  confuse  the  hysterical  stigmata  with 
the  symptoms  of  such  organic  change.  It  is  only  within  a  comparatively 
recent  period,  and  chiefly  in  France,  that  this  subject  has  been  investigated 
with  understanding  and  profit.^ 

Hysteria  in  all  these  cases  is  due  ^Drobably  to  a  psychic  impression — either 
fr'ight,  apprehension,  or  worry,  the  direct  effect  of  the  consciousness  of  the 
patient  that  he  has  become  the  victim  of  a  poison.  Hence  the  action  of 
causes  in  these  cases  is  not  unlike  that  of  trauma  and  acute  disease.  This 
probably  suggests  the  key  to  the  whole  problem,  so  that  instead  of  seeing  in 
these  cases  some  special  form  of  symptomatic  neurosis  we  should  see  in  them 
merely  the  display  of  the  classical  hysteria,  plus  the  effects  of  organic  dis- 
ease. 

As  far  back  as  1859  Briquet,  in  describing  hysteria  in  the  male,  reported 
seven  cases,  of  which  four  were  in  workers  in  lead.  He  seems  to  have  recog- 
nized the  full  significance  of  this  apparent  coincidence.  Later  the  marked 
analogy  of  saturnine  anaesthesia  and  hysterical  anaesthesia  did  not  escape 
French  writers,  most  of  whom  attempted  to  explain  it  away  and  to  differen- 
tiate the  one  fr'om  the  other.  The  discovery,  first  published  by  Landolt  and 
Oulmont,  that  these  saturnine  anaesthesias  could  be  transferred  or  even  cured 
by  a  magnet,  first  marked  incontestably  the  hysterical  character  of  some,  at 
least,  of  them.  Debove  and  Achard  first  suggested  for  this  class  the  name 
toxic  hysteria,  which  has  full  recognition  now  in  France.  Guinon  thinks  that 
lead  can  be  placed  in  the  front  rank  of  the  causes  of  hysteria.  In  this  coun- 
try this  subject  has  been  little,  if  at  all,  investigated,  all  the  phenomena  of 
disease  shown  by  workers  in  lead  being  attributed  indiscriminately  to  the 
organic  changes  wrought  by  the  poison. 

Mercury  has  a  power,  similar  to  that  of  alcohol  and  lead,  to  excite  hyster- 
ical symptoms.     Letulle''^  was  the  first  to  establish  this  fact  satisfactorily. 

1  Gilles  de  la  Tourette,  op.  cit.,  p.  101. 

'  Letulle  :  De  I'Hysterie  mercurielle  (Soc.  Med.  des  Hop.  de  Paris.    12  aoflt,  1887). 


GENERAL  MORBID  STATES.  95 

Later  Mugnerot^  proved  that  some  forms  of  mercurial  tremor  can  be  cured 
by  ffisthesiogenic  agents,  a  fact  which,  like  the  cure  of  saturnine  hemianses- 
thesia  with  a  magnet,  tends  to  prove  their  hysterical  character.  This  is  by 
no  means  an  assertion  that  all  tremors  due  to  mercury  are  hysterical,  but  only 
that  a  certain  type  of  them  may  be — and  this  is  the  "  type  Rendu  "  of  hys- 
terical tremor  in  which  the  rhythm  is  from  seven  to  nine  vibrations  to  the 
second,  and  which  continues  during  repose,  but  is  much  exaggerated  by  vol- 
untary movements.  In  these  cases  I  believe  that  the  powerful  psychic  im- 
pression is  the  immediate  cause  of  the  appearance  of  the  hysterical  stigmata. 
The  truth  of  this  was  proved  by  the  case  of  a  lady  who  had  a  badly-fitting 
set  of  false  teeth  made  by  an  inexperienced  dentist,  which  caused  irritation 
of  her  gums.  She  was  told  by  a  throat  specialist  that  she  was  seriously  poi- 
soned with  mercury,  which  he  asserted  had  been  absorbed  from  the  vermilion 
in  the  vulcanite  plate  of  the  set  of  teeth.  The  patient  was  much  alarmed 
by  this  statement,  and  developed  at  once  a  variety  of  purely  psychic  and 
hysterical  symptoms,  among  them  a  marked  tremor  of  the  facial  and  some 
other  muscles.  She  had  no  symptoms  of  geiiuine  mercurial  poisoning ;  but, 
Avhat  was  just  as  potent,  she  believed  that  she  had. 

Other  poisons,  such  as  morphine,  absinthe,  and  tobacco,  have  the  hystero- 
genous  quality.  In  fact,  there  is  no  reason  w^hy  any  poison  could  not  excite 
hysterical  symptoms  in  persons  who  are  predisposed.  It  is  probable  that  the 
general  lowering  of  nerve  tone  and  of  resisting  power,  which  are  the  results 
of  the  long-continued  use  of  these  j)oisons,  are  factors,  as  well  as  the  mental 
impressions  before  referred  to. 

Hysteria  can  occur  in  either  sex,  at  any  age,  and  in  every  race  and  coun- 
try. The  assertions  made  by  some  writers,  notably  English  and  German, 
that  hysteria  does  not  occur  in  their  respective  countries  in  all  its  classical 
phases,  are  erroneous,  and  are  disproved  constantly  by  other  writers  among 
their  own  countrymen,  who  occasionally  rejiort  typical  cases ;  and  by  ob- 
servers in  America,  who  not  infrequently  find  typical  cases  also  in  English 
and  German  emigrants.  Such  assertions,  therefore,  are  evidences  either 
of  defective  observation  or  of  a  prejudice  respecting  hysteria  that  is  not 
more  enlightened  than  the  ancient  belief  that  the  disease  has  its  seat  in  the 
womb,  and  is  confined,  therefore,  to  the  female  sex.  During  the  j)ast  year 
alone  I  have  seen  some  of  the  worst  forms  of  hysteria  in  young  English  and 
German  women.  One  English  girl  could  be  hypnotized  readily;  she  had 
the  grand  attacks,  just  as  they  are  seen  in  la  Salpetriere,  with  many  interparox- 
ysmal  stigmata.  One  young  German  w^oman  had  astasia- abasia ;  her  case  is 
reported  in  this  chajDter  further  on. 

The  recognition  of  hysteria  in  children,  and  especially  in  boys,  has  been 
very  slow  and  almost  entirely  modern.  Le  Pois  was  probably  the  first 
to  note  the  occurrence.  Whyte,^  in  his  old  book,  gives  a  case  of  hysteria  in 
a  boy.  Briquet^  made  a  statistical  study  of  87  cases,  apparently  all  girls. 
During  recent  years  in  France  this  aspect  of  hysteria,  as  all  others,  has  been 
thoroughly  explored.*  Clopatt*  has  given  the  most  complete  statistics,  which 
are  as  follows : 

1  Mugnerot :  Du  tremblement  mercuriel  et  de  son  traitement  par  les  agents  esthesiogSnes.  7th, 
Paris,  1889. 

2  See  Conolly's  paper  on  Hysteria,  Cyclopaedia  of  Medicine. 

3  Op.  cit.,  p.  55. 

*  Among  writers  especially  on  this  subject  are  Casaubon,  Pengniez,  Paris,  Guiraud,  Clopatt,  and 
Goldspiegel.  most  of  whose  contributions  may  be  found  among  the  Paris  theses.  Bournville's  Annual 
Contributions  on  Idiocy,  Epilepsy,  and  Hysteria  contain  many  instances. 

°  Quoted  by  Gilles  de  la  Tourette,  op.  cit. 


96  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Girls.  Boys.  Total. 

In  early  cMldhood      ........    19               1  20 

3  years 1  l 

4  ■  "     1       1  2 

5  "     4  2  6 

6  "     3  2  5 

7  "     15  4  19 

8  "     16  6  22 

9  "      15  7  22 

10  " 18  15  33 

11  "  ■    .  24  17  41 

12  "  22  13  35 

13  "  27  16  43 

14  "  12  8  20 

15  "  .    .    • 3  3 

176      96      272 

According  to  the  combined  statistics  of  Landouzy,  Georget,  Beau,  and 
Briquet,  as  given  by  the  last  author,^  hysteria  is  most  common  in  women  at 
the  age  of  twenty  years.  Briquet's  general  conclusions,  from  his  extensive 
statistical  study,  are  that  one-fifth  of  the  cases  in  the  female  sex  occur  before 
puberty ;  that  rather  more  than  one-third  of  the  cases  develop  between  the 
ages  of  fifteen  and  twenty  years ;  that  the  frequency  of  hysteria  decreases 
rapidly  from  twenty  to  twenty-five  years;  that  it  then  remains  stationary 
until  the  age  of  forty  years ;  and,  finally,  that  the  disease  is  very  rare  after 
forty  years. 

Batault^  has  made  a  similar  statistical  study  of  hysteria  in  men.  He 
found  that  the  disease  is  most  frequent  between  the  ages  of'  ten  and  twenty 
years,  after  which  it  decreases  in  a  ratio  very  similar  to  that  seen  in  the  other 
sex.  Gilles  de  la  Tourette  thinks,  however,  that  hysteria  develops  rather 
later  in  men  than  in  women,  and  attributes  this  to  the  fact  that  traumatism 
and  alcoholism,  which  are  common  causes  in  men,  act  so  much  more  fre- 
quently in  adult  life. 

As  to  the  comparative  frequency  of  hysteria  in  the  two  sexes,  statistics 
differ.  Bodenstein,  from  the  polyclinic  of  Eulenberg  and  Mendel,  observed 
one  case  of  hysteria  in  men  to  ten  in  women.  On  the  other  hand,  Marie,  in 
Charcot's  clinic,  was  surprised  to  find  by  statistics  that  hysteria  of  a  grave 
type  was  relatively  more  frequent  in  men  than  in  women,  but  this  observation 
applies  particularly  to  the  lower  classes,  among  whom  hysteria  in  the  male  is 
much  more  prevalent  than  it  is  in  the  higher  classes.  According  to  Sougues, 
hysteria  in  the  male  is  twice  as  frequent  in  the  hospitals  as  is  hysteria  in  the 
female — a  fact  that  will  surprise  many  in  America,  who  still  cling  to  the 
idea  that  hysteria  is  rare  in  men.  I  doubt  not  that  carefully  made  statistical 
studies  in  the  hospitals  of  this  city  (Philadelphia)  would  show  a  much  larger 
proportion  of  cases  of  the  disease  in  men  than  is  now  suspected.  As  the  French 
claim,  this  preponderance  is  due  to  the  efiects  of  trauma  and  alcoholism.  In 
this  country,  however,  the  tendency  is  to  ignore  traumatic  hysteria  in  men, 
or  to  call  it  by  other  names.  It  is  common,  for  instance,  for  hysterical  stig- 
mata to  be  overlooked  entirely  in  surgical  cases,  and  yet  some  of  the  most 
interesting  of  these,  as  tremor  and  anaesthesia,  may  occur.  I  have  noted  an 
extensive  hysterical  anaesthesia  involving  the  upper  arm,  the  shoulder,  and  a 
large  part  of  the  trunk  in  a  case  of  injury  to  the  elbow  in  a  young  man. 

Hysteria,  finally,  has  its  habitat  in  every  race  and  nation.  It  is  customary 
to  claim,  especially  in  England  and  Germany,  that  racial  characteristics  tend 
to  modify  or  to  give  complexion  to  hysteria  as  it  appears  in  some,  and  par- 
ticularly in  those  countries.  This  is  not  more  probable  of  this  disease  than  it 
is  of  insanity,  or  of  epilepsy,  or  of  any  other  grave  nervous  disease.  The 
conditions  that  predispose  to  hysteria  and  the  causes  that  excite  it  have 

1  Op.  Cit.,  p.  73. 

2  Contribution  a  I'Etude  de  I'Hysterie  chez  Thomme,  Paris,  1885. 


GENERAL  MORBID  STATES.  97 

already  been  detailed ;  these  are  not  peculiar  to  any  nation,  nor  is  any  race 
exempt  from  them.  It  is  only  when  from  some  particular  social  or  political 
circumstances  some  particular  nation  or  race  is  exposed  to  an  unusual  extent 
to  the  exciting  causes  of  the  disease  that  we  see  a  distinct  ethnic  jDredominance 
of  hysteria.  This  is  probably  the  explanation  of  the  fact  that  hysteria  is 
prevalent  among  the  Jews.  This  is  so  in  Europe  in  contrast  to  this  country, 
and  this  very  contrast  proves  that  the  prevalence  is  due  rather  to  social  than 
to  distinctly  racial  causes.  The  position  of  the  Hebrew  race  in  Europe  at 
the  present  time  is  a  very  peculiar  one.  The  Jews  have  been  slowty  appro- 
priating, in  fact,  almost  monopolizing,  in  some  countries,  as  Germany,  the 
professional  and  more  intellectual  pursuits,  such  as  medicine,  law,  literature, 
journalism,  and  banking.  With  this  gain  in  influence  and  riches  there  has 
been  no  corresponding  gain  in  social  caste,  but,  on  the  contrary,  of  late  years 
the  Jews  have  met  a  bitter  and  increasing  Anti-Semitic  crusade.  These 
circumstances  have  developed  in  the  European  Jew  a  highly  wrought  and 
highly  strung  nervous  system,  and  with  this  has  occurred  in  the  race  a  most 
significant  increase  of  the  two  diseases,  insanity  and  hysteria,  which,  more 
than  all  others,  are  the  products  of  the  struggle  for  modern  existence.^  This 
instance  of  the  Jews  in  Europe  probably  illustrates  better  than  could  any 
other  the  real  racial  elements  in  the  development  of  hysteria ;  in  their  case 
the  occurrence  of  the  disease  is  not  due  to  race,  but  rather  to  circumstances. 
In  conclusion,  it  is  enough  to  say  that  hysteria  has  been  observed  in  'every 
quarter  of  the  globe,  and  in  many  barbarous  peoj^les.^ 

Symptoms.  The  symptoms  of  hysteria  are  divided  natu.rally  into  two 
classes — the  paroxysmal  and  the  inter-paroxysmal.  Of  these,  the  former  are 
the  most  conspicuous,  but  the  latter  are  often  the  most  important.  The  former 
are  transient,  and  hence  are  not  often  available  for  study,  while  the  latter  are 
more  or  less  permanent,  and  hence  are  more  available  for  diagnosis.  The 
distinction  in  these  two  classes,  therefore,  is  a  most  important  one,  especially 
for  students  of  the  disease  in  America,  where,  just  as  in  England,  the  sys- 
tematic study  of  hysteria  has  not  been  customary  or  popular.^  In  accord, 
however,  with  the  plan  and  scope  of  this  chapter,  which  is  to  make  a  strictly 
systematic  presentation  of  this  subject,  this  distinction  will  be  observed  in 
description,  just  as  it  is  observed  by  nature  in  the  disease  itself.  In  this  con- 
nection I  cannot  omit  to  emphasize  the  statement  once  more  that  hysteria  is 
a  morbid  entity,  and  not  a  mere  conglomerate  of  fantastic  symptoms ;  that, 
in  a  word,  it  is  a  disease  with  a  natural  history  and  a  definite  symptomatology, 
and  that  pervading  and  controlling  all  its  manifestations  are  definite  and 
recognizable  laws. 

The  Paroxysm.  The  paroxysm  of  hysteria  has  been  called  unfortunately 
hystero-epilepsy.  This  is  a  misnomer.  The  term  seems  to  convey  the  idea  that 
the  paroxysm  is  a  mixture  of  the  two  diseases,  hysteria  and  epilepsy,  whereas  in 
truth  there  is  no  such  commingling.  The  paroxysm,  on  the  contrary,  is  hys- 
terical, pure  and  simple.  It  is  unfortunate,  moreover,  because  the  paroxysms 
of  hysteria  and  epilepsy  may  occur  in  the  same  patient ;  but  when  they  do  so 
occur  they  are  always  distinct  both  in  time  and  in  character.  This  form,  in 
which  the  two  diseases  coexist  in  the  same  patient,  has  been  called  by  the 
French  hystero-epilepsy,  with  separate  crises.  But  this  does  not  avoid  the 
error  involved  in  a  joint  term.  It  is  claimed  by  some  that  a  high  grade  of 
paroxysmal  hysteria  may  merge  into  or  develop  epilepsy,  but  this  statement 

1  See  a  most  interesting  paper,  "  Ttie  Anti-Semitic  Movement,"  by  Sidney  Whitman,  in  the  Con- 
temporary Review,  May,  1893. 

2  Tourette  gives  instances  of  the  occurrence  of  hysterical  symptoms  in  the  lower  animals.    There 
is  nothing  inherently  improbable  in  the  claim  that  such  phenomena  occur. 

8  Exception  to  this  statement  must  be  made  in  favor  of  the  exhaustive  paper  on  Hysteria  by  Dr. 
Charles  K.  Mills,  in  the  American  System  of  Medicine,  Philadelphia,  1886. 

7 


98  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

is  without  adequate  foundation.  Once  hysteria,  always  hysteria.  On  the 
other  hand,  epileptics  may  exhibit  both  the  paroxysmal  and  the  inter-parox- 
ysmal symptoms  of  hysteria,  of  which  the  epilepsy  is  an  exciting  cause,  just 
as  other  grave  diseases  may  excite  hysteria,  as  abeady  shown.  In  these  cases, 
however,  the  diseases  have  separate  crises.  From  all  this  it  appears  that 
there  is  no  true  hystero-epilepsy,  but  only  a  paroxysmal  form  of  hysteria.  It 
would  be  as  aj)propriate  to  speak  of  an  hystero-tetanus  or  of  a  tetano-epilepsy. 

The  best  term,  therefore,  by  which  to  designate  the  paroxysm  is  simply 
hysterical  con%Tilsion,  but  if  a  more  striking  and  distinctive  term  is  desired  it 
may  be  called,  after  Charcot,  the  grand  hysteria. 

The  hysterical  con-^Tilsion  has  been  divided  by  Charcot,  Eicher,  and  their 
followers  into  four  periods.  For  this  division  they  have  been  criticised  not  a 
little  by  those  who  profess  not  to  be  able  to  see  in  hysteria  a  consistent  and 
homogeneous  disease.  I  am  convinced  that  this  criticism  is  not  based  upon 
conscientious  and  intelligent  obser^'ation ;  or  else  that  it  is  biased  by  preju- 
dice against  hysteria.  Probably  no  modern  instance  of  fine  analytical  faculty 
in  the  observation  and  description  of  disease  can  be  named  that  can  surpass 
the  exhibition  of  the  exercise  of  thLs  faculty  by  Charcot  in  his  original  study 
of  the  hysterical  fit.  He  has  the  supreme  merit  of  having  established  a 
type  ;  and  tlois  type  will  doubtless  endure  and  be  recognized  in  all  succeeding 
medical  literature.  It  has  the  great  advantage  of  combining  innumerable 
features  in  one  easily  recognized  picture,  and  of  estabhshing  a  standard  by 
which  can  be  studied  and  contrasted  all  forms  of  the  grand  neurosLs,  however 
atypical  and  diverse.  It  will  be  impossible,  henceforth,  for  anyone  to  study 
this  convulsion  with  profit  without  reference  to  this  type  of  Charcot,  and  it 
is  safe  to  predict  that  each  succeeding  obser^'ation  by  scientists  will  in  the 
future,  as  in  the  past,  confirm  the  general  accuracy  of  the  iconography  of 
the  great  French  neurologist.  Diversities  and  departures  from  the  typical 
form  doubtless  occur,  just  as  he  pointed  out,  but  they,  like  all  variants  in 
the  evolution  of  natural  forms,  are  best,  and  in  fact  alone,  accounted  for  by 
reference  to  the  type.  The  recognition  of  this  fact  is  of  great  sen'ice  to  the 
clinician  in  diagnosing  some  of  the  more  obscure  forms  of  con\'ulsive  hysteria. 

The  paroxysm  is  invariably  preceded  by  prodi'omes.  It  never  occurs,  like 
that  of  epilepsy,  suddenly  and  almost  without  warning.  These  prodi'omes 
are  easily  recognized  by  experienced  observers,  and  even  by  the  patient  him 
or  herself.  Thus  Richer  gives  the  case  of  a  woman  who  thought  herself 
cured,  but  who  after  a  long  interval  of  exemption  recognized  the  approach 
of  a  seizure  by  the  appearance,  several  days  before  the  onset,  of  familiar 
mental  and  physical  prodi'omes.  It  is  not  uncommon  in  hospitals  for  nurees 
and  attendants  to  acquire  this  knowledge  and  to  predict  a  con^-ulsion. 

The  first  prodromes  are  mental,  and  they  may  appear  some  days  before  the 
convulsion.  The  patient  presents  a  change  of  character,  or  rather  of  mood. 
She  may  recognize  this  herself.  She  is  no  longer  able  to  apply  herself  to  her 
accustomed  avocations ;  she  cannot  concentrate  her  mind  ;  hence  she  cannot 
read  or  sew  or  attend  as  usual  to  household  duties.  It  is  observed  by  others 
that  the  patient  is  abstracted,  self-concentrated,  depressed,  or  absorbed  in  re- 
flections. She  shuns  the  society  of  others,  and  if  approached  may  be  irri- 
table, repellant,  and  not  inclined  to  make  confidences.  These  changes 
indicate  indubitably  the  psychical  essence  of  hysteria  ;  it  is  a  disease  of  dis- 
turbed cerebration.  Later,  as  the  climax  approaches,  a  more  distinct 
emotional  element  apj^ears :  the  patient's  affective  nature  is  more  and  more 
easily  disturbed  and  thrown  out  of  equilibrium.  Tears  and  laughter  are 
excited  readily  and  alternate  without  apparent  cause ;  in  fact,  this  loss  of 
emotional  balance  may  usher  in  the  fit.  Hallucinatirms,  delusional  ideas, 
and  disturbed  dreams  are  common  during  this  prodromal  period.     Thus, 'a 


GENERAL  MORBID  STATES.  99 

lady  under  my  care  had  as  hysterical  prodromes  nightmares  and  dreams  of 
her  scalp  falling  off,  and  these  accompanied  headaches,  which  persisted  during 
the  day.  In  accord  with  the  psychic  disorder  are  the  iieglect  of  dress  and 
disregard  of  the  proprieties  which  noAV  appear ;  and  a  change  of  facial  ex- 
pression, which  is  quite  characteristic  in  some  patients.  Sometimes  the  mental 
agitation  is  so  pronounced  that  it  becomes  maniacal  in  character ;  the  patient 
then  shows  incessant  motor  activity,  paces  the  floor,  gesticulates,  utters  inco- 
herent and  exclamatory  phrases,  and  seems  to  be  in  acute  mental  distress. 
In  other  cases,  again,  the  psychosis  has  a  melancholic  tinge ;  the  patient 
broods,  and  is  sluggish  in  both  speech  and  movement.  In  all  that  the 
patient  does  and  says  in  either  case  the  disturbed  emotions  and  the  lowered 
volitional  control  are  the  conspicuous  psychical  phenomena. 

Very  common  prodromes  of  the  grand  attack  are  disorders  of  the  digestive 
apparatus ;  among  these  are  loss  of  appetite,  perversions  of  taste,  and  vomit- 
ing. Many  patients  have  a  peculiar  spasm  of  the  thi'oat  muscles,  and  perhaps 
of  those  also  of  the  oesophagus,  which  produces  a  sense  of  suffocation.  This 
was  conspicuously  described  by  the  ancients.  Many  or  all  of  these  symptoms 
may  also  appear  as  iuter-paroxysmal  stigmata  of  hysteria,  and  will  be 
described  more  in  detail  later. 

The  same  mav  be  said  of  most  or  all  of  the  sensory  and  motor  prodromes 
described  in  detail  by  Eicher.  These  consists  of  various  forms  of  ansesthesia, 
h}^Dereesthesia,  paralysis,  and  contracture,  which  may  appear  in  some  patients 
as  prodromes  of  the  fit.  They  are  properly,  however,  intervallary  stigmata, 
and  as  such  will  be  described  in  their  appropriate  place.  It  may  be  empha- 
sized in  this  connection  that  the  hysterical  con^T,Tlsion  is  often  the  occasion  or 
the  starting  point  for  the  display  of  some  of  the  most  persistent  of  the  per- 
manent stigmata ;  these  may  show  themselves  occasionally  as  prodromes, 
being  excited  by  the  peculiar  psychical  state  that  culminates  in  a  paroxysm. 
After  the  paroxysm  they  may  survive,  and  even  persist  for  indefinite  periods. 
We  see  something  analogous  to  this  in  epilepsy  in  the  occurrence  of  charac- 
teristic psychical  states  before  the  explosion,  and  in  the  persistence  of  them 
for  some  hours  or  days  after  the  fit. 

The  hysteric,  like  the  epileptic,  fit  is  ushered  in  by  an  aura.  This  aura  in 
reality  may  be  classed  among  the  prodromes.  It  has  this  distinctive  mark, 
that  whereas  the  ordinary  prodrome  may  appear  several  days  before  the  par- 
oxysm, the  aura  immediately  precedes  the  paroxysm,  and  in  a  sense  may 
even  be  considered  a  part  of  it.  The  most  common  aurge  are  the  globus,  the 
clavus,  and  the  ovarian  h}^ersesthesia.  The  globus  hystericus  consLsts  in  the 
sense  of  a  ball  rising  in  the  throat ;  it  is  attended  with  a  sense  of  suffocation, 
and  usually  with  palpitation  of  the  heart.  The  clavus  is  a  circumscribed 
pain  in  the  head,  of  very  limited  extent,  which  has  been  likened  to  a  i3ain 
such  as  would  be  produced  by  driving  a  nail  into  the  part — hence  the  name. 
It  may  be  accompanied  with  ringing  and  beating  noises  in  the  ears  and  with 
a  feeling  of  being  beaten  on  the  temples  Avith  mallets.  The  most  common 
aurse  are  those  emanating  from  the  ovaries.  These  may  be  spontaneous ; 
they  may  even  be  preceded  by  a  degi'ee  of  tenderness  on  pressure  that  sug- 
gests peritonitis.  These  ovarian  aur^e  doubtless  had  some  influence  in 
directing  the  attention  of  the  ancients  so  exclusively  to  the  womb.  Other 
areas  on  the  surface,  almost  exclusively  on  the  trunk,  are  sometimes  the 
stalling  points  for  awne.  These  aurse  may  be  spontaneous,  or  they  may  be 
excited  by  pressure.  Hence  these  areas  have  been  called  hysterogenous  zones, 
and  will  he  described  briefly  later  among  the  stigmata. 

The  four  periods  of  the  typical  or  classical  hysterical  convulsion  as  described 
by  the  French  school  are:  (1)  The  epileptoid  ;  (2)  the  period  of  grand 
movements ;  (3)  the  period  of  passionate  attitudes ;  (4)  the  period  of  delir- 


100  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ium.  These  are  not  equally  developed  in  all  cases  ;  in  fact,  from  my  obser- 
vation, I  should  say  that  atypical  or  abortive  attacks  are  perhaps  the  most 
frequent  in  this  country.  It  is  necessary  in  description,  however,  to  conform 
to  the  type,  and  this  will  be  done,  with  the  preliminary  statement  that  the 
author's  hospital  services  in  this  city  have  amply  confirmed  the  accuracy  of 
the  description  of  Charcot,  and  with  the  further  statement  that  the  abortive 
attacks  will  be  studied  with  care  later. 

The  first,  or  epileptoid,  period  of  the  hysterical  fit  resembles  closely  the 
convulsion  of  true  epilepsy.  Like  it,  its  first  phase  is  one  of  tonic  rigidity 
of  the  muscles.  The  arms  and  legs  are  usually  extended,  the  hands  clenched, 
the  trunk  bent,  usually  in  a  mild  degree  of  opisthotonos,  the  eyes  crossed  or 
fixed  in  conjugate  deviation,  and  the  teeth  set.  The  breath  is  arrested  and 
the  pulse  accelerated.  The  consciousness  is  obtunded  and  even  lost,  although 
the  degree  of  unconsciousness  is  certainly  not  so  profound  as  in  epilepsy. 
This  is  proved  by  the  fact  that  pressure  over  the  ovaries,  or  the  action  of  an 
electric  current,  usually  promptly  arrests  the  fit.  In  falling,  the  patient  as  a 
rule  does  not  injure  himself,  and  the  tongue  is  not  bitten.  The  tonic  is  suc- 
ceeded by  the  clonic  phase,  in  which  the  muscles  of  the  face  and  limbs  are 
thrown  into  rhythmical  shock-like  movements.  These  movements  are  not 
identical  with  those  of  the  true  epileptic  fit,  although  it  is  difiicult  to  indicate 
in  what  respect  they  diflfer.  They  have  not  the  same  quality  of  intensity,  of 
reflex  activity,  and  of  mechanical  force  that  marks  the  discharge  of  the 
lower  centres,  which  constitutes  true  epilepsy.  There  is  in  hysteria  always  a 
psychical  element,  which  is  not  altogether  wanting  even  in  the  most  severe 
seizure.  If  consciousness  is  lost  it  is  at  least  not  very  far  below  the  surface ; 
and  so,  if  the  clonic  movements  are  involuntary,  they  are  not  so  profoundly 
so  that  it  is  impossible  to  summon  the  will  again  to  the  control  of  them. 
This  is  seen  in  the  prompt  arrest  of  the  fit  by  j)ressure  over  the  ovary.  At 
the  same  time  special  and  general  sensibility  are  profoundly  affected.  The 
patient  sees  and  hears  nothing,  in  spite  of  the  assertions  of  some  medical 
writers  that  such  patients  are  always  peeping  out  from  under  half-closed  lids. 
This  statement  is  based  probably  on  the  fact  that  slight  clonic  movements 
may  be  seen  in  the  eyelids  in  some  patients.  General  sensibility  is  so  blunted 
that  tactile  and  even  painfiil  impressions  are  not  noted.  The  clonic  move- 
ments in  some  cases  are  localized,  i.  e.,  they  are  confined  to  one  member,  to 
one  muscle  group,  or  to  one  side.  During  the  movements  the  respirations 
are  labored  and  embarrassed.  The  clonic  phase  is  succeeded  by  the  thii'd 
and  last  phase,  resolution.  The  clonic  movements  subside  gradually,  and 
finally  disappear.  The  patient  lies  relaxed  and  suj)ine.  She  reclines  with 
head  to  one  side ;  saliva  flows  from  the  mouth.  Consciousness  is  still 
obscured,  and  perhaps  light  sleep  supervenes.  There  is  no  incontinence  of 
urine  or  feces.  Occasional  shocks  may  occur  during  this  period,  and  it  is 
common  for  the  eyelids  to  present  slight  oscillations. 

After  a  short  interval  the  second  period  begins.  The  second  period  of  the 
grand  attack  is  that  of  grand  movements,  or,  as  it  has  been  called,  "  clown- 
ism."  It  is  characterized  by  violent  and  extravagant  muscular  movements, 
either  in  the  nature  of  disordered  contortions  or  of  regulated  and  apparently 
purposive  feats.  Movements  of  this  character  have  acquired  great  promi- 
nence in  some  of  the  epidemics  of  hysteria,  as,  for  instance,  the  epidemic  of 
St.  Medard,  in  which,  as  Briquet  says,  the  movements  were  so  astonishing 
and  inexplicable  that  it  was  thought  necessary  to  attribute  them  directly  to 
divine  influence.  By  a  reversal  of  the  same  logic,  they  were  attributed  in 
some  of  the  earlier  epidemics,  which  contributed  to  the  brutal  superstition  in 
witches,  to  the  influence  of  the  devil.  All  the  dances,  contortions,  mimicries, 
and  bizarre  and  grotesque  feats  of  dexterity  which  we  read  about  in  those 


GENERAL  MORBID  STATES.  101 

old  middle-age  crazes,  or  ■which  we  see  occasionally  at  present  in  the  devotees 
of  emotional  religion,  were  and  are  instances  of  this  "  clownism,"  which  con- 
stitutes the  second  period  of  the  hysteric  con\^lsion.  These  same  phenomena 
are  seen,  moreoyer,  in  some  of  their  most  important  aspects,  when  they  con- 
stitute the  at\q)ical  attacks  which  appear  sometimes  in  isolated  cases.  They 
may  then  constitute  the  whole  of  the  attack  and  undergo  such  an  extra- 
ordinary deyelopment  as  to  lose  almost  entirely  their  primary  affinities,  and 
may  thus  present  difficult  problems  in  diagnosis.  Again,  this  second  period 
may  almost  or  entirely  abort ;  in  fact,  in  hysteric  con^Tilsions  of  a  mild  grade 
it  is  not  uncommon  in  my  exiDerience  to  see  it  abort,  or,  at  least,  to  assume  a 
yery  minor  part.  The  most  common  of  these  moyements  is  the  so-called  arc  of 
a  circle,  in  which  the  patient  assumes  a  position  of  opisthotonos,  which  may  be 
complete  or  incomplete.  The  patient  may  assume  this  position  lying  either 
on  her  back  or  on  her  side.  Other  movements  of  extreme  contortion,  too 
numerous  and  varied  to  be  detailed,  may  be  shown.  In  contrast  to  these 
inco-ordinate,  or,  as  the  French  say,  illogical,  movements,  are  others  of  a 
more  regulated  and  comjDlex  kind.  Richer  has  described  and,  with  his  own 
^lencil  illustrated,  these  movements.  The  most  common  is  that  called  "  salu- 
tation," in  Avhich  the  patient,  lying  on  her  back,  suddenly  bends  the  body 
forward  until  the  head  almost  touches  the  knees  ;  this  is  repeated  many  times. 
Others  consist  in  bending  and  arching  the  body  and  flexing  and  extending 
the  limbs  in  various  ways,  rapidly  repeated,  usually  while  the  patient  reclines 
on  her  bed.  This  extreme  motor  agitation  seems  to  have  some  mental  asso- 
ciation, or  to  be  at  least  the  expression  of  a  mental  state.^  In  some  cases  this 
mental  state  appears  to  bystanders  to  be  quite  alarming,  and  the  cases  to 
have  a  veritable  demoniac  element  in  them.  There  is  not  loss  of  conscious- 
ness during  this  second  period,  for  the  patient  seems  to  be  reacting  to  some 
kind  of  a  mental  stimulus,  but  there  is  not  the  same  association  with  delusions 
and  hallucinations  as  appears  in  the  next  period. 

The  next,  or  third,  period  has  been  called  by  Charcot  the  period  of  pas- 
sionate attitudes ;  but  as  these  attitudes  are  but  expressions  of  mental  phe- 
nomena, it  would  be  more  aj)f)ropriate  to  name  this  stage  accordingly,  and 
call  it  the  emotional  period.  It  has  been  customary  for  French  writers  to 
say  that  it  is  characterized  by  delusions.  The  objection  to  this  is  that  it  con- 
veys the  idea  of  an  insane  state,  in  which  a  delusion  dominates  the  mind. 
Xo  such  domination  by  insane  delusions  can  be  demonstrated  in  hysteria, 
and,  therefore,  the  term  delusion  in  the  English  language  conveys  an  errone- 
ous meaning.  The  same  may  be  said  of  the  term  "  hallucinations,"  also  used 
by  French  writers.  It  is  doubtful  if  the  hysteric  in  her  most  perverted  stages 
has  genuine  hallucinations  in  the  sense  in  which  the  term  is  used  in  English. 
With  us  it  means  a  false  sensory  concept  accepted  by  the  patient  as  true.  It 
is  a  symptom  of  profound  alterations,  such  as  characterize  some  of  the  more 
grave  states  of  insanity.  The  hysterical  patient  scarcely  has  delusions  and 
hallucinations  in  the  sense,  therefore,  in  which  we  use  these  terms  for  the 
insane.  What  she  has  can  more  properly  be  termed  mental  images  or  rev- 
eries, rising  into  consciousness,  either  as  a  cause  or  a  consequence — more 
probably  the  former — of  her  disturl^ed  emotional  state.  In  the  height  of  the 
paroxysm,  amidst  the  favorable  conditions  of  lowered  volition  or  cerebral 
inhibition  that  characterize  the  psychical  state  in  hysteria,  the  patient  simply 
passes  into  a  melee  of  her  emotions,  the  most  prominent  of  which  are,  doubt- 
less, expressive  of  ideas  or  experiences,  often  painful,  derived  from  her  past 
life.    Hence  the  third  period  of  grand  hysteria  is  essentially  dramatic  ;  hence, 

1  Sauvages  used  the  term  hysteria  libidinosn  for  those  cases  in  which  during  convulsion  the  patient 
alternates  rapidly  from  opisthotonos  to  dorsal  decubitus. 


102  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

too,  it  is  capable  of  almost  indefinite  expansion  in  the  hands  of  expert  scien- 
tists, who  may  be  tempted,  perhaps,  too  often,  to  play  the  role  of  stage- 
director.  This  explains  why  these  exhibitions  are  not  common  in  localities 
or  countries  in  which  the  taste  for  them  does  not  exist.  The  tendency  to 
them  is  probably  just  as  inherent  in  hysterics  in  one  country  as  in  another, 
having  slight  diversities  in  such  minor  national  traits  as  the  expression  of 
motion,  but  the  greatest  distinction  exists  among  races  and  nations,  due  to 
causes  that  need  not  be  discussed  here,  in  their  appetence  or  relish  for  the 
melodramatic.  Perhaps  the  exaggeration  of  development  which  this  stage 
has  experienced  in  France  has  done  much  to  excite  j^rejudice  against  and 
criticism  of  the  disease.  Its  true  importance,  however,  ought  not  to  be 
ignored.  From  the  purely  pyschical  standpoint,  it  is  perhaps  the  most 
significant  of  all  the  stages  of  hysteria. 

Little  or  no  interval  occurs  between  the  motor  excitement  of  the  second 
jDcriod  and  the  tableaux  of  the  third.  In  fact,  it  is  well  to  recall  that  these 
two  periods  merge  so  naturally  the  one  into  the  other  that  many  cases  do  not 
present  the  typical  divisions  into  stages.  These  grand  movements  and  these 
passionate  attitudes  are  simply  expressions  of  emotions,  and  as  such  may  be 
blended,  confused,  or  modified  in  various  ways,  according  to  the  circum- 
stances and  the  individuality  of  the  patient.  It  is  obviously  impossible  in  a 
short  space  to  recount  or  to  classify  all  the  varied  modes  of  dramatic  expres- 
sion into  which  hysterical  patients  can  throw  themselves.  They  are  as  count- 
less as  are  the  shifting  phases  of  their  emotions,  reacting  to  every  stimulus  of 
both  memory  and  environment.  Richer,  indeed,  has  attempted  such  a  classi- 
fication, based  upon  cases  observed  by  himself,  which  cases  had  evidently 
been  subjected  to  the  more  or  less  unintentional  hypnotic  suggestions  Avhich 
characterize  very  plainly  the  work  of  the  French  school.  Hence  it  is  by  no 
means  sure  that  his  observations  on  the  third  stage  of  the  classical  attack  will 
be  confirmed  by  all  other  observers  in  all  other  countries.  These  manifesta- 
tions will  doubtless  take  form  and  complexion  from  the  personnel  of  both 
patient  and  audience.  This  is  no  reflection,  however,  upon  the  scientific 
accuracy  and  value  of  the  writings  and  drawings  of  this  gifted  French 
author.  Hysteria  is  a  disease  of  suggestibilities :  its  possibilities  are  count- 
less. The  varieties  of  passionate  attitudes,  as  given  and  depicted  by  Richer, 
are  as  follows :  the  attitude  of  the  cross,  of  defense,  of  menace,  of  appeal,  of 
lubricity,  of  ecstasy,  of  dread  of  animals,  such  as  rats,  etc. ;  of  listening  to 
music,  of  scorn,  and,  finally,  of  lamentations.  He  even  attempts  to  allot  the 
time  in  seconds  which  each  scene  of  this  drama  consumes.  Thus  the  attitude 
of  the  cross  requires  twenty-three  seconds  ;  appeal,  ten  seconds  ;  lubricity,  four- 
teen seconds,  etc.  This  is  obviously  an  excess  of  refinement  in  description. 
It  is  sufficient  for  our  purposes  here  to  state  merely  that  the  third  period  of 
the  hysterical  convulsion  is  one  'of  dramatic  repi'esentation  of  emotional 
images,  and  that  these  are  of  countless  variety,  according  to  time  and  person. 
They  are  apt  to  preserve  curiously  the  same  physiognomy  always  in  the  same 
case.  In  other  words,  peculiarities  of  words  and  expressions  and  attitudes 
are  repeated  by  the  patient  in  successive  fits.  They  are  stereotyped,  as 
Richer  says.  It  is  important,  finally,  to  indicate  that  some  particular  phase 
of  this  period,  as  ecstasy,  for  instance,  may  acquire  in  some  cases  excej)- 
tional  conspicuousness  and  persist  as  an  isolated  phenomenon,  thus  con- 
stituting an  atypical  form  of  grand  hysteria.  This  fact  ^vill  be  alluded  to 
again. 

During  the  third  period  sensory  stigmata  of  a  high  grade  are  present.  The 
patient  dees  not  feel  tactile  and  painful  impressions,  the  conjunctiva  are  in- 
sensate, the  hearing  is  lost  for  even  loud  sounds,  and  the  patient  is  oblivious 
of  all  her  surroundings.     Pressure  over  the  ovaries  and  the  use  of  electricitv 


GENERAL  MOBBID  STATES.  103 

are  said,  however,  always  to  abort  the  attack.  After  the  attack  the  patient 
retains  a  memory  of  the  events  of  this  period. 

The  fourth  period  of  the  attack  has  been  called  the  period  of  delirium. 
Here,  again,  some  slight  criticism  of  terms  is  called  for.  The  terminal  stage 
of  the  grand  attack  of  hysteria  is  not  marked  by  a  delirium  as  intense,  or 
even  of  just  the  same  nature,  as  that  which  characterizes  the  febrile  diseases, 
and  which  is  suggested  by  this  term  in  the  English  language.  It  is  rather  a 
paroxysm  of  emotional  disturbance,  continuous  with  that  of  the  third  period, 
but  not  marked  by  the  active  motor  expressions  of  that  period,  which  seem 
now  to  have  exhausted  themselves.  The  tinge  of  this  emotion  is  usually  one 
of  sadness,  and,  just  as  in  the  former  period,  it  feeds  upon  painful  ideas 
which  are  gathered  from  the  memory  of  the  past  life.  Sometimes  there  are 
noisy  weeping  and  lamentation,  and  instead  of  acting,  as  in  the  third  period, 
the  patient  iiow  declaims.  Richer  makes  of  this  a  vital  distinction  between 
the  two  periods :  the  former  is  one  of  acting  the  latter  one  of  speech.  This 
distinction,  however,  is  likely  to  be  lost  in  many  cases ;  the  characteristics  of 
the  two  periods  may  blend  in  cases  departing  slightly  from  the  type.  In  the 
fourth  period  consciousness  is  returning  or  has  returned ;  hence  the  patient 
is  en  rapport  with  her  surroundings.  During  this  period  the  sensory  stig- 
mata which  were  seen  in  the  third  period  may  persist,  but  added  to  them 
may  be  motor  stigmata,  which  were  quite  absent  before.  Among  these  the 
most  common  are  various  forms  of  contracture ;  these  may  persist  for  many 
days  after  the  seizure.  Other  motor  stigmata,  sometimes  originating  in  this 
period,  and  persisting  as  relics  of  the  convulsion,  are  the  several  varieties 
of  paralysis  and  tremor.  The  delirium,  finally,  may  merge  into  an  obsti- 
nate mutism,  or  even  into  more  rare  complications,  such  as  trance  and 
lethargy. 

The  hysterical  convulsion,  such  as  we  have  now  described,  lasts  from  one- 
quarter  to  one-half  an  hour ;  this  is  exclusive  of  the  "  delirium "  of  the 
fourth  period,  which  may  be  prolonged  to  several  hours,  or  even  to  a  day. 
In  very  rare  cases  the  convulsions  may  be  repeated  at  short  intervals,  the 
patient  not  regaining  her  self-possession  between  the  attacks  ;  thus  there  may 
be  a  veritable  hysterical  eclamptic  status,  analogous  to  the  epileptic  status. 
This  may  continue  for  a  day  or  even  more,  the  patient  having  as  many  as 
fifty  or  even  a  hundred  spasms.  When  this  status  occurs  the  fourth  period 
is  entirely  omitted  until  the  end  of  the  series,  and  the  phenomena  of  the  other 
periods  are  much  blended  and  confused. 

As  shown  by  Richer's  historical  study  the  grand  attack  of  hysteria  is  not 
confined  to  any  race  or  nation.  Conclusive  evidence  of  it  is  found  in  the 
older  literature.  It  exists,  however,  in  many  varieties,  and  in  not  a  few  abor- 
tive and  atypical  forms,  which  Avill  now  be  examined  into  briefly. 

The  varieties  of  the  hysterical  paroxysm  can  be  shown  to  be,  without  ex- 
ception, modifications  of  the  type  already  described.  They  are  abortive 
attacks,  in  which  the  phenomena  of  one  period  alone,  sometimes  curtailed, 
sometimes  intensified,  are  seen ;  or  they  are  combinations  of  two  or  more 
periods,  or,  finally,  they  merge  into  special  ot  terminal  stages,  such  as  som- 
nambulism, catalepsy,  and  trance,  which  seem,  at  first  sight,  to  be  epiphe- 
nomena,  but  which,  on  closer  examination,  are  seen  to  have  a  strictly  logical 
connection  with  the  grand  attack.  Briquet,  among  the  first,  described  clearly 
the  varieties  of  hysterical  convulsions,  including  catalepsy  and  trance,  but 
Charcot  Avas  the  first  to  demonstrate,  as  has  already  been  shown,  the  laws  of 
development  of  these  varieties  from  one  classical  type.  It  can  readily  be 
appreciated  how  great  the  number  of  these  varieties  may  be,  and  how  diverse 
and  unique  may  be  their  symptoms,  when  it  is  recalled  that  these  four  periods 
present  many  minor  phases,  and  hence  may  make  innumerable  combinations. 


104  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

It  will  be  possible  here  merely  to  indicate  some  of  the  most  common  and 
most  important  of  these. 

One  of  the  most  common  of  hysterical  paroxsyms  is  really  an  abortive 
attack  in  which  the  prodromes  are  the  conspicuous  features,  and  in  which  few, 
if  any,  of  the  convulsive  symptoms  appear.  The  patient,  after  presenting 
for  some  hours  or  days  some  of  the  mental  prodromes  abeacly  described,  such 
as  change  of  moods,  depression,  irritability,  and  fickleness,  has  an  emotional 
outburst  of  alternate  tears  and  laughter,  to  be  followed  by  a  partially- 
developed  tetanoid  and  eclamptic  period,  ending  with  mutism  and  sleep.  This 
has  been  called  hysteria  minor,  in  contrast  with  the  grand  attack.  It  is  the 
ordinary,  or  A-ulg'ar,  hysterical  fit.  It  may  be  associated  with  or  followed  by 
some  of  the  physical  stigmata,  such  as  paralysis  and  contracture.  In  others 
of  these  minor  attacks  the  period  of  passionate  attitudes,  or  dramatic  repre- 
sentation, may  be  partly  developed,  and  sometimes  proving,  as  Bernutz '  has 
claimed,  that  in  some  cases  there  is  but  a  short  step  from  these  phenomena  to 
a  more  or  less  prolonged  access  of  delirium,  of  somnambulism,  of  ecstasy,  or 
of  catalepsy.  These'grave  terminal  stages,  following  a  brief  or  abortive 
paroxysmal  seizure,  are  more  usual  in  children. 

Among  the  most  remarkable  of  the  aberrent  forms  of  grand  hysteria  is 
that  condition  known  as  "  chorea  major."  This  term  originated  in  Germany, 
and  is  open  to  the  same  objections  as  those  urged  against  the  term  "hystero- 
epilepsy."  It  is  borrowed  from  another  and  distinct  disease,  which  has  no 
connection  with  hysteria.  The  so-called  chorea  major  is  in  no  sense  choreic. 
It  is  purely  an  hysterical  aflfection,  and  finds  its  proper  place  in  nosology  by 
reference  to  Charcot's  classical  t^-pe  of  hysterical  con^-ulsions,  by  virtue  of 
which,  indeed,  it  has  been  rescued  fi'om  the  anomalous  and  false  position  in 
which  it  was  formerly  left.  The  term,  indeed,  is  very  vague  and  inexact,  and 
probably  has  been  made  to  include  more  than  one  variety  of  nervous  afiec- 
tion,  but  if  we  observe  attentively-  we  can  see  that  most  of  the  cases  reported 
belong  to  the  second  and  third  periods  of  the  grand  attack  of  hysteria.  They 
are  characterized  by  strange  exaggerations  or  grotesc^ue  modifications  of  the 
grand  movements  and  the  passionate  attitudes  of  the  hysterical  convulsion. 
In  children  examples  of  isolated  movements,  feats  of  automatism,  mimicry, 
acc[uired  dexterity,  and  semi-purposive  contortions  occur  which  are  doubtless 
abortive  or  atypical  hysterical  seizures.  They  may  be  preceded  sometimes  by 
an  epileptoid  phase.  Thus,  in  a  boy,  whose  case  was  reported  by  the  writer, 
rotatorv  and  gyratory  movements  followed  an  aura  and  epileptoid  stage.  One 
such  case  may  cause  many  others  in  schools,  by  imitation  ;  the  epidemic 
assuming  astonishing  and  bizarre  features.  Such  epidemics,  under  religious 
excitement,  occurred  during  the  middle  ages  and  later.  Charcot  gives  to 
these  and  someAvhat  similar  phenomena  the  term  "  clownism." 

Ecstasy  is  a  rather  rare  phenomenon,  sometimes  obser^-ed  as  an  isolated 
state,  which  in  reality  is  but  an  exaggeration  of  one  of  the  phases  of  the 
thircl  period  of  hysteria  major.  It  is  an  exaltation  of  certain  ideas  in  which 
the  patient  becomes  so  absorbed  that  all  sensory  impressions  are  unrecognized 
and  all,  or  almost  all,  motor  functions  are  in  suspense.  Occasionally,  how- 
ever, the  ecstatic  declaims  and  even  smgs.  The  state  has  been  described  by 
Michea.^  There  are  varieties  of  this  peculiar  mental  state,  and  some  cases 
that  have  been  described  as  ecstatic  were  possibly  not  truly  hysterical ;  but 
the  most  common  form  is  a  variety  of  one  of  the  passionate  attitudes  of  the 
gi-and  attack.  Here  we  see  the  patient  en  rapport  with  a  train  of  mental 
images  even  to  a  more  profound  extent  than  in  the  other  phases.     Stigmata 

1  Art.  Hysterie.    Xouv.  dictionnaire  de  Med.  et  de  Chirurgie,  Paris,  1874,  t.  xviii,  p.  221. 

-  Eulenberg's  Art.  Ziemssen's  Encyc. 

3  Nouv.  Diet,  de  Med.  et  deChir.  Prat.    Art.  Extase. 


GENERAL  MORBID  STATES.  105 

would  probably  be  found  in  most  patients  during  the  intervals  between  the 
attacks. 

What  has  been  said  of  ecstasy  may  also  be  said  of  somnambulism,  cata- 
lepsy, trance,  and  lethargy,  which  sometimes  complicate  or  terminate  the 
hysterical  paroxysm.  They  are  modifications  of  the  mental  state  of  the  hys- 
terical subject.  But  as  their  relations  are  complex  they  must  be  investigated 
in  some  detail. 

Somnambulism  is  another  of  those  terms  that  have  been  used  for  hysterical 
symptoms  without  proper  definition.  Like  "  chorea  major,"  it  is  a  misnomer, 
and  has  been  borrowed  from  a  condition  which  has  no  connection  whatever 
Avith  hysteria.  Somnambulism  proper  is  a  disorder  of  sleep,  occurring  mostly 
in  children  in  whom  there  is  no  evidence  of  disease,  even  of  hysteria.  The 
patient,  if  he  can  be  called  a  patient,  remembers  nothing  of  the  attack,  which 
is  closely  allied  to  dreaming,  for  in  it  the  patient  simply  reacts  to  a  dream- 
like state.  This  is  entirely  distinct  from,  first,  the  automatism  of  epilepsy, 
and,  second,  the  pseudo-somnambulism  of  hysteria.  These  latter  two,  again, 
have  nothing  in  common.'  The  somnambulism  of  hysteria  is  not  a  disorder 
of  sleep,  but  simply  a  transformation  of  one  of  the  phases  of  the  third  period. 
It  is  a  dramatic  representation  of  an  emotional  state.  In  it  the  patient 
may  be  oblivious  to  sensory  impulses,  but  she  retains  a  distinct  memory  of 
the  attack  after  it  has  passed.  Moreover,  the  attack  may  be  preceded  by 
other  phases  of  grand  hysteria,  such  as  prodromes,  epileptoid  symptoms,  etc. 
Finally,  the  patient  usually  presents  intervallary  stigmata.  We  see  from  all 
this,  that  the  condition  is  more  closely  allied  to  ecstasy,  just  described,  than 
to  true  so  mnambulism.  In  other  words,  it  is  purely  hysterical.  Its  nature  is 
emphasized  by  the  fact  likewise  that  the  pseudo-somnambulism  of  hysteria 
can  be  induced  by  hypnotism. 

Catalepsy,  like  somnambulism,  has  several  varieties,  or,  rather,  the  term  is 
used  for  a  variety  of  mental  states.  It  is  a  condition  of  both  mental  and 
motor  inertia,  the  patient's  thoughts,  apparently,  as  well  as  his  limbs,  tending 
to  remain  in  the  state  or  position  in  which  they  are  placed.  Hence,  in  some 
cases  it  is  a  natural  and  appropriate  manifestation  of  the  hysteric  paroxysm. 
Here,  again,  the  psychic  element  is  marked ;  the  patient's  thoughts,  immobile 
and  unyielding,  dominate  the  motor  sphere.  The  limbs  retain,  for  incredibly 
long  periods,  a  statuesque  rigidity,  or  yield  slowly,  with  wax-like  stiffiiess,  to 
the  influence  of  gentle  pressure.  The  patient  is  apparently  insensible,  or 
almost  insensible,  to  external  impression ;  the  countenance  is  set  and  unintel- 
ligent ;  the  somatic  functions  are  sluggish.  The  relation  of  catalepsy  to 
hysteria  is  found  in  the  era  of  attitudinizing,  which  is  named  the  third  period. 
Its  relation  with  this  period  is  logical  and  intelligible.  It  may  present  itself 
as  a  phase  of  the  grand  attack,  many  of  the  precedent  features  of  which  may 
have  been  lacking,  and  gradually  assume  an  isolated  and  exaggerated  role  ; 
or  it  may  appear  as  a  strictly  isolated  phenomenon  from  the  first.  In  the 
hysteric  it  is  probably  not  as  profound  a  state  as  it  is  in  some  forms  of 
insanity,  for  it  can  often  be  induced  by  hypnotism,  and  it  can  be  dispelled 
by  pressure  over  the  ovaries  or  by  the  action  of  an  electric  current.  It  is, 
however,  in  both  conditions  a  psychosis  favorable  for  the  manifestation  of 
the  complex  and  unhealthful  processes  that  characterize  the  functions  of  the 
brain  in  both  states. 

Lethargy,  unlike  catalepsy,  is  not  marked  by  motor  rigidity,  unless  it  be 
occasionally  a  contracture  of  a  limb.  But  this  renders  the  limb  stiff*  and  un- 
yielding, differing  from  the  "lead-pipe"  flexibility  of  catalepsy.    In  lethargy 

1  The  Freuch,  who  are  largely  responsible  for  this  misuse  of  the  term  somnambulism,  have  lately 
seen  the  necessity  for  the  differentiation  observed  in  the  text.  See  "  Les  Somnambulisms  "  by 
Blocq.  Cliniq.  d.  Mai.  du  Syst.  Nerv.,  Guinon,  1893. 


106  NERVOUS  DISEASES  AXI)  THEIR  TREATMEXT. 

the  patient  lies  in  a  semi-stupor,  with  closed  eves.  The  eyelids  may  present 
a  fine  fibrillary  tremor.  This  state  may  endure  for  hours.  It  is  a  phase  of 
the  grand  attack,  and  may  be  an  isolated  and  abortive  form ;  or,  again,  in 
some  cases  a  terminal  stage. 

Trance  is  an  intensification,  as  it  M'ere,  of  lethargy.  It  may  endure  for 
many  days  or  weeks.  It  has  supplied  in  the  past  many  notable  cases  of 
patients  who  have  lain  profoundly  dormant  for  long  periods,  to  the  amaze- 
ment of  the  curious  and  superstitious,  and  who  have  recovered,  sometimes 
amidst  emotional  and  devotional  rites,  to  the  edification  of  the  devout.^ 
Trance,  in  its  profound  states,  presents  many  problems  of  physiological  inter- 
est, which  cannot  be  discussed  here.  It  is  best  understood  by  the  light 
thrown  upon  it  and  kindred  states  by  a  study  of  the  grand  hysteria.  In  it 
the  patient  has  suspended  cerebration,  to  the  extent,  at  least,  that  the  brain 
functions  are  exercised  to  the  most  limited  extent  compatible  with  a  neces- 
sary continuance  of  some  physiological  activity.  Coma,  vrhich  sometimes  is 
said  to  occur  in  hysteria,  is  probably  only  a  modified  form  of  trance ;  as  is, 
also,  hysterical  sleep  and  mutism.  Attentive  observation  and  experiment 
have  demonstrated,  as  in  the  Scotch  case  published  some  years  ago,  that  even 
in  the  most  profound  trance  the  patient's  consciousness  of  the  environment  is 
not  entii'ely  lost.  It  must  not  be  forgotten  that  some  cases  of  trance  are 
probably  cases  of  melancholia  attonita. 

Finally,  hysterical  sleep  may  be  considered  in  this  connection.  Hitzig,  of 
Halle,  has  reported  recently  a  most  instructive  case  of  this  sleep.^  It  may 
serve  for  a  description.  A  laborer,  aged  twenty  years,  received  severe  wouncls 
on  his  head  and  arm  by  an  accident  while  at  his  work.^  A  few  weeks  later 
he  began  to  have  sleeping  spells,  which  were  as  follows :  They  occurred  at 
intervals  of  from  seven  to  thirteen  days,  and  lasted  from  thirty-four  to  thirty- 
six  hours,  once  forty-one  hours.  During  the  spell  the  patient  usually  reclined 
Cjuietly  on  his  back ;  sometimes,  however,  he  tossed  about.  The  eyelids  did 
not  quiver.  Contraction  of  the  masseters  was  not  present.  The  eyelids  were 
directed  upward,  and  when  the  lids  were  kept  open  for  a  time  the  eyeballs 
moved  slowly  to  and  fro.  Temperature,  pulse,  and  respiration  did  not  show 
any  considerable  changes.  The  patient  could  be  aroused  by  pressure  on  one 
of  the  scars,  or  on  one  "  ovarian  "  region.  When  roused  thus  he  asked  for 
water  and  drank  ;  he  did  not  eat.  Duriug  the  sleep  the  weight  of  the  body, 
the  volume  and  specific  gravity  of  the  urine,  and  the  quantity  of  nitrogen 
decreased.  After  the  sleep  the  patient  had  a  violent  headache ;  soon,  how- 
ever, he  began  to  eat  fr-eely,  and  all  functions  were  quickly  restored.  The 
prodromes  consisted  of  change  of  disiDosition,  etc.  He  Avas  readily  influenced 
by  hjq^notic  suggestion,  and,  practically,  was  cured  by  it.  This  hysterical 
sleep  is  possibly  identical  with  lethargy,  abeady  considered.  Hitzig  considers 
that  the  spell  in  his  case  Avas  an  abortive  form  of  the  classical  "  hystero- 
epileptic"  attack. 

This  may  end  the  consideration  of  the  varieties  of  the  grand  attack  of 
hysteria.  As  said  l^efore,  these  varieties,  consisting  of  combinations  of  the 
phases  of  the  classical  attack,  as  well  as  abortive  and  atA"[3ical  seizures,  are 
much  more  numerous  than  there  is  space  to  describe  them  in.  Only  the  more 
important  of  the  class  have  been  considered  here. 

1  Cases  of  trance  have  lost  nothing  in  the  telling.  Thus,  such  a  case  is  said  to  have  occurred  to 
the  anatomist  Vasalius,  whose  "  subject "  was  aroused  by  the  first  stroke  of  the  knife.  A  somewhat 
similar  case  was  that  of  Lady  Russell,  who  returned  to  consciousness  at  her  own  funeral. 

-  Brain  :  Spring  and  Summer,  November,  1893. 

3  The  traumatic  origin  of  this  case  is  most  significant  in  its  bearings  upon  the  vexed  question  of  the 
"  traumatic.neuroses."  Hitzig  has  some  judicious  remarks  upon  this  question  ;  he  does  not  regard 
with  approval  the  views  of  those  who  affect  to  ignore  hysteria  and  hypochondria  of  traumatic 
origin. 


GENERAL  MORBID  STATES.  107 

According  to  the  researches  of  Gilles  de  la  Tourette  and  Cathelineau/  the 
nutrition  of  the  hysterical  patient  is  affected  during  the  grand  convulsive 
attack,  but  not  during  the  intervals  between  the  attacks.  In  Hitzig's  case 
of  hysterical  lethargy''  there  was  a  loss  of  w^eight  before  and  during  the  sleep 
of  so  much  as  seven  "kilogrammes.  At  the  setting  in  of  the  prodromes  there 
was  increased  excretion  of  urea,  the  patient  not  eating  as  much  as  usual  and 
losing  weight,  the  augmented  excretion  of  urea  being  accounted  for  by  the 
loss  of  weight.  During  the  sleep  the  excretion  of  urea  diminished.  The 
urine  was  diminished  during  the  sleep.  For  more  details  the  original  papers 
may  be  consulted.  It  is  significant  that  the  nutrition  of  the  lethargic  patient 
corresponded  closely  with  that  of  patients  in  grand  hysteria,  tending  to  prove 
that  lethargy  is  but  a  modification  of  the  grand  attack. 

The  Inteeparoxysmal  Symptoms.  The  interparoxsmal  symptoms  of  hys- 
teria have  been  called  wdth  good  reason  the  stigmata.  They  are  the  marks  of  the 
disease,  and  by  this  highly-suggestive  name  they  seem  to  indicate  how  persistent 
and  ineradicable  they  are  in  many  cases.  They  are  by  far  the  most  charac- 
teristic and  most  important  of  the  symptoms  of  hysteria,  because,  first,  they 
are  the  most  prevalent,  and,  second,  they  are  the  most  available  and  valua- 
ble for  scientific  purposes.  Without  them,  indeed,  few  cases  of  hysteria  can 
be  diflTerentiated  successflilly,  and  with  them  no  cases  can  be  mistaken.  It 
is  too  much  the  custom  to  regard  hysteria  as  a  disease  of  motor  explosions 
and  of  follies  and  affectations,  but  a  study  of  the  intervallary  stigmata  can- 
not fail  to  impress  upon  the  mind  that  the  paroxysmal  features,  while  of  su- 
preme importance  in  their  own  sphere,  are  of  but  secondary  importance  to 
the  permanent  signs,  and  that  instead  of  being  a  disease  of  simulation  and 
conceit  hysteria  is  one  that  is  marked  by  persistent  physical  stigmata,  which 
are  quitebeyond  the  control  of  the  patient's  wall,  and  sometimes,  indeed,  are 
beyond  the  domain  of  his  consciousness.  So  persistent  are  many  of  these 
signs  that  they  are  called,  especially  by  the  French,  the  permanent  stigmata  ; 
but  this  term  is  open  to  the  very  obvious  objection  that,  while  these  symp- 
toms are  likely  to  be  obstinately  fixed  for  long  periods,  they  are  not  essenti- 
ally permanent,  because  many,  or  all  of  them,  may  disappear  in  favorable 
cases.     Hence,  it  is  best  to  call  them  interparoxysmal  or  intervallary. 

The  interparoxysmal  symptoms  of  hysteria  may  be  divided  into  four 
classes :  sensory,  motor,  visceral,  and  psychical. 

Sensory  Symptoms.  The  alterations  of  sensation  in  hysteria  are  of  three 
kinds — ansesthesia,  hyperesthesia,  and  j)argesthesia.  Ansesthesia  may  be  sub- 
divided into  alterations  of  the  various  modes  of  sensation,  as,  for  instance, 
tactile  ansesthesia,  thermo-angesthesia,  analgesia,  and  loss  of  muscular  sense. 

The  anaesthesias  of  hysteria  played  a  conspicuous  role  for  many  centuries 
before  they  attracted  the  attention  of  scientific  observers.  As  the  "  marks 
of  the  devil"  (.stigmata  diaboli),  they  had  been  noted  and  described  by 
churchmen  as  far  back  as  the  times  of  Tertullian,  and  they  had  served  their 
purposes  as  the  distinguishing  marks  of  witches  all  through  the  middle  ages.^ 
It  had  been  noted  that  witches  and  those  possessed  had  areas  of  ansesthesia 
in  which  the  prick  of  a  needle  was  not  felt  and  did  not  draw  blood.  In 
epidemic  hysteria,  excited  by  Avitchcraft  crazes,  the  poor  wretches  who  dis- 
played these  sensory  stigmata  were  too  often  doomed.  Most  ingeniovis  meth- 
ods were  taken  by  experts  to  detect  these  signs,  which,  far  from  being  simu- 
lated, were  disguised  by  the  unhappy  victims.  In  some  cases,  hoAvever,  it  is 
significant  that  the  sorcerers  had  no  consciousness,  until  they  Avere  detected, 
that  they  possessed  these  signs.  Hoav  different  all  this  appears  from  AA'hat 
Avould  haA^e  been  the  case,  if,  as  some  modern  Avriters  state,  these  symptoms 

1  La  nutrition  dans  I'hysterie,  Paris,  1890.  2  Op.  cit.  a  Tourette :  Op.  cit. 


108  NERVOUS  DISEASES  AND  THEIR  TREATMENl. 

are  unreal.  The  anaesthesia  of  hysteria  may  occur  in  various  forms.  The 
most  common  are  hemiansesthesia,  anaesthesia  in  plaques,  and  aucesthesia  of  one 
limb,  associated,  or  not,  with  paralysis  of  the  Kmb.  In  some  very  rare  cases 
the  anaesthesia  is  total. 

Before  studyuig  these  most  imj)ortant  marks  of  hysteria  it  is  well  to  cau- 
tion students  against  the  too  prevalent  skepticism  that  exists  on  the  subject 
of  anaesthesia  in  hysteria.  Only  a  personal  study  of  cases  seems  able  to  dis- 
pel this  unbelief  from  some  minds.  The  history  of  this  aspect  of  hysteria  is 
most  curious ;  for,  in  spite  of  the  prominence  of  these  stigmata  among  reli- 
gious fanatics  and  so-called  witches  in  past  ages,  the  recognition  of  them  by 
scientists  has  been  most  tardy.  In  spite  of  the  writings  of  Piorry,  Gendrin, 
and  Briquet  in  France,  and  Szokalsky  in  Germany,  all  before  1860,  the  sub- 
ject, as  Pitres  says,i  seemed  likely  to  be  ignored  again  until  Charcot,  in 
1872,  emphasized  its  importance.  It  is  sufficient  to  say  that  some  form  of 
anaesthesia  is  the  most  common  of  all  the  intervallary  stigmata,  and  that  the 
study  of  no  case  is  complete  without  a  careful  search  for  these  signs. 

The  hemianaesthesia  of  hysteria  has  some  features  that  serve  to  distinguish 
it.  It  is  a  very  profound  anaesthesia,  and  it  is  complete,  that  is,  it  extends 
from  the  crown  of  the  head  to  the  sole  of  the  foot.  Exceptions  occur,  but 
they  are  exceptions.  It  is  so  profound,  often,  that  painftil  impressions  do  not 
alter  it,  and  it  is  often  associated  with  some  vasomotor  changes,  for  a  pin- 
stick  does  not  bleed.  This  anaesthesia  is  not  confined  to  the  skin,  but  in- 
volves even  the  subcutaneous  structures,  notably  the  nerve-trunks.  Pitres 
wounded  the  ulnar  nerve  at  the  elbow,  so  as  to  cause  contractions  of  the  mus- 
cles supplied  by  it,  but  failed  to  excite  sensation.  Occasionally  this  anaes- 
thesia is  accompanied  by  a  mottled  and  oedematous  state  of  the  limb  (oedeme 
hleii).  It  is  accompanied  fi'equently  by  anaesthesia  also  of  the  mucous  mem- 
brane of  the  eye,  nose,  mouth,  rectum,  urethra,  and  vagina.  But  its  most 
significant  accompaniment  is  anaesthesia  of  the  special  senses.  Thus  the 
patient  does  not  hear,  see,  nor  smell  on  the  affected  side,  and  the  taste,  also, 
is  affected,  usually  unilaterally.  Finally,  this  hemianaesthesia  is  transferable 
occasionally  from  one  side  to  the  other ;  but  usually  this  transfer  is  only 
temporary,  as  the  affection  tends  to  resume  its  primary  seat.  This  transfer 
occurs  under  the  influence  of  emotion,  or  by  suggestion,  or  by  the  action  (a 
purely  suggestive  one),  of  certain  aesthesiogenic  agents.  This  phenomenon 
of  transfer  is  peculiar  to  the  hemianaesthesia  of  hysteria,  and  distinguishes  it 
from  hemianaesthesia  of  organic  origin — a  fact  that  must  be  borne  in  mind 
when  studying  the  hemianaesthesia  of  chronic  alcoholism  and  of  lead-poison- 
ing (see  supra).  For  some  reason,  not  readly  explained,  the  hemianaesthesia 
of  hy  steria  is  much  more  frequent  on  the  left  side  ;  in  the  proportion,  ac- 
cording to  Briquet,^  of  7  to  2. 

A  very  common  form  of  anaesthesia  m  hysteria  is  that  in  which  the  loss  of 
sensation  occurs  in  limited  areas  of  various  sizes,  shapes,  and  locations.  They 
assume  curious  geometric  forms.  (Figs.  26  and  27.)  These  areas  of  anaes- 
thesia may  change  from  time  to  time ;  in  fact,  it  is  not  usual  to  find  them 
the  same  upon  succeeding  days.  The  patient  is  ignorant,  frequently,  that  she 
is  thus  marked.  They  are  not  the  products  of  suggestion,  because  often  they 
may  be  demonstrated  on  patients  who  have  never  before  been  submitted  to 
the  test  and  who  are  ignorant  of  its  object. 

One  of  the  most  characteristic  forms  of  anaesthesia  in  hysteria  is  the  seg- 
mental form,  or  that  in  which  the  anaesthesia  is  limited  to  one  liml)  or  to 
part  of  a  limb.  It  may  take  the  position  of  a  gauntlet  or  of  a  stocking.  It 
is  often  the  accompaniment  of  hysterical  paralysis  and  contracture  of  an 

1  Des  ansesthesies  hysteriques,  Bordeaux,  18S7.  2  op.  cit.,  p.  278. 


GENERAL  MORBID  STATES. 
Fig.  26.  Fig.  27. 


109 


Fig.  26.    Irregularly  distributed  fflS  Tactile  Anaesthesia  from  a  ease  of  hysteria  at  the  Home  for 
Kiil  and  Analgesia 
Crippled  Children,  Philadelphia. 


Fig.  27.    Areas  of 


TJiermo- Anaesthesia  in  the  same  case. 


arm  or  leg,  and  in  this  association  is  very  characteristic,  because  no  organic 
lesion  can  give  just  this  symptom-complex.     This  anaesthesia  is  not  limited 


Fig.  28. 


Almost  complete  ^^^  Anaesthesia  from  author's  case  of  hysterical  astasia-abasia,  Methodist  Hos- 
pital, Philadelphia. 


110  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

to  the  distribution  of  any  one  or  more  nerves ;  in  this  respect  indicating  its 
cortical  or  psychical  origin.  It  is  usually  sharply  delimited,  the  line  of  de- 
markation  being  at  right  angles  to  the  long  diameter  of  the  limb. 

Finally,  very  rarely,  anaesthesia  may  be  distributed  universally.  In  some 
cases  the  anaesthesia  is  almost  universal,  the  exceptions  occurring  in  small 
islets  in  which  sensation  is  normal.  A  diagram  of  such  a  case  is  shown  in 
Fig.  .28,  from  the  author's  clinic  at  the  Methodist  Episcopal  Hospital.  The 
anaesthesia  is  general,  with  the  exceptions  noted. 

According  to  Pitres^  the  anaesthesia  of  hysteria  is  never  isolated  tactile 
anaesthesia  ;  in  other  words,  one  or  more  of  the  other  forms  of  anaesthesia  is 
always  present.  The  most  common  of  these  forms  in  hysterical  anaesthesia, 
as  given  by  Pitres,  are :  first,  total  anaesthesia,  i.  e.,  in  all  modes ;  second, 
partial  anaesthesia,  of  which  the  most  common  are  analgesia,  thermo-anaes- 
thesia,  combined  tactile  and  thermo-anaesthesia,  electro-anaesthesia,  and  loss  of 
all  modes  except  electro-aesthesia. 

All  forms  of  hysterical  anaesthesia  are  likely  to  be  worse  after  a  fit.  They 
may  persist,  however,  as  intervallary  stigmata  without  the  patient's  knowl- 
edge. Hence,  the  patient's  own  statements  about  his  or  her  ability  to  feel 
must  not  be  accepted,  if  a  critical  examination  is  to  be  made ;  but  he  or  she 
must  be  stripped  and  thoroughly  tested.  Fuially,  anaesthesia,  while  very 
common,  is  not  found  in  all  cases  ;  hence,  its  absence  is  not  decisive  against 
a  suspected  case  of  hysteria.  Briquet  found  anaesthesia  in  240  of  400  cases 
examined  by  him  with  great  care'^ — that  is,  in  sixty  per  cent.  It  is  proba- 
ble that  this  percentage  is  too  small ;  certainly,  in  my  own  experience  anses--' 
thesia  in  some  of  its  forms  is  more  frequent  than  this. 

The  hyperaesthesias  of  hysteria  form  an  important  group,  especially  be- 
cause this  group  contains  the  hysterogenous  zones.  It  contains,  also,  the 
almost  equally  important  sub-group  of  hj^eralgesias. 

The  hysterogenous  zones  may  be  defined  briefly  as  localized  areas  of  extreme 
sensitiveness,  pressure  on  which  has  the  j)Ower  of  provoking  some  of  the 
hysterical  manifestations,  and  especially  the  convulsive  phenomena.  The 
location  of  these  zones,  or  areas,  varies  in  different  persons,  but  the  most 
common  are  over  the  ovaries,  along  the  spine,  on  the  breasts,  and  on  the 
trunk  beneath  the  ribs.  They  have  been  found  on  the  vertex.  Per  contray 
pressure  on  these  areas  has  the  effect  of  arresting  the  convulsion  even  when 
at  its  height.  The  latter  fact  was  observed  and  utilized  by  empirics  long 
since.  The  con^iilsionnaires  of  St.  Medard,  for  instance,  were  influenced  thus 
by  strong  j)ressure  upon  the  abdomen.  The  number  of  these  zones  vary ; 
some  patients  have  but  one,  others  have  several.  In  patients  with  hemianses- 
thesia  they  may  be  unilateral,  and  are  then  confined  to  the  anaesthetic  side. 
They  are  frequently  the  seats  of  spontaneous  pain  during  the  prodromal 
period,  and  may  then  simulate  other  diseases.  For  instance,  I  recently  ob- 
served a  woman  whose  severe  ovarian  pain  simulated  a  local  inflammation ; 
possibly  a  peritonitis ;  but  who,  as  events  proved,  was  in  the  prodromal 
stage  of  hysteria  major.^  The  purely  hysterical  character  of  such  neuralgic 
pains  is  demonstrated  by  the  fact  that  they  disappear  entirely  with  the  cure 
of  hysteria  by  some  of  the  well-recognized  means. 

The  h}"peralgesia  of  hysteria  may  simulate,  in  the  most  puzzling  way, 
organic  disease.     It  simulates  especially  disease  of  the  joints.     This  is  one  of 

1  Lejons  Cliniques  sur  I'Hysterie  etl'Hypnotism,  Paris,  1891.  -  Op.  cit.,  p.  273. 

3  This  ovarian,  and  sometimes  uterine  and  general  vaginal,  hypersesthesia  is  doubtless  the  cause 
and  the  excuse  for  some  useless  gynecological  surgery  during  the  present  epoch.  A  more  systematic 
study  of  hysteria  ought  to  demonstrate  that  it  is  a  psycho-neurosis  and  not  a  genital  affection.  It 
ought  not  tb  be  necessary  to  remove  a  woman's  ovaries  in  order  to  cure  her  by  suggestion. 


GENERAL  MORBID  STATES.  HI 

the  most  commou  forms  of  neuro-mimesis,  and  was  so  prevalent  in  Brodie's 
time  that  he  said  that  four-fifths  of  his  cases  of  joint-disease  were  hysterical, 
a  proportion  far  in  excess  of  what  can  be  observed  at  the  present  time,  in 
spite  of  the  alleged  tendency  now  to  over-describe  hysteria.  This  nervous 
mimicry  of  organic  disease  of  the  joints  is  one  of  the  most  striking  proofs  of 
the  fact  that  hysteria  is  a  disease  of  peiTerted  and  fixed  ideas.  These  are  the 
cases  that  recover  in  an  instant  under  the  care  of  a  charlatan  or  of  a  priest. 
Hysterical  disease  of  the  hip  or  knee-joint  is  not  associated  with  deformity 
and  shortening  of  bone,  nor  with  the  formation  of  pus,  nor  with  the  local 
rigidity,  nor  with  the  septic  temperature  that  is  seen  in  tuberculous  diseases. 
The  stifihess  is  caused  by  contracture  of  the  muscles,  which  is  usually  much 
more  extensive  than  in  organic  disease ;  and  the  pain  is  usually  more  diffuse 
and  more  spontaneous.  There  are,  moreover,  characteristic  mental  and 
physical  stigmata.  The  hysterical  patient  dreads  to  move  or  to  assist  in  the 
examination,  and  obviously  dwells  with  exaggeration  upon  each  symptom ; 
while  she  is  very  apt  to  have  segmental  anaesthesia  in  the  affected  limb,  or 
even  hemianjesthesia,  as  in  the  case  rej)orted  elsewhere.  A  very  significant 
symptom  is  paralysis  of  the  limb,  which  is  never  present  in  hip-joint  disease. 
Finally,  under  full  etherization,  the  hysterical  joint  is  found  to  be  freely  mov- 
able in  all  directions.  It  must  not  be  forgotten  that  hysterical  symptoms  may 
be  added  to  those  of  genuine  organic  disease  of  the  hip  or  knee,  just  as 
hysteria  may  be  caused  by  any  other  severe  disease,  as  already  indicated. 

Finally,  hyperalgesia  may  exist  as  various  forms  of  neuralgic  pain.  After 
traumata  it  is  commou  to  have  such  pains,  especially  about  the  occiput,  the 
back  of  the  neck,  and  along  the  spine.  A  common  form  of  hysterical  neu- 
ralgia is  the  clavus,  already  described  as  among  the  prodromes.  A  very 
obstinate  pain  is  fixed  sometimes  in  the  female  breast,  which  may  even 
become  slightly  swollen  and  excpisitely  painful  to  touch.  It  is  called  mas- 
todynia.  In  women  with  the  hysterical  breast  the  mental  suflTering  is  often 
very  great,  the  patient's  mind  dwelling  constantly  on  her  ailment,  and  her 
imagination  becoming  the  prey  to  fears  of  malignant  disease.  This  breast 
occurs  not  infrecpiently  in  young  women,  before  the  usual  age  for  cancerous 
disease.  It  sometimes  follows  a  slight  trauma.  Other  forms  and  locations  of 
neuralgia  may  be  observed,  according  to  persons  and  circumstances. 

The  special  senses  are  involved  frequently  in  hysteria.  The  most  important 
of  these  is  sight,  which  may  be  totally  abolished  (amaurosis)  or  only  partially 
obscured  (amblyopia).^ 

Hysterical  amaurosis,  or  blindness,  is  a  rare  affection,  which  usually  occurs 
suddenly,  and  not  infi'equently  disaj^pears  as  suddenly.  Thus,  Pitres  relates 
the  case  of  a  young  girl,  aged  sixteen  years,  who  after  a  slight  illness  became 
suddenly  blind.  At  the  same  time  she  became  analgesic  over  the  whole  sur- 
face of  her  body.  She  was  cured  after  a  few  days  with  a  few  applications  of 
electricity.  Hysterical  blindness,  however,  is  not  always  of  such  short  dura- 
tion ;  it  has  been  known  to  persist  for  months,  and  even  for  years.  It  is 
sometimes  unilateral,  and  not  infrequently  is  confused  with  malingering.  Its 
exact  nature,  as  in  the  case  of  so  many  hysterical  phenomena,  is  difficult  to 
explain,  and  has  been  the  subject  of  much  discussion.  When  subjected  to 
crucial  tests,  as  done  by  Pitres,  these  patients  with  unilateral  amaurosis  are 
found  sometimes  to  see  Avith  both  eyes,  and  yet  clinically  thej'  act  and  are 
practically  like  persons  blind  in  one  eye.  The  explanation  lies  not  in  simu- 
lation, but  probably  in  the  fact  that  the  affection  is  psychical  and  purely 
subjective. 

1  Pansier :  Les  Manifestations  Oculaires  de  I'Hysterie,  Paris,  1892.  This  work  contains  a  full  bibli- 
ography. 


112  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Hysterical  amblyopia,  or  partial  blindness,  may  be  divided  into  several 
varieties,  to  understand  Avhich  it  is  necessary  to  understand  the  physiology  of 
the  visual  field.  When  the  normal  eye  is  fixed  upon  a  given  point  the  extent 
of  vision  has  definite  limits  in  all  directions  about  that  fixed  point.  This  extent 
of  vision  about  a  fixed  point  is  called  the  visual  field.  Supposing  this  point  to 
be  the  approximate  centre  of  the  field,  the  extent  of  vision  upward  will  be 
about  65°  ;  outward,  toward  the  temporal  side,  about  90°  ;  downward,  about 
75° ;  and  inward,  toward  the  nasal  side,  about  55°.  These  limits  are 
nearly  constant  for  all  normal  eyes.  The  visual  field  is  affected  in  hys- 
teria in  three  ways.  There  may  be,  according  to  Pitres,  a  central  area  in 
which  nothing  is  seen,  while  all  around  the  periphery  sight  is  retained.  This 
is  called  a  central  scotoma.  It  is  rare,  and  many  observers  have  never  seen 
it.  There  may  be,  secondly,  homonymous,  bilateral  hemianopsia,  in  which 
the  half-field  on  the  same  side  for  each  eye  is  blank.  This  is  also  exceedingly 
rare  in  hysteria,  but  not  so  uncommon  in  organic  brain  disease.^  I  present  a 
diagram  (Fig.  29)  made  by  Dr.  de  Schweinitz  from  a  patient  in  my  wards  at 
the  Philadelphia  Hospital.    Her  case  is  related  briefly  elsewhere.    Hysterical 

Fig.  29. 


Diagrams  of  fields  of  vision  in  a  case  of  hysterical  homonymous  hemianopsia  from  author's  clinic 
at  the  Philadelphia  Hospital.  Contraction  of  the  sensitive  half  field.  Colors  correctly  named  at 
flxing-point  in  the  left  eye.  Colors  correctly  named  within  temporal  side  in  an  area  10°  wide  in  right 
eye. 

homonymous  hemianopsia  is  associated  usually  with  hysterical  hemianesthesia 
and  with  unilateral  affection  of  the  other  special  senses.  There  is  almost  always 
ansesthesia  of  the  conjunctivse,  a  symptom  which  may  serve  to  distinguish  the 
afiection  from  hemiansesthesia  due  to  organic  brain  disease.  The  blind  fields 
are  always  on  the  anaesthetic  side.  The  half-fields  in  which  sight  is  retained 
are  usually  contracted,  as  in  the  case  here  shown  ;  this  contraction,  as  will 
presently  be  demonstrated,  is  a  peculiarly  hysterical  phenomenon.  A  rare 
form  of  hemianopsia  is  the  binasal  variety,  which  is  illustrated  in  the  accom- 
panying diagrams  (Fig.  30),  from  a  case  of  Mitchell  and  de  Schweinitz. 
Finally,  there  may  be  a  concentric  narrowing  of  the  visual  field.  In  this  form 
of  amblyopia  sight  is  retained  for  the  centre  of  the  field,  Avhile  it  is  lost  in  vary- 
ing proportions  for  the  periphery.     In  some  cases  the  restricted  field  is  very 

1  Weaker  et  Landolt  (Traite  Comp.  d'Ophthalomologie,  article  on  "Amblyopic  Hysterique,"  p.  712) 
refer  to  a  number  of  cases  of  hystero-epileptic  amblyopia  which  presented  the  characters  of  an 
homonymous  hemianopsia.  Such  cases  have  been  reported  by  Rosenthal,  Sturge,  Galezowski,  West- 
phal,  and  others. 


GENERAL  MORBID  STATES. 


113 


small ;  in  some,  also,  it  is  almost  round ;  in  others  it  is  oval,  or  it  may  be 
rather  irregular  in  shape.  It  may  be  narrowed  to  less  that  20°  (Fig.  31).  It 
is  practically  a  concentric  narrowing,  i.  e.,  the  centre  of  the  normal  field  re- 


PlG.  30. 


Diagrams  of  the  fields  of  vision  in  a  case  of  hysterical  hemiansesthesia.  Irregular  binasal  hemian- 
opsia ;  partial  reversal  in  the  color  fields  of  the  left  eye  ;  color  perception  only  at  the  flxing-point  in 
the  right  eye.    (Mitchell  and  de  Schweinitz.) 

-• =  red.    =  blue =  green. 


Fig.  31. 


Diagrams  of  the  fields  of  vision  in  a  case  of  universal  hysterical  anaesthesia,  showing  mariied 
concentric  contraction.    (Mitchell  and  de  Schweinitz.) 

mains  the  centre  of  the  restricted  one.  This  concentric  narrowing  of  the 
visual  fields  is  one  of  the  most  common  of  the  sensory  stigmata  of  hysteria. 
It  is,  of  course,  as  a  rule,  unknown  to  the  patient.^ 

In  hysteria  the  perception  for  colors  may  be  affected  ;  hence  there  may  be 
achromatopsia  or  dyschromatopsia.  In  the  former  the  perception  for  all 
colors  is  lost.  All  objects  are  described  as  being  of  a  dull-gray  tint.  A 
much  more  common  affection  is  the  latter  state,  or  dyschromatopsia,  in  which 
the  normal  perception  for  colors  is  perverted.     In  the  normal  eye  the  several 

1  It  is  important  for  examiners  to  bear  in  mind  that  this  narrowing  of  the  visual  field  is  influenced 
readily  sometimes  by  suggestion  ;  and  this  not  so  much  to  produce  it,  as  to  abohsh  it.  An  impatient 
or  brusque  manner  may  defeat  the  object  of  the  examiner.  This  may  account  for  the  varying  results 
reported. 


114 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


colors  of  the  spectrum  are  not  perceived  in  coequal  and  coextensive  fields : 
thus,  violet  occupies  the  smallest  or  innermost  field,  green  the  next  largest, 
red  the  next,  yellow  the  next,  and  blue  the  largest  or  outermost.  This  order 
of  perceptions  is  changed  in  hysteria  usually  by  the  exchange  of  places  in  the 
series  between  red  and  blue.  Hence,  red  comes  to  occupy  the  largest  field 
(Fig.  32).  Moreover,  in  the  narrowing  of  the  visual  fields,  already  described, 
the  color  fields  are  also  narrowed  and  in  the  order  of  their  normal  position. 

Fig.  32. 


Diagrams  of  fields  of  vision  in  a  case  of  hysteria,  showing  normal  form  field  and  reversal  of  the 

red  and  blue  lines,  the  red  field  being  largest  in  extent.    (Mitchell  and  de  Schweinitz.) 
-.-.-  =  red.    =  blue,    =green. 

Thus,  violet  disappears  first,  then  green — or,  as  someone  has  said,  they  are 
"  squeezed  out  at  the  centre  ;  "  but  the  blue  disappears  before  the  red,  which 
is  the  most  persistent  color-perception  in  the  hysterical  patient.  So  much  is 
this  the  case  that  some  writers  have  claimed,  rather  fancifully,  that  the  color 
red  plays  a  part  in  the  deliria  and  hallucinations  of  the  grand  attack. 
Finally,  in  some  cases  of  hysteria  there  may  be  little  or  no  alteration  of  the 
fields  of  vision. 

A  very  curious  visual  phenomenon  seen  in  hysteria  may  be  mentioned 
here,  although  it  is,  probably,  a  muscular  rather  than  a  purely  sensor}^  defect. 
This  is  monocular  diplopia  or  polyopia.  In  this  the  patient  sees  two  or  more 
images  of  the  same  object  with  one  eye,  the  other  being  closed.  It  has  been 
ascribed  by  Perinaud^  to  a  spasm  of  the  muscle  of  accommodation,  and  is  not 
confined  to  hysteria.^  It  was  noted  in  an  hysterical  patient  of  the  writer's 
at  the  Philadelphia  Hospital,  and  also  in  another  patient  in  the  same  clinic 
who  was  suspected  to  have  hysterical  symptoms  grafted  on  syphilis  of  the  spinal 
cord,  and  who  was  found  by  Dr.  de  Schweinitz  to  have  a  syiDhilitic  choroiditis. 
The  diplopia  was  more  probably  due  to  hysteria  than  to  the  organic  disease, 
for  it  is  difiicult  to  see  how  a  choroiditis  could  cause  monocular  diplopia. 

The  other  special  senses,  as  said  already,  may  be  afiected  in  various  ways 
in  hysteria. 

Hysterical  deafness  is  a  not  uncommon  accompaniment  of  hysterical 
hemiansesthesia.'     It  may  occur,  however,  independently,  and  may  be  sudden 

1  De  la  polyopic  monoculaire  dans  I'hysterie  et  les  affections  du  systeme  nerveux.  Annals  d'Ocu- 
listique,  1878. 

2  It  occurs  in  commencing  cataract,  and  is  due  apparently  to  a  disturbance  of  the  refractive  power 
of  the  lens,  which  would  also  be  its  immediate  cause  in  spasm  of  the  muscle  of  accommodation. 
Perinaud  says  it  is  produced  sometimes  by  atropia,  which  also  interferes  with  refraction. 

3  See  paper  by  Walton  on  "  Deafness  in  Hysterical  Hemiansesthesia."    Brain,  v.  1883,  p.  458. 


GENERAL  MORBID  STATES.  115 

and  complete,  although  this  is  rare.  It  is  frequently  not  complete ;  in  other 
words,  the  hearing  is  not  abolished,  but  only  impairecl.  It  is  not  accompanied 
with  tinnitus  or  noises  in  the  head.  That  it  is  a  purely  central  or  psychic 
affection  can  be  demonstrated  by  the  tuning-fork,  which  can  be  heard  by 
aerial  conduction  better  than  by  bone  conduction — a  proof  that  the  deafness 
does  not  depend  upon  disease  of  the  external  or  middle  ear.  In  this  respect 
hysterical  deafness  is  analogous  to  hysterical  blindness — it  is  a  strictly 
psychical  affair.  In  hysterical  deafness  the  sensibility  of  the  auditory  canal, 
tympanum,  and  even  of  the  middle-ear  is  abolished.  The  patient  tolerates 
manipulation  of  the  drum,  and  the  use  of  the  Politzer  bag  excites  no  sensa- 
tion. Walton  says  that  the  degree  of  deafness  corresponds  with  that  of  gen- 
eral anaesthesia.     The  deafness  may  be  transferred  with  the  anaesthesia. 

Loss  of  smell,  or  anosmia,  is  present  apparently  is  cases  of  hemiansesthesia. 
It  seemed  to  be  so  in  the  case  reported  elsewhere  in  this  paper  from  the 
writer's  clinic  at  the  Philadelphia  Hospital.  It  is  difficult,  in  hysterical 
cases,  to  make  satisfactory  tests  of  the  sense  of  smell.  In  this  case  all  the 
special  senses  on  the  anaesthetic  side  were  involved. 

The  sense  of  taste  may  be  affected  in  hysteria,  either  entirely  or  unilater- 
ally, or  in  limited  areas.  The  unilateral  involvement  of  this  sense  in  hys- 
terical hemiansesthesia  can  be  demonstrated  satisfactorily,  but  the  other  forms, 
especially  the  loss  of  taste  in  limited  areas  as  reported  by  some  writers,  must 
be  very  hard  to  be  demonstrated,  because  both  of  the  difficulty  of  limiting 
the  action  of  a  sapid  substance  to  small  areas  on  the  tongue  and  of  the 
extreme  likelikood  of  influencing  the  patient  by  suggestion  in  the  necessary 
manipulation.  Pitres^  states  that  there  is  no  necessary  connection  between  the 
loss  of  general  sensibility  of  the  tongue  and  the  loss  of  the  sense  of  taste. 
In  some  cases,  he  affirms,  the  taste  is  abolished  in  the  anaesthetic  areas  only ; 
in  others  the  taste  is  lost,  although  the  general  sensibility  is  retained ;  in 
others,  again,  the  taste  is  preserved  on  parts  of  the  tongue  that  are  insensible 
to  heat  and  to  pain  ;  and,  finally,  in  some  cases,  there  may  be  areas  of  tactile 
anaesthesia  and  areas  of  gustative  anaesthesia  not  coextensive. 

Motor  Symptoms.  The  motor  symptoms  of  hysteria  may  be  divided 
into  four  groups :  paralysis,  contracture,  tremor,  and  inco-ordination.  They 
will  be  described  in  the  order  named. 

The  paralysis  of  hysteria  has  various  forms.  It  may  be  a  monoplegia,  a 
paraplegia,  an  hemiplegia,  or  even,  in  rare  cases,  a  total  palsy.  It  some- 
times presents  itself  as  a  very  limited  paralysis — i.  e.,  it  may  be  confined  to 
a  few  muscles  or  muscle-groups.  Thus  it  may  present  the  form  of  a  facial 
paralysis,  a  paralysis  of  some  of  the  arm  or  hand  muscles,  or  of  the  muscles 
of  the  neck  (causing  torticollis).  Finally,  there  may  be  paralysis  of  the 
muscles  of  the  tongue,  pharynx,  larynx,  oesophagus,  and  even  of  the  anus. 
Most  of  these  forms  of  hysterical  paralysis  are  likely  to  be  accomj)anied  with 
contracture,  so  that  it  is  difficult  to  describe  these  two  symptoms  apart.  But 
for  clearness  this  will  be  done,  attention  being  called  occasionally  to  this  fact 
by  appropriate  illustration. 

Hysterical  paralysis,  with  or  without  contracture,  has  several  well-recog- 
nized causes.  It  is  especially  likely  to  be  caused  or  aggravated  by  a  con- 
vulsion. Thus  it  may  appear  as  a  pi'odrome,  and  may  persist  after  the  fit 
for  various  periods.  It  may  be  caused  by  trauma — a  not  infrequent  cause, 
and  a  most  important  one  to  be  recognized.  This  paralysis,  combined  with 
certain  other  stigmata,  as  segmental  anaesthesia,  may  play  a  conspicuous  role 
in  medico-legal  cases  due  to  trauma.  In  surgical  cases  forms  of  this  paralysis 
may  assume  great  importance  as  confusing  complications.     Again,  hysterical 

1  Op.  cit.,  p.  88,  vol.  i. 


116  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

paralysis  may  be  caused  by  emotion,  such  as  fright,  anger,  chagrin,  or  dis- 
appointed love.  I  have  referred  elsewhere  to  the  case  of  a  young  woman, 
once  under  my  care,  who  became  paraplegic  after  an  exciting  episode 
with  her  favorite  parson.  This  paralysis  may  be  caused  also  by  various 
toxic  and  morbid  states,  as  by  the  infection  of  s}^Dhilis,  tj^Dhoid  fever,  or 
other  zymotic  disease,  and  by  such  poisons  as  alcohol.  Finally,  most  or  all 
of  the  causes  referred  to  under  the  head  of  the  general  etiology  of  hysteria 
may  cause  paralysis.  This  symptom  does  not  always  occur  immediately  after 
the  primary  action  of  the  cause ;  thus  some  days  may  elapse,  in  the  case  of 
trauma  especially. 

Hysterical  paralysis  may  vary  in  degree  from  a  slight  loss  of  power 
(amyosthenia)  to  total  palsy.  The  deep  reflexes  of  the  affected  side  are 
usually  increased  and  the  skin  reflexes  aboHshed ;  the  tendency  to  contrac- 
ture is  often  marked.  Some  cases,  however,  present  a  flaccid  type.  In 
mild  cases  the  nutrition  of  the  limb  is  not  afiected,  but  in  severe  cases  of  long 
duration  slight  but  distinct  loss  of  volume  may  be  noted.  True  atrophy,  with 
reactions  of  degeneration,  is  practically  unknown,  and  when  present  must 
throAv  a  doubt  over  the  exactness  of  the  diagnosis.  Some  French  writers 
claim,  however,  that  such  atroj)hy  and  reactions  do  occur.  Care  must  be 
taken  not  to  conftise  electro-ansesthesia — a  common  hysterical  stigma — with 
abolition  of  electro-contractility. 

Hysterical  paralysis,  as  said  already,  may  be  accompanied  with  contrac- 
ture in  various  degrees.  It  is  often  accompanied  also  with  anesthesia  or 
hyperassthesia.  This  anaesthesia  is  likely  to  be  sharply  defined  and  limited  to 
the  paralyzed  part ;  thus  in  hemiplegia  it  is  a  hemianaesthesia,  and  in  mono- 
plegia a  monoanaesthesia.  This  anaesthesia  of  the  paralyzed  limb  is  sharply 
delimited,  the  boundary  being  at  right  angles  to  the  long  diameter  of  the 
limb.  In  transfer  of  hemianesthesia,  already  described,  mild  grades  of  amyo- 
sthenia also  may  be  transferred.  The  paralyzed  part  may  become  oedema- 
tous  and  blue  or  mottled — a  phenomenon  that  was  noted  by  Sydenham. 
The  hyperaesthesia  accompanying  paralysis  is  usually  h}^3eralgesia.  This 
hyperalgesia  may  be  attended  Avith  contracture,  the  painfull  cramj)-like  state 
of  the  muscles  causing  the  patient  to  cry  out  and  to  shed  tears. 

Finally,  hysterical  paralysis  may  come  on  suddenly,  or  it  may  develop  as 
a  mild  form,  gradually  growing  worse.  In  all  forms  of  this  paralysis  there 
is  likely  to  be  some  slight  movement  left,  but  there  is  often  an  indisposition 
in  the  patient  to  exert  him  or  herself  to  make  even  this  slight  movement. 
The  paralysis  is  not,  as  a  rule,  confined  to  the  distribution  of  particular  nerve- 
trunks  :  in  other  words,  it  is  central,  not  peripheral.  Occasionally  hysterical 
paralysis  is  transitory  and  recurring — an  access  of  paralysis  comes  apparently 
without  cause,  or  with  prodromes,  endures  for  a  period,  passes  away,  and  then, 
after  a  longer  or  shorter  interval,  recurs.^  Such  a  type  is  peculiarly  hysteri- 
cal, and  is  produced  by  no  other  disease.  Richer^  records  such  a  case  of 
transitory  paralysis,  affecting  now  one  limb  and  now  the  other,  in  which  there 
was  abolition  of  electro-contractility  in  certain  groups  of  muscles.  Briquet^ 
noted  that  in  some  cases  the  paralysis  passes  fi-om  one  side  of  the  body  to  the 
other,  or  leaves  successively  one  ]Dart,  as  the  arm,  the  leg,  the  larynx,  or  the 
diaphragm,  to  pass  into  another. 

The  duration  of  hj^sterical  paralysis  may  be  greatly  prolonged.  Some 
cases  recover  promptly,  but  others  j)ersist  so  long  and  simulate  so  closely  the 
effects  of  organic  disease,  that  even  the  most  careftil  observer  may  come  to 
distrust  the  exactness  of  his  diagnosis.     I  have  such  a  case  now  under  obser- 

1  See  "  Report  of  a  Case  of  Periodical  Paralysis,"  by  Dr.  C.  W.  Burr,  Univ.  Med.  Mas.,  August,  1893. 

2  "Paralysie  Erratique,"  etc.,  in  his  Paralysis  et  Contractures  Hvsteriques,  p.  30. 
8  Op.  cit. 


GENERAL  MORBID  STATES. 


117 


vation,  described  in  this  chapter  which  began  as  a  pseudo-coxitis,  became  a 
paraplegia,  and  is  now  a  hemiplegia  plus  the  paraplegia,  and  exhibits  also 
sensito-sensorial  hemiansesthesia,  and  yet,  after  several  years,  gives  no  promise 
of  recovery. 

The  termination  of  hysterical  paralysis  is  sometimes  sudden,  following  some 
shock  or  strong  mental  or  moral  impression.  Sometimes,  however,  recovery 
is  gradual  under  well-directed  treatment. 

The  hemiplegia  of  hysteria  has  some  special  characteristics.  The  leg  is  more 
paralyzed  than  the  arm.  The  arm  usually  lies  flaccid  by  the  side,  but  the 
foot  assumes  the  position  of  equino-varus.  There  may  be,  and  usually  is, 
stiffness  of  the  leg,  which  is  extended.  If  the  patient  retains  an  ability  to 
walk  the  leg  drags  as  an  inert  mass,  very  different  from  the  spastic  gait  of 
organic  hemiplegia.  The  muscles  of  the  face  and  tongue,  as  an  almost  uni- 
versal rule,  are  not  paralyzed.^  There  may  be,  however,  a  contracture  of 
the  facial  muscles  on  either  the  paralyzed  or  the  sound  side.  There  is  no 
true  aphasia.  The  hemiplegia  in  the  great  majority  of  cases  is  on  the  left 
side.  Usually  there  is  hemiauEesthesia,  involving  the  special  senses,  of  the 
paralyzed  side.  In  bed-ridden  cases  bed-sores  do  not  form.  According  to 
Briquet's  statistics,  hemiplegia  occurred  in  74  cases  in  a  total  of  430  hysterical 
patients. 

The  following  case  of  hemiplegia  presents  a  type  : 

D.  K.,  aged  twenty-five  years,  was  a  patient  of  the  writer's  in  the  Phila- 
delphia Hospital.     Her  long  history  can  be  given  in  brief  epitome.    She  had 

Fig.  33. 


Hysterical  paraplegia  with  contractures.    (Philadelphia  Hospital.) 

first  presented  a  pseudo-coxitis  of  the  left  side.  There  had  followed  a  para- 
plegia with  contractures  (Fig.  33).  Then  paralysis  of  the  left  arm  and  hand 
developed  rather  suddenly  after  the  paraplegia  had  continued  for  several 
months.  Thus  the  case  became  a  combined  para-  and  hemiplegia.  The  arm 
remained  flaccid.  At  the  date  of  these  notes  the  case  was  as  follows :  The 
motor  symptoms  were  as  described.     The  legs  were  paralyzed  and  contrac- 


1  The  few  exceptions  reported  by  Chantemesse  and  others  cannot  be  held  to  invalidate  this  rule 
until  they  are  strengthened  by  additional  observations. 


118  n:eb  ro  us  diseases  and  their  trea  tmeni. 

tured,  Avith  the  feet  in  the  position  of  equraus.  The  knee-jerks  were  retained, 
but  not  exaggerated ;  there  was  no  ankle  clonus.  There  was  no  paralysis  of 
the  bladder  and  no  bed-sores.  The  left  arm  was  paralyzed  and  flaccid,  and 
lay  extended  along  the  body.  The  faradic  contractility  of  some  of  the  leg- 
muscles  was  slightly  diminished ;  the  galvanic  response  ia  the  same  muscles 
was  also  CjuantitatiTely  diminished,  and  in  some  few  muscles  the  anodal  con- 
tracture about  equalled  the  cathodal.  (This  Ls  rather  in  accord  with  the 
claim  of  some  French  observers  that  the  reactions  of  degeneration  are  found 
occasionally  in  hysteria.) 

(a)  Tactile  seimbiUty.  Hemiansethesia  on  the  left  side  of  the  body  from 
head  to  foot ;  anaesthesia  does  not  touch  meridian  line  in  front,  but  begins 
one  and  one-half  niches  to  the  left.  On  the  right  side  sensation  is  present  on 
the  face,  arm,  and  trunk.  In  the  lower  limbs  it  is  absent,  except  ia  a  small 
area,  5x2  inches,  on  the  anterior  surface  of  the  thigh.  The  right  sole  is 
hypergesthetic.  On  the  back  there  is  the  same  area  of  ansesthesia.  The 
ansesthesia  involves  the  mucous  membranes. 

(h)  Pain-sense.  Analgesia  corresponds  to  anaesthesia,  except  that  the  right 
arm  and  right  side  of  the  back  are  also  analgesic.  Analgesia  includes  also 
the  bones  and  muscles. 

(c)  Muscular  sense.  This  is  almost  totally  lost.  The  patient  does  not  know 
the  position  of  her  limbs.     The  sense  of  fatigue  also  is  lost. 

(d)  Electro-sensibility.     Tliis  is  lost  in  the  anaesthetic  areas.     On  the  left 
side  of  the  neck  the  current  produces  a  tonic  spasm  of  the  sterno-cleido-mas-  - 
toid  muscle,  which  is  not  painful. 

Special  semes.  There  is  loss  of  taste  on  the  left  half  of  the  tongue.  Loss 
of  smell  is  noted  in  the  left  nostril.  Hearing  is  diminished  on  both  sides, 
more  so  on  left.  Watch  R.  E.,  10  cm. ;  L.  E.,  6  cm.  Sight:  contraction  of 
the  visual  field,  reversal  of  the  color  field  in  the  left  eye. 

By  the  application  of  metals  no  transfer  could  be  obtained,  nor  any  change 
in  the  ansesthetic  area  of  any  kind. 

The  patient  had,  as  characteristic  mental  stigmata,  passiveness  of  mind, 
radisposition  to  exert  herself,  indifierence  to  being  cured,  and  some  emotion- 
alism.    She  never  had  had  a  convulsive  attack. 

The  paraplegia  of  hysteria  simulates  closely  organic  paraplegia,  but  it  has 
some  reliable  differentiating  points.  After  trauma  or  violent  emotion  it  may 
occur  rather  brusquely,  but  otherwise  its  approach  is  insidious.  It  is  not 
accompanied  with  pains  nor  with  a  guxlle-sense,  neither  does  it  present  reac- 
tions of  degeneration.  It  usually  presents  a  characteristic  anaesthesia.  This 
is  segmental — ;'.  e.,  it  is  sharply  delimited,  not  involving  the  genitalia,  and 
running  no  farther  than  the  crests  of  the  ilia.  The  bladder  and  rectum  are 
not  paralyzed,  and  bed-sores  and  other  trophic  lesions  do  not  form.  The 
tendon-reilexes  may  be  exaggerated,  but  exceptions  occur.  Contractures 
frequently  occur;  the  legs  usually  are  rigidly  extended,  the  feet  m  the 
position  of  equino-varus.  I  have  etherized  such  a  patient  in  the  Pliiladel- 
phia  Hospital,  and  found  that  under  ether  the  limbs  were  entirely  relaxed 
and  freely  movable  in  aU  directions.  After  recovery  from  the  ansesthetic  no 
complaiat  was  made  of  pain  in  the  limbs,  which  had  thus  been  submitted  to 
very  energetic  passive  movements.  In  protracted  cases  the  muscles  become 
rather  reduced  from  misuse,  but  do  not  truly  atrophy ;  in  fact,  in  some  cases 
with  contracture,  rather  the  reverse  is  seen,  the  muscles  remaining  firm  and 
well-nourished. 

Paralysis  of  the  four  limbs  has  been  seen  in  hysteria,  but  it  is  extremely 
rare.  It  usually  occurs  gradually,  and,  according  to  Richer,  invades  the  leg 
before  the'  arm,  'and  the  left  side  before  the  right.     Chevalier,  in  a  special 


GENERAL  MORBID  STATES.  119 

study,  was  able  to  find  only  twenty-one  authentic  cases  recorded.'  The  mus- 
cles of  the  face  and  trunk,  and  of  respiration,  are  not  paralyzed,  but  the  blad- 
der may  be  so.  There  may  be  aphonia  and  dysphagia.  One  side,  usually 
the  left,  is  more  paralyzed  than  the  other.^ 

Other  special  forms  of  paralysis  are  seen  in  the  face,  in  the  eye-muscles,  in 
the  tongue,  and  in  the  muscles  of  the  neck.  They  are  not  to  be  confounded 
with  contractures.  They  may  coexist,  in  fact,  with  contractures,  the  muscles 
of  one  side  being  paralyzed  and  of  the  other  contractured.  Contracture  of 
the  face-muscles,  as  already  shown,  may  be  observed  in  hysterical  hemiplegia 
much  more  commonly  than  jjaralysis.  The  tongue  also  may  deviate  because  of 
contracture.  I  have  seen  the  tongue  in  a  case  of  hysterical  hemif)legia  devi- 
ate to  the  sound  side  by  reason  of  contracture  of  its  muscles.^  Part  of  the 
face  only  may  be  involved  in  palsy. 

Contracture,  as  already  said,  is  very  likely  to  coexist  with  paralysis  in  hys- 
teria ;  still,  this  is  not  a  constant  rule.  Neither  is  the  reverse  true,  that  the 
contractured  limb  or  muscle  is  always  paralyzed.  The  contracture  of  hysteria 
has  a  few  distinguishing  traits.  It  may  be  caused  by  most  of  the  agents  which 
cause  paralysis,  and  its  onset  may  be  sudden  or  gradual ;  a  sudden  onset  is 
the  more  common.  It  may  follow  and  complicate  a  paralysis,  or  it  may 
occur  independently  of  one.  It  is  a  most  obstinate  and  resisting  contracture, 
being  very  difficult  to  be  overcome,  even  with  great  force.  Moreover,  the  an- 
tagonistic muscles  are  involved  ;  in  other  Avords,  the  limb  is  held  in  a  vise-like 
immobility.  The  contracture  is  sometimes  so  persistent  that  it  does  not  relax 
even  in  sleep  ;  it  does  relax,  however,  under  ether  or  chloroform.  The  mus- 
cles retain  their  nutrition,  although  in  long-continued  cases  the  limb  may 
waste.  Sensation  is  often  abolished  in  the  affected  limb.  The  contracture 
may  appear,  disappear,  and  reappear :  it  may  return  to  the  same  limb ;  or  it 
may  be  erratic,  like  some  forms  of  paralysis,  and  reappear  in  another  limb. 
The  duration  of  this  symptom  is  very  variable ;  sometimes  it  is  most  pro- 
tracted ;  sometimes  it  yields  suddenly  to  some  unexpected  cause.  In  some 
cases  the  contracture  is  painful ;  in  such  cases  the  general  health  suffers,  the 
patient  loses  flesh,  and  passes  into  bad  morale.  I  have  known  such  a  case  to 
present  a  marked  remittent  type,  a  contracture  in  the  arm  coming  on  in  the 
midst  of  an  abortive  convulsive  seizure,  and  enduring  for  some  hours.  It 
could  be  excited  by  pressure  on  the  musculo-spinal  nerve,  and  was  so  painful 
that  the  patient  cried  out  with  it. 

The  case  briefly  was  as  follows  : 

W.  T.,  aged  twenty-three  years,  female,  dressmaker,  was  admitted  to  the 
Methodist  Episcopal  Hospital  under  my  care.  There  was  marked  heredity. 
The  parents  were  both  neurotic,  and  one  sister  had  had  convulsive  hysteria. 
Six  years  before  admission  the  patient  had  an  hysterical  convulsion,  Avith  un- 
consciousness. Subsequent  attacks  occurred.  They  were  preceded  by  an 
aura  of  pain  in  the  ball  of  the  left  foot,  spreading  up  the  leg  and  thigh. 
Following  the  first  seizure  the  patient  Avas  confined  to  bed  for  one  year  and  a 

1  Two  instances,  evidently  of  this  form  of  hysterical  paralysis,  are  reported  in  the  St.  Bartholo- 
mew's Hospital  Reports  for  1892,  under  the  misleading  title  of  "General  Spastic  Rigidity."  The 
authors  of  the  report  do  not  recognize  the  hysterical  nature  of  the  cases. 

-  Moehius  has  described  a  form  of  paralysis  which  he  calls  akinesia  algera  (pain-paralysis),  and 
which  depends  apparently  upon  an  inhibitory  imperative  conception.  The  patient  dreads  to  move 
for  fear  of  pain.  The  affection  is  rare  and  is  allied  probably  to  the  intention  psychoses,  such  as 
claustrophobia,  agoraphobia,  etc.  It  is  a  symptom  of  degeneracy  rather  than  of  hysteria.  Genuine 
hysterical  symptoms  were  not  observed  in  Moebius'  patients,  one  of  whom  became  insane. 

While  not  ambitious  to  coin  new  names,  I  suggest  that  kinesiphobia  better  expresses  the  mental 
state  in  these  patients  than  does  the  compound  name  given  to  the  affection  by  Moebius.  It  is  a  fear 
of  movement  analogous  to  the  fear  of  contamination  (mysophobia)  and  the  "other  morbid  fears  ot 
this  group  that  seems  to  characterize  his  patients. 

3  The  tongue  is  capable  of  complex  co-ordinated  movements,  hence  it  is  not  likely  that  the  mus- 
cles of  one  side  alone  are  contractured  in  hysterical  cases.  These  hysterical  contractures  of  the 
tongue  are  co-ordinated  movements  in  which  muscular  fibres  on  both  sides  may  be  involved. 


120 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


half.  Ever  after  the  attack  she  had  aphonia,  the  voice  being  scarcely  audible, 
and  she  had  also  pains  in  the  back  and  sides.  One  year  before  admission  she 
fell  and  struck  her  back,  after  which  trauma  the  seizures  "svere  worse  and  the 
aphonia  increased.  Pains  increased ;  there  were  hypersesthetic  zones  on  the 
dorsal  and  cervical  spine.  She  had  felt  a  numbness  in  the  neck  for  a  long 
while  after  falling.  The  patient  could  always  foretell  a  fit  by  the  pain  in  the 
ball  of  her  foot ;  she  voided  much  urine  of  light  color  and  low  specific  gravity 
before  the  attack.  In  the  attack  opisthotonos  was  marked,  and  the  period 
of  grand  movements,  the  clonic  stage,  was  aborted.  She  never  bit  her  tongue. 
There  was  much  embarrassment  of  breathing.  There  was  slight  intervallary 
tremor  and  occasional  vomiting.  Nutrition  was  poor,  but  weight  had  not 
decreased  for  some  years.  A  single  whiif  of  ether  was  said  to  stop  the  con- 
vulsion. On  admission  the  patient  was  found  to  have  anaesthesia,  as  depicted 
on  the  diagram  (Fig.  34).     She  was  not  aware  that  she  had  any  loss  of  sensa- 

FiG.  34. 


Anaesthesia  in  a  case  of  hysteria.     (Methodist  Episcopal  Hospital, 


Segmental  and  insular 
Philadelphia.) 

tion.  There  was  ovarian  hyperalgesia.  A  few  days  after  admission  she  was 
excited  by  an  accident  case  that  was  admitted  into  the  ward  ;  shortly  afterward 
a  spasmodic  painful  contracture  of  the  fingers,  hand,  and  forearm  occurred, 
as  shown  in  the  jDhotograph  (Fig.  35).  It  could  be  relaxed  gradually  by 
firm,  continued  extension.  It  was  accompanied  with  great  pain  not  only  in 
the  arm,  but  in  the  chest,  neck,  and  back.  In  a  few  minutes  the  left  thigh 
was  drawn  up  on  to  the  abdomen,  with  the  leg  and  toes  extremely  flexed.  On 
forcible  extension  of  the  leg  the  patient  lapsed  into  unconsciousness,  with  eyes 
closed,  lids  quivering,  pupils  widely  dilated,  mouth  open,  and  head  retracted. 
The  other  arm  and  leg  then  became  tonically  contractured.  The  patient  wept 
toward  the  close  of  the  attack.  Pressure  on  the  supraorbital  nerve  ended 
the  attack.-  In  some  attacks  there  was  great  dyspnoea  following  the  convul- 
sive phenomena.  It  was  found  that  all  these  phenomena  could  be  induced 
by  making  firm  pressure  on  the  musculo-spinal  nerve.     The  painfiil  contrac- 


GENERAL  MOBBID  STATES. 


121 


ture  of  the  arm  was  the  most  persistent  symptom.     This  patient  was  cured  by 
isolation,  hydrotherapy,  massage,  and  the  ministrations  of  a  wise  and  firm 


Fig.  35. 


Hysterical  contracture.    (Methodist  Episcopal  Hospital,  Philadelphia.) 
Fig.  36. 


Hysterical  contracture;  progression  on  the  toes.    (Philadelphia  Hospital.) 

nurse.     The  aphonia  was  the  first  symptom  to  yield.     She  was  discharged 
cured,  with  much  increased  weight,  in  about  one  month. 


122  NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 

Hysterical  contracture  may  be  confined  to  some  few  muscles  of  a  limb.  In 
such  cases  the  limb  may  not  be  disabled,  but  only  limited  in  movement  to 
the  extent  of  the  contracture.  Some  of  these  cases  assume  strange  t}^Des, 
and  may  be  very  puzzHng  for  a  while  in  the  diagnosis.  One  of  the  rarest  of 
these  types  that  has  come  under  my  notice  was  the  following : 

S.  A.,  aged  eighteen  years,  widow,  Eussian  Jewess,  was  in  the  Philadelphia 
Hospital  under  my  care  for  several  months.  She  was  dwarfish  in  stature  and 
of  rather  low  intelligence.  Xo  history  was  attainable.  She  was  in  good 
general  health  and  attracted  attention  merely  by  the  peculiarity  of  her  gait. 
She  walked  entirely  on  her  toes,  i.  e.,  on  the  balls  of  her  feet  and  toes,  the 
heels  being  elevated  almost  one  inch  fi'om  the  ground  (Fig.  36).  On  close 
inspection  it  was  observed  that  this  mode  of  progression  was  caused  by  firm 
contracture  of  the  calf  muscles.  These  were  so  firmly  contractured  that  the 
utmost  allowable  force  could  not  overcome  them.  The  tendines-AchilKs  were 
taut  as  in  cases  of  club-foot,  to  which  class  of  affections  it  was  at  first  thought 
that  the  case  belonged.  It  was  soon  seen,  however,  that  the  case  was  not  an 
example  of  ordinary  double  pes  ec|uinus.  The  muscles  were  well  nourished, 
and  reacted  normally  to  the  electric  currents.  The  skin  was  not  cold, 
although  slightly  mottled.  There  was  no  true  deformity  of  the  foot.  The 
contractures  were  not  painful  except  when  attempts  to  overcome  them  were 
made.  The  pain  then  was  felt  mostly  in  the  regions  of  the  popliteal  spaces. 
The  two  legs  were  exactly  alike,  which  would  be  rather  a  rare  occurrence  in 
double  club-foot.  A  diagnosis  of  hysterical  contracture  was  made.  It  was 
confirmed  by  the  discovery  of  anaesthesia  in  extensive  areas,  involving  espe- 
cially the  left  arm  and  left  chest.  There  was  also  aphonia.  The  patient 
contmued  to  walk  as  described  for  many  months.  Close  observation  by 
internes  and  nurses  failed  to  detect  any  remission  of  the  affection.  It  sud- 
denly disappeared,  however,  on  the  reception  of  some  pleasant  news,  which 
occasioned  the  patient's  removal  from  the  hospital.     She  walked  out  cured. 

Other  forros  of  contracture  are  in  the  muscles  of  the  face,  tongue,  eyes,  and 
neck.  Some  of  these,  as  ah-eady  observed,  may  coexist  with  paralysis  of 
other  muscles.  Facial  hemispasm  is  not  uncommon  in  hysterical  hemiplegia, 
and  must  not  be  confused  with  paralysis.  It  may  be  associated  with  peculiar 
contractures  of  the  tongue,  drawing  it  to  one  or  the  other  side,  the  appear- 
ance and  seat  of  these  contractures  producing  deformities  that  are  not  iden- 
tical with  the  hemiparesis  of  the  lower  face  and  of  the  tongue  as  seen  on  the 
same  side  in  organic  hemiplegia.  Thus  the  contracture  may  protrude  the  tongue 
away  from  the  paralyzed  side,  instead  of  its  being  protruded  toward  that  side 
as  in  organic  disease.  The  contracture  of  the  face  may  be  associated  with 
contracture  of  some  of  the  eye  muscles,  called  blepharospasm ;  this  may  give 
a  superficial  appearance  of  ptosis,  when  in  fact,  instead  of  paralysis  of  the 
upper  lid,  there  is  a  slight  contracture  of  the  orbicularis  muscle.  Torticollis, 
due  to  contracture  of  some  of  the  muscles  of  the  neck,  is  seen  occasionally  in 
hysteria.^ 

'  Tremor  is  one  of  the  most  important  of  the  motor  stigmata  of  hysteria.^ 
It  Ls  caused  especially  by  trauma  and  by  toxic  agents,  as  alcohol,  lead,  and 
mercury.  In  traumatic  hysteria  this  symptom  is  always  bound  to  play  an 
important  part,  being  conspicuous  sometimes  in  medico-legal  cases,  and  in 
men  as  fi'equently,  if  not  more  fi-equently,  as  in  women.  It  may  be  a  very 
persistent  symptom,  and  may  simulate  closely  the  effects  of  organic  disease. 
In  toxic  cases,  as  from  alcohol,  lead  and  mercury,  it  is  likely  to  be  confounded 
with  the  organic  effects  of  the  poison  ;  yet,  as  shown  elsewhere  (page  95),  the 

1  See  Rich^r's  work  for  details  of  these  various  forms. 

2  I  have  described  elsewhere  at  length  the  symptoms  and  course  of  hysterical  tremor,  "  Hysterical 
Tremor  and  Hysterical  Anorexia,  etc."    Am.  Jour.  of  Med.  Sci.,  September,  1893. 


GENERAL  MORBID  STATES. 


123 


tremor  observed  in  these  cases  is  sometimes  purely  hysterical.  I  have  twice 
seen  persistent  tremor  caused  by  the  shock  of  a  supposed  poisoning,  once  by 
mercury  and  once  by  saltpetre.  In  neither  case  was  there  any  real  injury 
done  by  the  poison.  I  have  also  seen  it  caused  by  a  severe  fall,  by  the  terror 
from  an  earthquake,  and  by  ether  anaesthesia  during  a  surgical  operation. 
Two  of  those  cases  lasted  for  years,  one  being  cured  entirely ;  the  others 
lasted  for  variable  periods  of  months.  This  tremor  may  be  divided  into 
classes,  as  Dutil  has  done,  according  to  the  number  of  oscillations  per  second. 
Thus  (1)  oscillations  rapid  or  vibratory  (8  to  12  per  second),  (2)  medium 
rhythm  (5  J  to  7*  per  second),  (3)  oscillations  slow  (4  to  5  5  per  second).  In 
the  last  two  groups  some  tremors  occur  only  on  voluntary  motion,  but  the 
most  common  is  what  is  called  the  "type  Rendu,"  in  which  the  rhythm  is 
from  about  7  to  9  per  second,  and  in  Avhich  the  tremor  continues  during 
repose,  but  is  much  increased  in  amplitude,  but  not  in  rhythm,  during  volun- 
tary movement.  This  type  was  presented  by  all  of  my  own  cases,  as  well  as 
by  the  cases  of  Luys  and  of  Westphal  (which  latter  are  of  interest  because 
they  were  not  attributed  to  their  true  cause),  and  also  by  cases  reported  by 
Charcot  and  others.     The  following  is  an  illustrative  case : 

S.  C,  aged  twenty-four  years,  w^hite,  single,  has  been  an  inmate  of  the 
Home  for  Crippled  Children  under  my  care  for  eleven  years.  During  all  of 
that  time  she  has  been  confined  to  her  bed.  She  is  a  case  of  muscular  dys- 
trophy. She  is  almost  totally  paralyzed  in  her  legs,  but  retains  some  move- 
ment of  her  feet  and  toes.  Gradual  contractures  of  her  legs  had  been 
established  during  several  years  until  the  heels  were  against  the  buttocks. 
These  contractures  were  very  painftil,  and  caused  the  patient  much  unrest. 
In  order  to  straighten  the  legs,  both  for  the  patient's  comfort  and  for  the  bet- 
ter nursing  and  care  of  her  person,  she  was  etherized.     It  was  proposed  by 


Fig.  37. 


Fig.  38. 


LEFT  HAND 


Tracings  of  hysterical  tremor  following  surgical  aneesthesia.    (Home  for  Crippled  Children.) 

Dr.  Willard,  the  surgeon  to  the  Home,  to  perform  tenotomies  and  to  put  the 
legs  in  plaster  dressings.  To  our  surprise  it  was  found  that  under  ether  the 
contractures  were  comj^letely  relaxed,  and  that  the  legs  ^vere  freely  movable 
in  all  directions.  No  tenotomies  were  required.  The  plaster  dressings  were 
applied,  and  the  patient  returned  to  the  ward.  For  many  days  after  the 
etherization  much  pain  in  the  legs  was  complained  of.  The  patient  was  de- 
pressed, and  was  much  imjoressed  with  the  idea  that  an  operation  had  been 
performed.     In  less  than  one  week  a  very  marked  tremor  appeared  in  the 


124 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


hands,  arms,  and  toes.     It  was  constant  during  repose,  but  mucL.  increased  by 

voluntary  motion.     It  prevented  the  patient's  constant  work,  sewing  and 

embroidering.     It  could  be  increased  by  suggestion,  and  was  eventually, 

after  several  weeks,  cured  by  it.     A  tracing  of  this  tremor  is  shown  in  Figs. 

37  and  38.      This  patient  has  had  other  stigmata,   as  aphonia  of  several 

weeks'  duration,  and  segmental  anesthesia  of  the  legs.      The  contractures 

were  suspiciously  like  those  of  hysteria.     She  has  worn  the  casts  now  for 

twelve  weeks,     the  tremor  is  cured,  and  the  patient  contentedly  works  at 

her  sewing. 

Fig.  39. 


Hysterical  astasia-abasia.    (Methodist  Hospital.) 

Finally,  the  fourth  motor  affection  of  hysteria  is  inco-ordination,  or  hyster- 
ical ataxia,  or,  as  it  has  come  to  be  called,  after  Blocq,  astasia-abasia.  This 
curious  and  rare  affection  was  referred  to  by  Brodie  and  later  by  Jaccoud.  It 
was  described  by  Charcot  and  Eicher  in  1883  and  by  Weir  Mitchell  in  1885. 
Briquet  refers  to  a  form  of  hysterical  ataxia  dependent  upon  ansesthesia  of 
the  legs  and  feet.  But  the  term  astasia-abasia  is  confined  almost  exclusively 
now  to  a  species  of  inco-ordination,  which  is  not  dependent  upon  ansesthesia 
or  paralysis,  and  is  not  associated  with  even  loss  of  the  finer  co-ordinated 
movements.  As  the  name  implies,  it  is  a  loss  of  power  of  standing  (astasia) 
and  of  walking  (abasia.)  When  the  patient  sits  or  reclines  there  is  full  mus- 
cular power  in  the  legs,  and  the  ability  to  execute  co-ordinate  movements,  as 
crossing  the  legs,  or  even  walking  on  "  all  fours  "  is  preserved.  There  are 
various  grades  of  the  affection,  from  total  inability  to  stand,  and  of  course 
to  walk,  up  to  a  slight  swaying  and  ataxic  gait.  In  cases  of  medium  grade 
the  patient  may  progress  if  supported  by  an  attendant  on  each  side.  The 
gait,  as  I  have  seen  it,  is  characterized  by  a  series  of  inco-ordinate  movements 


GENERAL  MORBID  STATES  125 

of  the  legs,  associated  with  alternate  bending  forward  and  arching  backward 
of  the  body  and  even  of  the  head.  But  little  forward  progress  is  made,  and 
the  limbs  seem  to  be  so  relaxed  that  without  support  they  would  double  up 
beneath  the  patient.  Occasionally  there  is  an  intercurrent  stiffening  of  the 
legs,  the  patient  tending  to  rise  on  the  toes.  This  occurs  Avith  an  associated 
backward,  or  opisthotonic,  movement  of  the  trunk.  The  knee-jerks  usually 
are  normal.  There  may  or  may  not  be  hyterical  anaesthesia,  but  it  is  not  the 
cause,  when  present,  of  the  inco-ordination. 

Astasia-abasia,  according  to  Blocq's^  study,  occurs  most  frequently  in  chil- 
dren and  young  persons.  It  is  especially  likely  to  be  caused  by  trauma,  and 
by  moral  or  emotional  disturbance.^  In  one  case  it  followed  a  hard  labor,  in 
another  an  attack  of  typhoid  fever. 

The  following  case  illustrates  this  anomalous  affection  : 

M.  R.,  aged,  twenty-eight  years,  German,  was  a  patient  in  my  wards  at 
the  Methodist  Episcopal  Hospital.  She  had  a  history  of  convulsive  attacks 
and  of  several  spells  of  ataxia.  Five  weeks  before  admission  she  had  been 
badly  frightened.  Then  followed  a  series  of  hysterical  prodromes,  such  as 
fulness  of  the  head,  aurse  in  the  stomach,  pulsations  in  the  chest  and  throat, 
and  headache.  Then  followed  an  abortive  seizure.  Then  the  astasia-abasia 
developed  suddenly.  This  was  the  most  marked  symptom  for  some  weeks. 
It  is  illustrated  in  the  photograph  (Fig.  39).  The  patient  required  support 
on  either  side.  The  movements  of  the  legs  were  wildly  in  co-ordinate,  tending 
now  to  fly  outward,  now  to  be  drawn  up,  and  again  to  be  arrested  by  a  tonic 
contracture,  which  drew  the  patient  up  on  her  toes,  with  her  body  backward  as 
in  opisthotonos.  But  little  forward  progression  was  made  unless  the  patient 
was  urged  or  partially  carried  along.  When  sitting  or  lying  she  had  full 
control  of  her  legs,  and  foil  power  in  them.  The  knee-jerks  were  exaggerated. 
This  patient  had  other  stigmata,  the  most  marked  of  which  was  an  almost 
total  anaesthesia,  as  shown  in  Fig.  28. 

Contrary  to  the  views  formerly  held,  muscular  atrophy  has  been  claimed 
recently  to  occur  in  hysteria.  It  affects  the  limbs  which  are  the  seats  of  other 
stigmata,  such  as  paralysis,  contracture,  and  anaesthesia.  It  may  even  show 
the  reactions  of  degeneration.  I  have  never  seen  such  a  degree  of  muscular 
degeneration  in  hysteria,  except  possibly  in  the  case  mentioned  elsewhere  in 
this  paper,  and  can  only  say  that  the  observations  of  it  are  still  far  from  num- 
erous.    LowenfekF  classifies  atrophies  in  hysteria  as  follows : 

1.,  Simple  atrophy,  (a)  in  connection  with  paralysis  and  contracture, 
developing  quickly,  without  fibrillation  or  De  R ;  (h)  unconnected  with 
paralysis  or  contracture,  but  occupying  the  site  of  an  hysterical  anaesthesia. 

2.  Degenerative  atrophy,  with  fibrillation  and  De  R. 

Visceral  Symptoms.  Among  the  visceral  and  internal  disorders  of  hys- 
teria may  be  considered  vomiting,  cardiac,  vascular,  and  vasomotor  affections, 
rapid  respiration,  pyrexia,  cough,  aphonia,  yawning,  phantom  tumors,  and 
anuria. 

Hysterical  vomiting,  or  anorexia  nervosa,  as  I  have  said  elsewhere,*  is  dom- 
inated by  a  mental  state  that  is  often  difficult  to  unravel.  These  cases  some- 
times exhibit  the  effects  of  profound  mental  impressions,  as  supposed  poison- 
ing or  imagined  disease  of  the  gullet  or  stomach.  The  two  symptoms,  vomit- 
ing and  anorexia,  are  not,  however,  strictly  synonymous.  Laseque^  has  shown 
that  a  prolonged  and  almost  persistent  refusal  of  food  may  coexist  with  the 

1  "  Sur  une  Affection  characterisee  par  de  I'astasie  et  de  I'abasie,"  par  Paul  Blocq. 

2  Fere,  "Pathologie  des  Emotions,"  attributes  the  affection  always  to  disturbed  emotions.  Later 
writers,  given  by  Fere,  p.  247,  are  Cahen.  Seglas,  and  Maigre. 

3  Pathologie  und  Therapie  der  Neurasthenic  und  Hysteric,  Munchen,  1894. 
*  American  Journal  of  the  Medical  Sciences,  September,  1893,  op.  eit. 

^  De  I'Anorexie  Hysterique,  Arch.  gen.  de  Med.  Ap.,  1873,  385. 


126  NERVOUS  DISEASES  AJSID  THEIR  TREATMENT. 

preservation  of  quite  a  remarkable  vitality,  but  not  associated  with  vomiting. 
Sir  AYilliam  Gull  described  a  series  of  similar  eases,  in  Avhicli  refusal,  not 
vomiting,  of  food  was  the  symptom.  AVhere  vomiting  is  added  to  anorexia 
an  element  of  danger  is  found  which  does  not  appear  to  have  been  present 
in  Laseque's  and  Gull's  cases.  In  the  case  reported  by  me^  the  vomiting 
had  been  caused  by  a  supposed  poisoning  by  saltpetre.  It  had  continued 
for  many  months,  had  reduced  the  patient  to  a  condition  of  extreme  ema- 
ciation, and  had  even  endangered  her  life.  The  vomiting  of  hysteria  has 
some  special  features.  It  is  accomplished  without  effort,  and  apparently 
without  nausea.  It  is  not  always  so  much  an  act  of  vomiting  as  it  is  one  o± 
regurgitation ;  in  fact,  it  seems  that  in  some  cases  the  food  does  not  always 
enter  the  stomach,  but  is  rejected  from  the  oesophagus.  Hence  this  symptom 
is  called  sometimes  cesophagismus.^  Sometimes,  as  in  my  case,  these  acts  of 
regurgitation  follow  each  other  in  regular  succession,  especially  if  the  patient 
is  observed.  As  the  gullet  and  stomach  frequently  are  empty,  these  acts  do 
nothing  more  than  detach  from  the  depths  of  the  throat  viscid  and  tenacious 
matter,  as  recorded  by  jS"audeau,^  of  a  case  more  than  a  century  since.  This 
vomiting,  with  the  attendant  emaciation,  may  cause  the  case  to  simulate 
organic  disease.  The  cause  of  the  malady,  the  character  of  the  vomiting, 
the  age  of  the  patient,  who  is  usually  young  (although  exceptions  to  this 
occur),  the  absence  of  cachexia,  and  the  presence  of  other  hysterical  stigmata, 
may  serve  to  distiuguLsh  the  affection.  Its  course,  as  said  already,  is  some- 
times very  prolonged,  but  its  cure  may  be  cpiite  sudden  and  due  to  some 
unexpected  cause ;  or  gradual  and  produced  by  tactful  management  and  the 
wise  use  of  suggestion. 

Cardiac,  vascular,  and  vasomotor  symptoms  are  not  imcommon  in  hysteria. 
Eapid  pulse  is  observed  frequently.  It  is  not  associated  with  cardiac  or  vas- 
cular murmurs,  unless  the  patient  happens  to  be  anaemic,  nor  with  dyspnoea. 
It  may  continue  in  spite  of  long  rest  in  bed,  and  may  be  very  obstinate  to 
drugs,  especially  to  digitalis.  In  paroxysmal  hysteria  the  heart  is  variously 
affected ;  in  the  beginning  of  a  seizure  its  action  is  usually  quickened,  but  in 
the  atypical  crises,  such  as  hysterical  sleep  and  trance,  its  action  is  so  depressed 
both  in  power  and  pulsation  that  it  can  be  perceived  only  with  difficulty.  Vaso- 
motor changes,  such  as  flushings,  blushings,  oedema,  and  erythema  are  seen. 
In  hysterical  women  a  tendency  to  flush  in  circumscribed  areas  about  the 
face  and  neck  can  be  seen  occasionally.  The  bloodless  state  of  the  paralyzed 
limb  in  hysteria  and  its  inability  to  bleed  to  a  pin-stick  were  objects  of  obser- 
vation in  past  centuries ;  sometimes  the  opposite,  a  flushed  or  erythematous 
state,  is  seen  in  the  part.  Oedema  and  a  blue  mottling  of  the  paralyzed  limb 
also  are  seen. 

Rapid  respiration  Is  observed  occasionally  in  hysteria,  and  when  present  is 
highly  characteristic,  because  it  is  not  obser^^ed  in  exactly  the  same  form  in 
any  other  condition.  The  rate  of  respiration  may  be  as  high  as  75,  80,  or 
even  90  to  the  minute.  It  is  not  accompanied  necessarily  with  a  rapid  heart- 
beat, in  fact  the  contrast  between  the  hurried  breathing  and  the  tranquil 
pulse  is  sometimes  quite  marked.  Xeither  is  it  accompanied  with  dyspnoea, 
nor  Avith  any  evidence  of  failure  in  the  proper  aeration  of  the  blood.  Tliis 
is,  perhaps,  "its  most  distinguishing  mark.  The  color  of  the  face  and  lips 
remains  normal — there  is  no  cyanosis.  This  respiration  is  decidedly  of  the 
upper  costal  type.  Auscultation  and  percussion  give  negative  results.  I 
once  saw  this  symptom  in  a  lady  during  prolonged  convalescence  from  a 

1  Log.  cit. 

2  The  affection  described  rather  sensationally  as  merycism,  or  chewing  of  the  cud,  is  protjabiy  a 
pure  neurosis,  and  similar  to,  if  not  identical  with,  some  forms  of  hysterical  vomiting. 

3  Sur  une  Maladie  Kerveuse,  Jouru.  de  Med.,  Chir.,  Pharm.,  etc.,  Juillet,  1789,  p.  197. 


GENERAL  MORBID  STATES.  127 

severe  surgical  operation.  In  her  case  the  number  of  respirations  was  about 
75  per  minute.  The  symptom  persisted  for  several  weeks.  It  ceased  during 
sleep.     It  was  cured  by  improving  the  general  health,  and  by  change  of  scene. 

Pyrexia  in  the  course  of  hysteria  has  been  observed.  This  elevation  of  tem- 
perature is  considered  by  some  to  be  a  true  fever,  by  others  it  has  been  called 
a  pseudo-jDyrexia.  The  amount  of  urea  excreted  has  not  usually  been  esti- 
mated. The  fever  may  be  continued,  intermittent,  or  remittent.  It  is  j)ossi- 
ble  that  some  reported  cases  have  been  instances  of  mild  malaria  or  abortive 
typhoid.  This  hysterical  pyrexia  is  observed  sometimes  after  childbirth.  I 
have  seen  it  in  one  patient  in  two  successive  lyings-in,  each  time  caused  by 
an  emotional  disturbance.  It  is  usually  caused  by  disturbed  emotions. 
Chauveau  described  a  psevido-meningitic  type  of  hysteria  with  fever.  Debove 
succeeded  by  means  of  suggestion  in  raising  the  temperature.  Rosenthal 
thinks  that  there  may  be  febrile  symptoms  in  hysteria,  but  never  true  fever, 
i.  e.,  an  elevation  of  the  temperature  of  the  body.  These  pseudo-pyrexial  symp- 
toms are  flushing,  rapid  pulse,  thirst,  anorexia,  etc.  It  is  evident  that  some 
confusion  exists  as  to  what  constitutes  true  fever ;  but  there  can  be  no  doubt 
from  the  number  of  cases  now  recorded  that  an  elevation  of  temperature  is 
observed  sometimes  in  hysteria.  • 

Persistent  cough  is  sometimes  one  of  the  symptoms  of  hysteria.  It  is  a 
peculiarly  exasperating  cough  to  those  who  are  obliged  to  hear  it,  but  it  does 
not  seem  to  particularly  harass  the  patient.  It  is  dry  and  brazen  in  char- 
acter, and  is  not  accompanied  with  expectoration. 

Aphonia  is  a  not  uncommon  permanent  stigma  of  hysteria.  In  some  cases 
the  voice  is  entirely  gone ;  in  others  an  almost  inaudible  whisj)er  is  distin- 
guished. Aphonia  usually  occurs  suddenly ;  it  may  depart  as  suddenly, 
although  it  does  not  always  depart  thus.  Sometimes  the  reappearance  of 
the  voiee  is  a  surprise  even  to  the  patient.  In  one  of  my  patients  who  had 
had  aphonia  for  six  years  a  momentary  sound  of  her  natural  voice  occurred 
one  day  while  she  was  laughing,  and  quite  astonished  her.  Rapid  restoration 
of  the  voice  followed.  Mitchell  refers  to  the  case  of  a  lady  Avith  aphonia  who 
talked  aloud  in  her  sleep  ;  she  was  awakened  by  the  unusual  sound,  but  could 
not  speak  after  awaking. 

Yawning  of  a  peculiar  type  is  seen  as  a  rare  symptom  in  hysteria.^  It 
may  occur  in  paroxysms  of  long  duration,  during  which  the  patient  may  be 
perfectly  conscious,  but  unable  to  sjDcak  because  of  the  alternate  contractures 
of  the  muscles  of  the  jaw  in  the  rej^eated  acts  of  gaping.  The  individual 
gape  is  much  exaggerated  and  prolonged.  There  is  an  extraordinary  inten- 
sity and  duration  of  each  gape.  It  differs  from  the  normal  act  also  in  not 
being  accompanied  with  the  deep  and  noisy  inspiration  so  familiarly  known. 
These  bouts  of  yawning  may  be  followed  by  other  hysterical  symptoms. 

Phantom  tumor  of  the  abdomen  occurs  occasionally  in  hysteria.  In 
women  it  may  simulate  pregnancy,  and  may  be  accompanied  even  with  en- 
larged breasts.  It  is  seen  also  in  men.  It  may  occur  with  surprising  rapidity 
in  some  cases,  and  may  disappear  gradually.  It  depends  apparently  upon 
an  accumulation  of  air  in  the  intestine. 

Anuria  was  observed  by  the  old  writers  on  hysteria.  It  is  usually  taken 
for  granted  that  it  is  a  common  symptom,  which  it  is  not,  according  to  my 
observation.  I  had  seen  it  in  hysterical  paraplegia.  In  one  case  in  a  young- 
woman  the  catheter  had  been  used.  But  this  is  not  a  wise  thing  to  do.  An 
excessive  flow  of  limpid  urine,  terminating  a  flt,  has  been  noted  for  ages. 

1  For  a  full  discussion  of  the  subject  of  hysterical  pyrexia,  with  citation  of  numerous  authorities, 
see  "  Critical  Digest  of  Hysteria  and  Neurasthenia,"  by  J.  Mitchell  Clark,  Brain,  Spring  number,  1894. 

2  "Contribution  k,  I'etude  des  baillements  hysteriques,"  par  M.  M.  G.  de  la  Tourette,  Georges 
Guinon,  et  Huet.    Clinique  des  Maladies  du  Syst.  Nerv.    Charcot,  Paris,  1892. 


128  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Cases,  like  the  one  recorded  by  Finch,  of  anuria  lasting  for  many  weeks,  are 
frauds,  not  true  hysterics.' 

Psychical  Symptoms.  It  is  a  difficult  task  to  describe  in  short  space  the 
mental  stigmata  of  hysteria.  When  it  is  recalled  that  hysteria  is  essentially  a 
psychosis,  and  that  all  the  paroxysmal,  as  well  as  all  the  interparoxysmal  symp- 
toms, are  but  representations,  in  some  sort,  of  psychical  states,  this  difficulty 
may  be  appreciated.  In  the  hysterical  child  or  young  person  the  affective 
faculties  especially  are  impressionable,  because  at  this  period  of  life  these 
faculties  dominate  the  mental  life.  Hence  the  depressing  emotions,  as  disap- 
pointment, shame,  and  chagrin,  have  especial  prominence  in  juvenile  hysteria. 
Moods  change,  and  motives  are  not  always  discernible.  Sometimes  these 
emotions  are  conspicuously  unrestrained ;  the  volition  is  at  fault ;  a  change- 
able and  capricious  temper  often  gives  way  to  atrocious  anger.  Then  there 
may  be  marked  depression,  sufficient  to  excite  the  anxiety  of  friends ;  and 
this  depression  may  alternate  with  exaltation,  even  maniacal  in  tone.  These 
affective  disturbances,  existing  as  hysterical  stigmata,  especially  as  prodromes 
of  or  even  as  substitutes  for  a  grand  convulsive  attack,  are  the  true  instances 
of  "  hysterical  insanity,"  which  unfortunately  has  been  confused  with  other 
mental  states,  especially  with  monomania  and  degeneracy.  With  Tourette, 
we  think  that  the  one  mental  trait  that  especially  characterizes  hysteria  is 
the  facility  for  receiving  peculiar  forms  of  impression,  and  that  this  mental 
state  may  be  called  suggestibility.  The  suggestions  may  come  from  without 
or  from  within,  but  in  every  case  they  make  a  profound  impression,  wliich  is 
reflected  by  the  patient's  mind  out  along  some  motor  or  sensory  nerve-track, 
and  thus  comes  to  make  some  one  or  more  of  the  numerous  stigmata  which 
have  been  described.  Thus  violent  emotion,  trauma,  and  the  various  other 
causes  already  described  may  make  in  the  vicissitudes  of  daily  life  these 
suggestions.  A  prolific  source  of  these  suggestions  is  no  doubt  within  the 
patient,  and  this  gives  forth  its  store  of  ill-contrived  ideas  at  the  time  espe- 
cially of  a  convulsive  paroxysm.  Hence  the  frequency  with  which  a  grand 
attack  is  followed  by  some  of  the  most  obstinate  permanent  stigmata.  The 
delirium  of  the  fourth  period  is  especially  prolific  of  these.  It  influences 
remarkably  the  mental  state  between  the  attacks.  Great  importance,  more- 
over, is  to  be  attached  to  the  nocturnal  dreams  and  nightmares  of  hysterical 
patients.  It  is  from  suggestions  received  or  prompted  by  these  terrors  of  the 
night  that  a  whole  train  of  hysterical  symptoms  sometimes  dates.  Under 
this  head  come  the  disorders  of  sleep,  such  as  the  motor  shocks  and  palsies, 
sensory  disturbances,  hallucinations  of  sight  and  hearing,  and  even  dream- 
like delusions,  that  are  not  infrequent,  in  some  degree,  in  hysteria,  and 
which  often  store  the  mind  with  the  evil  promptings  of  disease.  These  are 
seen  in  an  exaggerated  degree  sometimes  in  traumatic  hysteria,  the  patient 
living  over  again  night  after  night  the  alarming  incident.  Important  med- 
ico-legal questions  may  arise  with  reference  to  the  hallucinations  and  night- 
mares of  hysteria.  False  accusations  have  been  made  by  patients  while  in  a  true 
delusional  state  due  to  these  causes.  Attempts  at  suicide  have  been  prompted 
thus,  and  the  fact  that  they  are  usually  abortive  in  hysteria  is  possibly  because 
they  are  but  the  reflex  acts  from  an  hallucinatoiy  and  dream-like  state.  The 
explanation,  usually  given,  that  they  are  merely  simulated,  is  totally  inade- 
quate to  explain  their  exact  motive,  and  the  fact  that  occasionally  they  are 
successful. 

According  to  the  most  accurate  recent  observers  the  mental  state  in  hys- 
teria may  be  said  to  be  an  alteration  in  consciousness,  to  which  the  term 

1  The  writer  has  used  the  word  "  hysteric  "  as  we  use  the  word  "  epileptic,"  i.  e.,  as  a  suhstantive  to 
designate  the  patient  suflfering  with  the  disease. 


GENERAL  MORBID  STATES.  129 

"  hypnoid  "  applies  appropriately.  The  hysterical  patient  lives  in  a  sort  of 
double  consciousness ;  his  mind  forms  two  groups  of  phenomena,  the  one 
constituting  the  ordinary  personality,  the  other  forming  an  abnormal  one, 
differing  from  the  first  and  ignored  by  it.  In  this  abnormal  or  duplex  per- 
sonality, the  strange  association  of  ideas,  dating  back  to  the  initiation  of  the 
morbid  process  in  some  painful  emotion  or  shock,  perhaps  even  as  far  back 
as  in  childhood,  has  its  field  of  action.  From  this  background  these  ideas 
spread  out  and  influence  in  a  myriad  of  ways  the  bodily  functions,  often 
totally  without  the  consciousness  of  the  patient,  much  less  with  his  consent 
or  connivance.  In  this  "  hypnoid  "  state  we  see  the  relations  of  hysteria  to 
the  processes  known  as  hypnotism  ;  we  recognize,  in  fact,  that  hypnotism  is  but 
an  artificial  production  of  a  mental  state  clearly  analogous  to  hysteria ;  hence 
we  recognize  the  necessity  for  being  cautious  about  admitting  that  deep  hyp- 
nosis can  be  induced  in  perfectly  healthy  brains,  or  about  encouraging  its  pro- 
duction, lest  we  induce  irremediable  hysterical  perversions.  This  peculiar  men- 
tal state  leads  to  a  contraction  of  the  field  of  consciousness  by  reason  of  which 
perceptions  cannot  be  organized  ;  in  other  words,  the  synthetic  faculty  of  the 
brain  is  weakened.  Hence  there  result  the  various  stigmata,  such  as  exten- 
sive angesthesia,  paralysis,  contracture,  and  loss  of  memory.  In  this  weak- 
ened or  hypnoid  state  a  marked  feature  is  the  suggestibility  to  which  Tourette 
refers  as  the  essential  characteristic  of  hysteria.  From  this  purely  psycho- 
logical standpoint,  as  from  no  other,  can  be  understood  the  phenomena  of 
somnambulism,  trance,  and  catalepsy  which  we  see  occasionally  in  the  hys- 
terical patient.^ 

It  is  needless  to  say  that  some  of  the  traits  of  character  so  often  ascribed 
to  hysteria  by  former  writers,  such  as  simulation,  sexual  perversions,  scruples, 
and  morbid  impulses,  are  the  symptoms  of  degeneracy  and  not  of  hysteria. 
As  Lowenfeld  says  truly,  hysterical  persons  often  fulfil  their  duties  well  as 
daughters,  wives,  and  mothers,  and  are  not  always  seeking  to  attract  atten- 
tion to  themselves  and  their  complaints. 

Diagnosis.  If,  as  is  commonly  claimed,  hysteria  simulates  all  diseases,  it 
certainly  differs  from  all  in  this  very  respect,  that  it  has  such  a  multiformity 
of  symptoms.  It  is  in  the  recognition  of  this  multiformity  that  success  lies 
in  the  diagnosis  of  the  disease.  I  have  endeavored  to  present  a  simple  ar- 
rangement and  concise  description  of  these  symptoms,  and  to  show  that  they 
are  not  changeable  and  indeterminate,  but  that  they  are  fixed  in  their  char- 
acteristics and  often  of  long  duration.  If  a  proper  search  were  made  for 
these  stigmata  we  should  hear  less  of  the  difficulties  of  diagnosis,  and  see 
less  of  a  tendency  to  call  hysteria  by  misleading  names.  Hysteria,  instead 
of  closely  simulating  all  diseases,  really  simulates  none  exactly.  The  stig- 
mata of  the  disease  and  their  peculiar  groupings  ought  to  be  unmistakable. 
No  other  method  of  successful  diagnosis  can  be  given  but  a  reference  to  a 
study  of  them. 

Nevertheless,  there  are  some  prevalent  errors,  as  well  as  some  moot  points, 
that  must  be  discussed  briefly. 

The  most  common  vulgar  error  is  to  identify  hysteria  with  the  machina- 
tions of  frauds  and  malingerers.  The  young  woman  who,  decked  in  a  bridal 
garment,  fasts  and  is  fed  by  stealth,  the  heroine  of  the  story  of  the  Cock 
Lane  ghost,  and  the  vixen  wdio  gives  birth  to  frogs,  are  not  hysterics — they 
are  impostors.  There  is  no  more  reason  to  call  them,  than  to  call  any  other 
jugglers,  examples  of  this  profoundly  interesting  psychosis,  the  very  first 
essential  of  which  is  a  series  of  mental  impressions  of  undoubted  originality 

1  For  an  elaboration  of  some  of  the  ideas  expressed  in  the  text  the  reader  is  referred  to  Janet,  "  £tat 
Mental  des  Hysteriques ;"  to  some  of  Charcot's  recent  writings,  and  to  the  treatise  of  Gilles  de  la 
Tourette. 


130  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  genuineness.  Again,  hysteria  like  any  other  disease  may  be  feigned ; 
but  the  counterfeit  bears  a  superficial  stamp ;  the  malingerer  has  either  no 
knowledge  of,  or  no  ability  to  ape,  the  permanent  stigmata.  An  emotional 
crisis,  a  perverted  temper,  a  dramatic  outburst,  or  a  crafty  display,  do  not 
constitute  the  disease  of  which  I  am  here  writing. 

A  more  serious  error,  and  also  a  not  uncommon  one,  is  to  confuse  hysteria 
and  paranoia ;  in  fact,  the  word  "  hysteria  "  has  been  used  indiscriminately 
for  all  odds  and  ends  of  peculiar  and  perverted  mental  phenomena.  How- 
ever strange  the  case,  it  is  enough  to  call  it  hysteria,  and  all  is  explained. 
Hence  it  is  not  uncommon  to  see  the  stigmata  of  degeneracy  confiised  with 
those  of  hysteria ;  thus  we  may  read  descrij)tions  of  so-called  hysterics,  whose 
symptoms  are  described  as  having  been  those  of  the  insanity  of  doubt,  such 
as  uncertainty  and  scruples;  or  mysophobia,  agoraphobia,  claustrophobia, 
pyromania,  and  kleptomania.^  The  instability  of  character,  the  weakness 
of  will-power,  the  bizarre  aspect  of  these  cases  of  degeneracy  is  quite  suffi- 
cient, in  the  opinion  of  some,  to  merit  for  them  the  term  "  hysteria."  Still 
more  heinous  is  the  ascription  of  sexual  perversion  to  hysteria,  instead  of  to 
paranoia  and  degeneracy,  to  which  properly  it  belongs.  This  error  is  no 
doubt  a  relic  of  that  ancient  pathology  that  attributed  hysteria  to  disorders 
of  the  sexual  function.  In  this  connection  it  must  not  be  forgotten,  however, 
that  hysteria  may  coexist  with  various  forms  of  insanity,  just  as  it  may  coexist 
with  epilepsy  or  with  organic  disease  of  the  nervous  system.  This  conjunction, 
added  to  the  conflision  of  the  stigmata  of  degeneracy  and  hysteria,  ah-eady 
referred  to,  has  led  to  the  belief  in  that  somewhat  hypothetical  entity  known 
as  "hysterical  insanity,"  a  form  of  mental  disease  that  no  two  authors 
describe  alike.  The  truest  forms  of  insanity  in  hysteria  are  the  exaggera- 
tions of  the  prodromal  symptoms  of  depression  or  exaltation  into  veritable 
melancholy  or  maniacal  episodes,  and  the  extraordinary  development  of  delu- 
sional and  hallucinatory  states  in  the  deliria  of  the  grand  attack.  Beyond 
these  it  is  difficult  to  understand  what  is  meant  by  true  "  hysterical  insanity  " 
unless  the  term  be  applied  to  the  cases  of  monomania  or  other  psychosis,  to 
which  the  stigmata  of  hysteria  are  added  as  a  sort  of  epi-phenomena.  But 
to  call  such  a  case  of  insanity  "  hysterical "  would  be  no  more  proper  than 
to  call  a  case  of  tabes  hysterical,  because  there  happened  to  coexist  with  it 
some  of  the  hysterical  stigmata. 

It  is  not  unusual  to  ascribe  some  of  the  hysterical  symptoms  to  that  state 
called  neurasthenia.  In  fact,  neurasthenia,  as  usually  described,  is  made  to 
borrow  largely  from  both  hysteria  and  hypochondria.  It  were  better  if  med- 
ical writers  were  always  careful  to  distinguish  it  clearly  from  these  two 
classical  neuroses.  This  is  not  the  place  thus  to  distinguish  it,  but  simply  to 
state  that  the  hysterical  stigmata,  when  made  to  do  duty  for  neurasthenia,  are 
filched  from  their  proper  place.  Neurasthenia  means  a  state  of  malnutrition 
of  the  nervous  system  in  which  it  is  "  without  strength."  To  this  meaning 
its  application  should  be  limited,  but  the  tendency  at  present  is  too  often  to 
extend  it  almost  without  limit  until  it  is  made  to  include  a  conflised  medley 
of  the  symptoms  of  hysteria,  hypochondria,  dyspepsia,  and  chronic  ill-health 
from  various  causes.  This  tendency  is  seen  especially  with  reference  to  trau- 
matic cases,  all  the  hysterical  stigmata  of  which  are  included  in  the  more  vague 
and  more  comprehensive  term.  Thus  Lowenfeld  (op.  eit.)  says  that  "  our  pres- 
ent knowledge  indicates  the  resemblance  of  hysteria  and  neurasthenia  in  essen- 
tial points."  He  seems  to  think  it  of  small  importance  that  some  authors 
(apparently  German)  use  the  terms  indiscriminately  and  interchangeably. 
All  this  is  not  to  the  advantage  of  consistency  and  clearness  in  scientific 

1  As  done  by  Magnan  (quoted  by  Tourette). 


GENERAL  MORBID  STATES.  131 

nomenclature.  Hysteria,  as  lias  been  shown,  is  a  clearly  distinguishable  dis- 
ease, and  when  its  symptoms  arise,  from  whatever  cause,  it  should  be  called 
by  its  proper  name.  To  distinguish  it  from  other  states  of  the  nervous  system, 
it  is  but  necessary  to  study  its  symptoms.     (See  also  page  77.) 

The  diagnosis  of  the  so-called  "traumatic  neuroses"  from  hysteria  has 
given,  and  will  continue  to  give,  rise  to  the  most  animated  and  unprofitable 
controversy.  Hysteria,  as  has  been  shown  in  this  chapter,  numbers  among 
its  best  recognized  causes  trauma.  Hence  it  would  ajDpear  easy,  when  the 
hysterical  stigmata  arise  after  injury,  to  ascribe  them  to  their  proper  cause 
and  to  call  them  by  their  proper  name.  This,  however,  is  not  done  willingly 
in  all  cases,  with  tlie  result  that  w^e  see  most  of  the  hysterical  symptoms,  such 
as  localized  pains,  typical  anaesthesias  and  paralyses,  contractures  and  tremors, 
contractions  of  the  visual  fields,  and  paroxysmal  phenomena,  boldly  made  to 
do  duty  in  a  double  role.  It  is  needless  to  say  that  such  a  confrision  in  nos- 
ology is  not  defended  here. 

The  hysterical  convulsion  sometimes  simulates  that  of  epilepsy.  This  is 
so  especially  wdien  the  grand  attack  is  in  part  aborted,  and  the  first  period 
alone  is  prominent.  The  difiiculty  is  greatly  increased,  of  course,  if  the 
physician  does  not  have  the  opportunity  to  witness  for  himself  the  seizure. 
The  presence  of  some  of  the  permanent  intervallary  symptoms  is,  of  course, 
a  valuable  guide,  but  not  to  be  relied  upon  exclusively,  because  in  some  cases 
hysteria  and  epilepsy  may  coexist,  the  patient  having  at  one  time  an  hysterical 
and  at  another  an  epileptic  convulsion.  It  is  rare,  however,  for  the  true 
hysterical  convulsion  to  present  the  phenomena  of  only  the  first  period ;  some 
of  the  features  of  the  other  periods,  such  as  grand  movements,  passionate 
acts,  gestures  or  attitudes,  or  a  final  emotional  or  even  delirious  stage  usually 
presenting  themselves.  The  prodromal  stage,  also,  gives  very  important 
proofs  of  the  hysterical  fit ;  nothing  like  it  occurs  in  epilepsy.  Suggestion, 
or  even  frill  hypnotization,  ought  always  to  be  tried  in  doubtful  cases.  Hyp- 
notism, in  fact,  may  supply  a  crucial  test.  If  by  its  means  it  is  possible  to 
provoke  a  convulsion,  this  fact  alone  is  almost  proof  positive  that  the  fit  is 
hysterical.  Thus,  too,  the  convulsion  can  be  studied  more  at  leisure.  I  have 
made  satisfactory  use  of  this  test  on  more  than  one  occasion  in  doubtfril  cases. 
The  rules  formerly  laid  down  that  loss  of  consciousness  and  the  receipt  of 
injuries  w'ere  always  proofs  of  epilepsy  are  of  course  not  reliable.  Loss  of 
consciousness  does  not  occur  in  all  epileptic  fits,  and  does  occur  in  many 
of  the  major  attacks  of  hysteria ;  W'hile  the  receipt  of  injury  is  compara- 
tively rare  in  ej)ilepsy  and  not  unheard  of  in  hysteria.  I  would  make 
exception,  however,  of  biting  the  tongue,  which  is  always  very  suggestive  of 
an  epileptic  convulsion. 

The  diagnosis  of  the  various  stigmata,  such  as  j^aralysis,  tremor,  astasia- 
abasia,  hemianeesthesia,  etc.,  from  the  organic  afiections  that  they  resemble, 
has  been  indicated  more  or  less  clearly  in  the  description  of  these  symptoms. 
Hence  they  will  not  be  taken  up  again  seriatim,  A  general  rule,  hoW'Cver, 
should  always  be  observed,  i.  e.,  to  look  carefrilly  for  all  stigmata,  because  it 
is  by  the  peculiar  grouping  of  these  that  hysteria  often  is  characterized. 
Thus  an  hysterical  hemiplegia,  without  facial  palsy,  is  apt  to  be  accompanied 
with  hemiansesthesia,  involving  the  special  senses  and  the  conjunctiva  of  the 
eye  on  the  affected  side ;  hysterical  contracture  of  an  arm  is  almost  always 
accompanied  with  the  peculiar  segmental  anaesthesia ;  an  hysterical  amaurosis 
or  amblyopia  with  various  cutaneous  anaesthesias ;  astasia-abasia  with  anaes- 
thesia ;  while  the  hysterical  fit  usually  leaves  as  its  vestiges  some  of  the  same 
symptoms. 

Pathology.  Hysteria  cannot  be  said,  in  the  ordinary  sense,  to  have  a 
gross  pathology.    What  finer  histological  changes  underlie  the  manifestations 


132  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  the  hysterical  diathesis  it  is  not  in  our  power  yet  to  say.  That  profound 
changes  in  the  nerve-cells  occur  and  are  maintained  for  long  periods  cannot 
be  doubted  when  we  consider  the  turmoil  and  excitement  of  the  grand 
attack,  or  the  complex  and  sustained  phenomena  of  such  symj^toms  as  tremor, 
hemiplegia,  and  contracture.  That  the  nerve-cell  in  the  cortex  is  strangely 
at  fault  is  proved  by  the  absoluteness  of  hysterical  anaesthesia.  It  is  as  futile, 
however,  to  speculate  upon  these  histological  changes  in  hysteria  as  it  would 
be  in  the  cases  of  all  psychic  phenomena.  The  pathology  of  hysteria  is 
among  the  unsolved  problems  of  the  infant  science  of  psychology. 

The  nutritive  changes  that  occur  secondarily  to  the  seizures  of  hysteria 
have  been  described  among  the  symptoms  of  the  disease. 

Treatment.  The  treatment  for  hysteria  ought  to  be  of  two  kinds :  the 
first  is  to  be  directed  to  the  mental  state,  the  second  to  the  bodily  ftinctions. 
The  first  is  vastly  the  more  important,  and,  in  fact,  the  success  of  remedies 
in  the  second  class  often  depends  in  a  measure  upon  the  fact  that  they  make 
strong  mental  impressions.  In  the  first  class,  therefore,  are  included  all  the 
influences  of  a  strong  and  appropriate  personality  in  the  physician  and 
attendants,  all  moral  impressions,  all  appeals  to  the  emotions  and  imagina- 
tion, all  suggestions,  and  the  skilful  use  of  the  association  of  ideas.  Most  of 
these  influences  can  be  grouped  and  discussed  under  the  general  term  hypno- 
tism. This  term  has  come  to  mean  a  rather  elaborate  ritual,  which  is  sup- 
posed to  symbolize  some  mystical  influence.  This  influence,  however,  is  in  no 
respects  mystical,  and  it  requires  very  few  symbols  or  rituals.  The  essence 
of  it  is  suggestion,  and  this  has  been  used  from  time  immemorial  by  those 
skilled  to  treat  the  neurotic  and  hysterical.  It  is  used,  in  some  measure,  by 
all  successful  physicians  who  aim  to  gain  an  ascendant  influence  over  the 
minds  of  their  patients.  It  is  not  my  intention  here  to  discuss  the  subject  of 
hypnotism  in  detail,  but  simply  to  indicate  its  bearings.  Its  essence,  as 
already  said,  is  suggestion,  and  this  may  be  used  in  many  cases  without  the 
ceremony  that  is  usually  described.  In  other  words,  it  can  be  used  by  simply 
influencing  the  patient's  mind,  gaining  his  or  her  confidence,  and  exerting 
by  every  means  the  firmness,  tact,  and  knowledge  of  human  nature  that  are 
just  as  essential  to  the  practitioner  as  they  are  impossible  to  be  described.  It 
is  a  mistake  to  suppose  that  all  hysterical  patients  do  not  wish  to  get  well ; 
many  will  welcome  and  second  a  wise  physician's  efibrts ;  they  escape  from 
their  disease  as  from  a  bondage.  Upon  some  minds  the  elaborate  ceremony 
and  profound  impression  of  a  genuine  hypnotic  seance  do  not  act  favorably. 
Still,  there  are  others  in  which  it  is  advisable  and  permissible  to  gain  all  the 
possible  advantages  of  hypnotic  suggestions  by  all  the  accessories  usually 
described.  The  hysterical  mind  often  is  very  susceptible  to  the  influence  of 
hypnotism — that  is  to  say,  it  is  not  difficult  to  bring  the  patient  under  its 
sway ;  when  so  influenced  suggestions  of  the  abolition  of  this  or  that  symp- 
tom at  a  certain  time,  or  of  the  total  restoration  to  health,  are  made.  In  some 
cases  this  method  is  very  successful.  The  temptation  to  experiment  upon 
very  susceptible  patients,  and  to  produce  or  abolish  symptoms  at  will,  is  often 
great,  and  ought  to  be  resisted,  because  it  may  end  in  the  more  complete 
hysterical  perversion  of  the  patient  instead  of  his  or  her  recovery.  For  de- 
tails of  hypnotism  the  reader  is  referred  to  special  papers  and  treatises. 

Hydrotherapy  is  of  the  first  importance  in  the  treatment  of  hysteria.  I 
have  seen  more  striking  results  from  its  use  than  from  any  one  agent,  except 
from  suggestion  and  moral  influence.  In  fact,  it  is  j)ossible  that  some  of  the 
efficacy  of  the  hot  and  cold  bath  is  derived  from  the  powerful  impression 
that  this  makes  upon  the  patient's  mind.  Its  roborant  effect  upon  the  body, 
too,  is  very  striking,  and,  as  hysterical  patients  are  not  unusually  in  a  lower 
tone  of  health  than  normal,  it  acts  thus  with  direct  benefit  from  the  physical 


GENERAL  MORBID  STATES.  133 

side.  A  shrinking  hysterical  patient  will  naturally  dread  a  heroic  use  of  the 
bath,  and  on  this  account  it  ought  to  be  administered  with  a  firm  hand  by  a 
nurse  or  attendant  in  whom  the  patient  has  confidence.  Hence  it  can  be 
used  often  to  greater  advantage  in  hospitals  and  in  conjunction  with  isolation. 
The  alternate  hot  and  cold  baths  will  produce  a  quick  result  in  some 
patients,  but  if  for  any  reason  they  are  contra-indicated  at  first,  a  milder 
bath  can  be  used,  and  the  alternate  efiects  can  be  secured  gradually.  A 
plunge  or  shower  bath  also  can  be  given  if  practicable.  I  have  had  but  little 
experience  with  sea-bathing  in  hysteria,  but  if  given  in  the  midst  of  proper 
attendance  and  environment  I  think  that,  combined  with  the  change  of 
scene  that  it  usually  entails,  it  would  be  highly  advantageous  in  most  cases. 

After  the  bath  dry  ffiction  should  be  used  briskly  to  bring  about  reaction. 
It  is  very  advantageous,  in  fact,  to  use  systematic  rubbing,  or  massage,  in 
conjunction  with  the  bathing.  The  rubber  ought  to  have  some  special  qual- 
ifications to  do  good  work  with  an  hysterical  patient.  An  unpleasant  per- 
sonality, irritating  qualities,  inappropriate  talk,  and  cold  hands  are  graver 
faults  than  ignorance  of  the  exact  number  of  strokes  and  passes  that  custom 
dictates.  In  other  words,  the  rubber  ought  to  be  in  accord  with  the  physi- 
cian and  attendants,  and  have  intelligence  enough  to  understand  some  of  the 
mental  characteristics  of  hysterical  patients.  Some  of  the  best  results  ob- 
tained by  me  have  been  by  having  the  rubbing  done  by  a  good  attendant 
nurse,  whose  presence,  touch,  and  conversation  all  suggested  to  the  patient 
that  she  was  expected  to  get  well.  Massage,  in  other  words,  may  be  made 
an  avenue  of  aj)proach  to  the  patient's  mind  by  which  more  wholesome  and 
stimulating  ideas  may  be  introduced.  This  is  of  infinitely  more  importance 
than  its  purely  physical  efiect  as  a  mechanical  aid  to  the  circulation. 

In  order  to  establish  and  practise  successfully  the  treatment  here  laid  dow^n 
it  is  often  absolutely  necessary  to  procure  isolation.  In  many  cases  nothing 
can  be  done  in  the  patient's  home.  The  sympathy  of  friends,  the  demoral- 
ization of  the  household,  the  vicious  association  of  ideas,  must  all  be  com- 
bated. They  can  only  be  met  and  their  eflfects  neutralized  by  removing 
the  patient  from  their  influence.  The  change  of  scene,  the  powerftil  |impres- 
sion  made  upon  the  patient's  mind,  the  new  and  wholesome  train  of  ideas 
suggested  to  the  patient's  thoughts  by  the  removal  to  strange  surroundings, 
and  by  the  presence  and  control  of  strange  and  skilled  attendants,  all  have 
a  sovereign  curing  power,  the  credit  for  which  is  sometimes  given  exclusively 
to  the  physician. 

Electricity,  especially  static  electricity,  has  been  highly  lauded,  especially 
by  French  practitioners,  as  a  remedy  in  hysteria.  Its  efiect  is  probably 
entirely  psychical.  It  ought  to  be  used  cautiously  at  first,  because  it  might 
excite  the  patient,  and  even  fix  more  stubbornly  some  of  the  most  obstinate 
symptoms.  On  the  other  hand,  electricity  acts  sometimes  marvellously  on 
some  particular  symptoms.  I  once  saw  an  hysterical  paraplegia  of  long 
duration  cured  promptly  with  a  small  faradic  battery.  But  such  a  case  is  an 
exception. 

It  is  not  necessary  to  discuss  drugs  in  the  treatment  of  hysteria;  their 
office  is  a  strictly  secondary  one.  They  may  be  required  for  the  relief  of 
special  symptoms,  and  are  to  be  given  then  according  to  the  recognized  prin- 
ciples of  applied  therapeutics.  In  general  terms  it  may  be  said  that  all 
treatment  should  be  sustaining  and  tonic ;  hence  the  drugs  that  meet  this 
indication  are  to  be  preferred.  I  believe  that  sedative  and  depressing  drugs 
ought  never  to  be  used  in  hysteria ;  they  cannot  control  the  symptoms,  except 
temporarily,  and  they  may  even  aggravate  them  permanently.  The  whole 
list  of  bromides,  chloral,  opiates,  and  antipyrin  is  to  be  condemned.  Di-ugs 
are  used  sometimes  by  good  practitioners  for  their  moral  effects,  and,  provided 


134  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  drugs  are  harmless,  no  harm  can  come.  It  is  undoubtedly  important  to 
regulate  the  digestion  and  nutritive  fimctions  in  hysteria — in  a  word,  to  put 
the  general  health  in  the  best  possible  condition. 

Finallr,  among  special  therapeutic  agents  may  be  mentioned  metallo- 
therapy  and  the  use  of  magnets,  much  advocated  in  France.  By  the  appli- 
cation of  metals  and  magnets  to  the  skin  important  effects  may  be  procured, 
especially  in  ansesthesia.  This  symptom  may  be  abolished  or  transferred 
from  one  side  to  another.  It  is  enough  simply  to  say  that  these  effects  are 
produced  by  suggestion  and  by  influencing  the  imagination. 

Surgery  has  but  little,  if  any,  field  in  hysteria.  The  excision  of  the 
ovaries  for  pure  hysteria  is  a  barbarism  founded  upon  the  false  pathology 
of  the  disease  that  was  taught  by  the  ancients  and  in  the  middle  ages.  It  is 
a  crime  both  against  nature  and  against  science.  It  is  an  operation,  as  Pitres 
has  well  said,  that  is  not  justified  even  by  its  successes.  The  doubt  will  always 
remain  in  any  given  case  whether  a  cure  was  not  attainable  by  less  heroic 
and  less  unscientific  means. 


CHAPTER   IV. 
GENERAL  MORBID  STATES  OF  THE  NERVOUS  SYSTEM. 

(Continued.) 

By  PHILIP  COOMBS  KNAPP,  M.D. 

NERVOUS  AFFECTIONS   FOLLOTVING   RAILWAY  AND 
ALLIED  INJURIES. 

Trauma  is  classed  as  one  of  the  causes  of  the  majority  of  diseases  of  the 
nervous  system.  It  may  be  either  a  dnect  or  an  exciting  cause ;  but  in  many 
cases  its  influence  must  be  regarded  as  slight.  It  does  not  materially  modify 
the  type  of  the  disease  in  such  cases,  so  that  the  affections  themselves  need  no 
special  etiological  classification,  and  they,  therefore,  need  no  consideration  here. 
There  are,  however,  a  number  of  obscure  affections  of  the  nervous  system  in 
which  injury  is  a  frequent  and  important  cause,  and  the  injury  often  gives  a 
peculiar  stamp)  to  the  affection,  so  that  it  is  proper  to  group  these  affections 
under  one  heading. 

It  is  probable  that  the  traumatic  nervous  affections  to  be  considered  here 
have  increased  in  frequency  of  late  years.  There  has,  of  course,  been  an 
apparent  increase  by  reason  of  our  greater  knowledge  of  their  symptoms  and 
our  greater  ability  to  recognize  them  ;  but  it  is  also  fair  to  suppose  that  there 
has  been  an  actual  increase  on  account  of  the  enormous  increase  in  railway 
travel,  the  introduction  of  the  trolley  and  cable  system  of  street  railways, 
the  increased  use  of  poAverfiil  electrical  currents  and  of  many  other  modem 
inventions,  all  of  which  afford  greater  opportunity  for  accidents.  In  addition 
to  these,  the  increased  vulnerability  of  the  nervous  system  is  also  to  be  con- 
sidered. 

The  study  of  these  affections  has  been  rendered  obscure  from  certain  obvi- 
ous causes.  In  many  cases  the  victim  of  the  injury  has,  or  fancies  he  has,  a 
claim  on  account  of  his  injury  against  some  corporation  or  individual  for 
"damages,"  or  against  some  accident  insurance  company  for  support.  It  is, 
therefore,  for  his  interest  to  exaggerate  his  trouble,  just  as  it  is  for  the  inter- 
est of  the  company  to  make  light  of  it ;  and  the  physician,  too  often  called 
merely  as  a  partisan,  is  apt  to  take  a  biased  view. 

In  consequence,  however,  of  the  medico-legal  considerations  which  may 
arise,  such  cases  have  a  peculiar  importance.  A  single  railway  company 
doing  business  in  Boston  pays  each  year,  on  an  average,  more  than  8150,000 
for  damages  for  accidents.  Out  of  one  hundred  consecutive  cases  of  injury 
of  all  soi'ts  claiming  damages  from  this  corj^oration  as  a  result  of  their  injury, 
fifty-six  had  symptoms  referable  to  the  nervous  system.  It  will  be  seen,  there- 
fore, that  a  careful  study  of  the  various  nervous  affections  is  essential  in  order, 
on  the  one  hand,  that  the  corporations  may  not  be  defrauded  by  swindlers, 
and,  on  the  other,  that  the  victims  of  injury  may  not  ])e  deprived  of  their  just 
claims  by  unjust  charges  of  simulation  or  exaggeration.  In  injuries  of  other 
sorts  there  is  comparatively  little  likelihood  of  such  risks  for  either  side. 


136  XEEVOUS  DISEASES  AND  THEIR  TEEATMEXT. 

Fracture!?,  dislocations,  lacerated  wounds,  and  similar  injuries  can  be  readily 
recognized,  and  the  dangers  to  life  and  health  "u-hich  they  entail  can  be  readily 
estimated.  In  nervous  affections,  where  the  knowledge  of  the  average  physi- 
cian in  this  country  is  still  so  limited,  there  is  greater  room  for  error. 

Before  considering  the  various  forms  of  traumatic  affections  involving  the 
nervous  system,  it  will  be  necessary  to  review  briefly  the  various  theories 
which  have  been  held  in  regard  to  them. 

The  works  of  Erichsen,^  which  aj^peared  in  1866  and  1875,  may  be  taken 
as  the  starting  point,  not  only  because  they  are  among  the  first  works  wi'itten 
upon  the  subject,  but  because  they  had  for  years  a  most  important  influence. 
Written  by  a  surgeon,  twenty  years  ago,  when  spinal  anaemia,  spinal  hyper- 
emia, and  spinal  meningitis  had  an  important  place  in  nosology,  before 
hysteria  and  neurasthenia  were  fully  recognized  or  nen^ous  pathology  had 
made  much  progress,  it  is  little  wonder  that  Erichsen's  theories  as  to  the 
nature  of  the  cases  are  to-day  obsolete.  Erichsen  regarded  the  symptoms  as 
due  to  concussion  of  the  spine,  and  considered  that  the  shock  of  the  injury 
caused  molecular  changes  in  the  spinal  cord,  which  ultimately  led  to  chronic 
spinal  and  cerebral  meningitrs,  or  that  the  shock  caused  ansemia  or  h^-peraemia 
of  the  cord,  especially  in  its  posterior  columns.  Ericlisen,  however  faulty 
his  pathology  may  seem  to-day,  recognized  clearly  the  existence  of  cerebral 
symptoms,  of  symptoms  purely  hysterical,  and  of  symptoms  clearly  referable 
to  injury  to  the  muscles  and  ligaments  of  the  vertebral  column.  In  conse- 
quence of  the  unfortunate  choice  of  the  term  spinal  concussion  to  represent 
these  various  conditions,  many  writers  have  scouted  his  whole  work  and  have 
imagined  that,  because  they  have  proved  that  the  spinal  cord  was  not  con- 
cussed, therefore  the  affection  described  could  not  exist — as  sound  a  conclusion 
as  it  would  be  to  deny  the  existence  of  hysteria  in  persons  without  a  uterus. 

In  1880,  Hodges,^  of  Boston,  emphasized  the  fi-equency  of  strain  of  the 
vertebral  muscles,  and  of  purely  neurasthenic  symptoms  in  many  of  the 
cases,  and  gave  a  much  more  favorable  prognosis  than  Erichsen  had  done. 
In  the  following  year  Page"  emphasized  Hodges'  conclusions  that  the  major- 
ity of  cases  were  simply  muscular  strain  and  neurasthenia,  and  that  the  spinal 
cord  was  in  no  way  affected,  except  in  cases  of  true  violence  causing  fracture 
or  dislocation  of  the  vertebrae,  with  secondary  laceration  of  the  cord  or  spinal 
hemorrhage.  Page  furthermore  tabulated  two  hundred  and  thii'ty-four  cases 
which  he  had  seen  as  surgeon  of  the  Xorthwestern  Railway  in  England,  and 
claimed  that  the  majority  of  them  made  a  complete  recovery  within  a  year  or 
two  after  their  claims  were  settled. 

In  1884,  Putnam*  and  "Walton"  pointed  out  the  existence  of  hemianes- 
thesia in  certain  cases  that  had  come  under  their  obser\"ation,  and  noted  its 
resemblance  to  the  hemianesthesia  observed  in  hysteria.  Soon  after  Charcot 
began  the  study  of  hysteria  of  traumatic  origin,  and  to  his  researches  and 
the  researches  of  his  pupils^  we  owe  our  present  knowledge  of  the  subject. 
The  greater  fr-equency  of  hysteria  in  France  and  the  interest  naturally 
aroused  by  the  Avork  of  Charcot  have  led  the  French  to  exaggerate  the  im- 
portance of  hysteria  and  to  regard  most  of  the  obscure  forms  of  traumatic 
nervous  disease  as  merely  manifestations  of  hysteria. 

Some  years  before  this,  however,  Westphal'  had  advanced  the  hypothesis 

1  On  Railway  and  Other  Injuries  of  the  Nervous  System,  1866.    On  Concussion  of  the  Spine,  1S75. 

-  Boston  Med.  and  Surg.  Journ.,  April,  1880. 

3  Injuries  of  the  Spine  and  Spinal  Cord. 

*  Boston  Med.  and  Surg.  Journ.,  Septemher,  1883  ;  Amer.  Journ.  of  Xeurol.,  Xovember,  1884. 

5  Archives  of  Med.,  1883  ;  Boston  Med.  and  Surg.  Journ.,  October,  1883. 

6  Charcot :  Lerons  sur  les  maladies  du  systeme  nerveux,  T.  iii. ;  Lejons  de  mardi,  T.  i.,  ii.    Also  the 
works  of  Pitrfis,  Gilles  de  la  Tourette  Janet,  and  Guinon. 

"  Charite.  Annalen,  1878. 


GENERAL  MORBID  STATES.  137 

that,  in  some  cases,  the  symptoms  were  clue  to  small  disseminated  foci  of 
inflammation  in  the  brain  or  cord,  and  that  they  closely  resembled  the  symp- 
toms of  disseminated  sclerosis.  In  1884  his  assistants,  Thomson  and  Oppen- 
heim,^  made  an  elaborate  study  of  sensory  disturbances  in  the  various  forms 
of  nervous  disease.  They  disputed  the  French  claim  that  hemiansesthesia 
was  indicative  of  hysteria,  ancl  Oppenheim  inclined  to  Westphal's  hypothesis 
that  definite  structural  change  was  the  probable  lesion  in  a  majority  of  cases. 

In  1889  Oppenheim  published  a  monograph^  embodying  a  further  study  of 
these  conditions,  and  he  and  StriimpelP  described  them  at  length  under  the 
name  of  the  traumatic  neuroses.  Abandoning  in  large  part  his  former  views, 
OpiDenheim  regarded  them  as  functional  in  character,  that  is,  as  dependent 
upon  no  definite  structural  lesions.  Although  recognizing  their  close  alliance 
to  hysteria  ancl  neurasthenia,  both  Oppenheim  ancl  Striimpell  have  endeavored 
to  establish  a  separate  type  under  the  heading  of  traumatic  neurosis.  Striim- 
pell speaks  of  a  "  local  traumatic  neurosis,"  where  the  symptoms  are  limited 
to  one  portion  of  the  body.  Under  this  head  he  classes  the  monoplegias,  con- 
tractures, joint  neuroses,  etc. ;  but  most  of  these  local  neuroses  must  be 
grouped  under  the  more  general  heading  of  hysteria.  The  general  traumatic 
neurosis  is,  in  Oppenheim's  opinion,  characterized  by  pain,  mental  anxiety 
and  irritability,  hypochondriasis,  sleeplessness,  tremor,  paresis  or  paralysis, 
angesthesia,  contracted  visual  field,  exaggerated  tendon  reflexes,  and  cardiac 
irritability. 

Oppenheim's  views  have  met  with  much  opposition  from  the  French  writers, 
who  claim  that  the  conditions  which  he  describes  are  hysterical.  In  Ger- 
many, too,  since  1890,  a  considerable  number  of  neurologists,  headed  by 
Schultze,*  Hoffniann,^  and  Mendel,  have  opposed  the  establishment  of  a  special 
form  of  disease  known  as  traumatic  neurosis,  maintaining  that  these  cases  are 
hysteria  or  neurasthenia.  They  have  also  maintained  that  simulation  was 
very  common  in  these  cases.  This  opinion,  although  long  vipheld  by  surgeons 
and  general  practitioners,  had,  up  to  that  time,  lacked  support  by  neurolo- 
gists, and  even  now  comparatively  few  neurologists  believe  that  successful 
simulation  is  at  all  common. 

Since  then  many  German  observers  have  studied  the  individual  symptoms 
in  these  cases  (Wichmann"  ancl  others),  especially  the  visual  field  (Wil- 
brand,  Saenger,'  and  Konig^).  The  question  of  simulation  has  been  thoroughly 
discussed,  and  the  cases  reported  by  Schultze,  Hoffmann,  ancl  Seeligmuller' 
have  been  subjected  to  a  destructive  criticism.  In  this  country  Dana,'°  Seguin," 
and  Derciim'^  have  studied  the  conditions  and  have  endeavored  to  classify  them ; 
AValton'^  has  made  a  further  study  of  the  symptoms,  inclining  to  the  belief 
in  the  frequency  of  simulation,  ancl  giving  a  favorable  prognosis  in  the  major- 
ity of  cases ;  Clevenger'*  has  attempted  to  group  the  symptoms  under  one 
heading,  under  the  name  of  Erichsen's  disease;  and  Dana'^  has  recently  pub- 
lished an  admirable  ancl  exhaustive  article  upon  the  whole  subject.  The  ex- 
perimental ancl  pathological  researches  will  be  spoken  of  later. 

It  seems  better  to  differentiate  the  various  traumatic  nervous  affections  as 
much  as  possible  rather  than  to  group  them  under  one  general  heading  of 
traumatic  neuroses.     Cases  where  there  has  been  some  definite  gross  lesion  of 

1  Archiv  fiir  Psych.,  xv.  2  Die  traumatischen  Nenrosen.    Second  edition,  1892. 

3  Berliner  Klinik,  H.  3.  4  Samml.  kl.  Vortrage,  No.  14, 1890. 

6  Berlin,  klin.  Woeh.,  July  21,  1890. 

"  Der  Werth  der  Symptome  dersogen.  traum.  Neurose. 

''  Ueber  Sehstorungen  bei  functionellen  Nervenleiden. 

8  Berlin,  klin.  Woch,  No.  31, 1891.         '■>  Deutsche  med.  Woch.,  July-October,  1890. 
"  N.  Y.  Med.  Rec,  December,  1884.       "  Annual  Univ.  Med.  Sci.,  1890,  1891. 
12  Therapeut.Gaz.,  May-October,  1889,  and  Am.  Journ.  Med.  Sci.,  September,  1891. 
'3  Spinal  Concussion.  i-i  Journ.  Nerv.  and  Ment.  Dis.,  July,  1890. 

i»  Hamilton's  System  of  Legal  Medicine,  ii,  297. 


138  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  nervous  system,  tlie  result  of  accident,  such  as  crushing  or  laceration  of 
the  brain,  cord,  or  peripheral  nerves,  hemorrhage,  and  the  like,  or  cases  pre- 
senting the  symptoms  of  some  well-recognized  disease,  differing  from  the 
ordinary  type  only  in  etiology,  such  as  epilepsy,  progressive  muscular  atrophy, 
transverse  myelitis,  and  the  forms  of  mental  disease,  will  not  be  considered  here. 

Before  dealing  with  affections  involving  the  nervous  system  it  will  be 
necessary  to  consider  one  condition  which  often  compUcates  many  of  these 
affections,  namely,  traumatic  lumbago,  after  Avhich  the  true  nervous  affections 
can  be  better  appreciated,  since  the  effect  of  the  complicating  symptoms  of 
lumbago  can  be  properly  estimated. 

Among  the  most  important  of  the  affections  to  be  discussed  in  this  chapter 
are  two  which  are  treated  of  elsewhere.  Theii*  importance  and  the  fact  that 
the  traumatic  origin  gives  them  a  somewhat  different  stamp  warrants  their 
further  detailed  consideration  here.  These  affections  are  traumatic  neuras- 
thenia and  traumatic  hysteria. 

Neurasthenia  is  one  of  the  commonest  of  nervous  affections,  and  it  is  also 
one  of  the  commonest  of  traumatic  diseases.  It  is  the  first  manifestation  of 
disintegration  of  the  nervous  system  from  any  cause,  and,  as  Dejerine^  has 
shown,  it  may  arise  in  the  healthy  organism  and  form  the  foundation  upon 
which  more  profound  degenerations  may  develop,  either  in  the  individual 
or  in  his  descendants.  Its  origin,  as  will  be  shown  later,  is  more  often  psy- 
chical than  physical.  With  more  profound  disintegrating  -causes,  or  with 
causes  acting  on  a  weaker  organism,  there  may  develop  an  affection  which 
betokens  more  pronounced  disintegration  of  the  nervous  system,  and  which 
presents  more  marked  symptoms  of  deficit,  absolute  loss  of  function  instead 
of  impairment,  namely,  hysteria.  These  two  afiections  represent,  not  true 
diseases,  but  morbid  states  of  the  nervous  system ;  they  are  allied,  and  the 
symptoms  of  the  one  shade  into  symptoms  of  the  other,  so  that  it  is  difiicult 
to  fix  a  definite  boundary  between  them.  As  will  be  seen  later,  the  majority 
of  the  cases  of  traumatic  hysteria  present  distinct  symptoms  of  neurasthenia, 
and  many  neurasthenic  cases  are  also  somewhat  hysterical. 

For  reasons  that  will  be  mentioned  later,  it  has  not  seemed  best  to  accept 
Oppenheim's  classification  of  traumatic  neuroses  as  a  separate  affection ;  but, 
on  account  of  the  prominence  given  to  it  in  literature,  a  brief  description  must 
be  devoted  to  it. 

In  the  section  on  pathology  I  shall  state  my  reasons  for  rejecting  the  old 
distinction  between  functional  and  organic  disease.  There  are  probably  fine 
cortical  changes  in  cases  of  neurasthenia  and  hysteria.  In  the  severer  and 
more  chronic  forms  of  these  affections  it  is  probable  that  the  changes  become 
more  marked.  In  another  class  of  cases,  where  the  physical  injury  is  more 
pronounced,  there  are  probably  even  greater  changes  in  the  central  nervous 
system.  I  have,  therefore,  thought  it  justifiable  to  describe  this  class  under 
the  term  of  traumatic  sclerosis,  a  term  selected  simply  for  convenience.  In 
such  cases  I  believe  that  there  may  be  more  marked  changes  in  the  brain  and 
cord,  either  a  diffuse  or  disseminated  sclerosis.  As  the  symptoms  in  these 
cases  have  considerable  resemblance  to  the  symptoms  of  hysteria  and  neuras- 
thenia, it  is  not  impossible  that  the  changes  in  these  two  affections  are  similar 
although  not  so  pronounced.  In  a  limited  number  of  cases  the  morbid  pro- 
cess is  located  chiefly  in  the  spinal  cord,  giving  rise  to  a  special  form  of  disease 
which  demands  a  separate  description.  This  affection  will  be  described  as 
traumatic  spinal  sclerosis. 

Etiology.  The  affections  to  be  described  may  arise  from  injuries  of  various 
sorts.     The  injur}',  however,  usually  has  this  characteristic  feature,  namely, 

1  L'heredite  dans  les  maladies  du  systeme  nerveus. 


GENERAL  MORBID  STATES.  139 

that  it  gives  rise  to  a  general  jarriug  or  concussion  of  the  whole  body,  and 
that  it  is  often  associated  with  profound  psychical  disturbances. 

Local  violence  is  much  less  likely  to  give  rise  to  general  disturbance,  un- 
less there  are  coexisting  psychical  factors.  In  most  cases  it  will  produce 
only  a  localized  injury  to  the  nervous  system  at  the  seat  of  the  blow,  giving 
rise  to  the  symptoms  of  a  focal  lesion.  A  severe  blow  on  the  head,  however, 
may  give  rise  to  general  cerebral  disturbances,  due,  probably,  to  the  general 
concussion  of  the  contents  of  the  skull.  Blows  upon  the  back,  even  of  mod- 
erate violence,  seem  also  peculiarly  apt  to  produce  symptoms  similar  to  those 
due  to  general  concussion. 

It  is  obvious  that  the  special  accidents  which  may  give  rise  to  general  con- 
cussion may  be  of  all  varieties — a  fall  on  a  sidewalk,  from  a  ladder,  down  a 
flight  of  stairs,  or  from  a  carriage,  any  violent  and  severe  blow,  especially  on 
the  head  or  back,  the  bufietting  of  waves,  electincal  shocks,  and,  above  all, 
railway  accidents  of  various  sorts.  When  the  individual  is  exposed  to  great 
mechanical  violence,  as  in  railway  accidents,  the  concussive  force  is  naturally 
much  greater  than  that  from  a  simple  fall,  and  the  chances  of  injury  are 
naturally  increased.  Even  in  the  less  severe  railway  accidents,  the  sudden 
stopping  of  a  train  may  throw  the  individual  forward  with  considerable 
force,  and  he  may  then  be  thrown  backward  with  almost  equal  force  when 
he  strikes  the  seat  or  partition  in  fr'ont. 

The  amount  of  inj  ury  to  the  nervous  system  cannot,  however,  be  measured 
by  the  intensity  of  the  physical  shock.  In  many  cases  another  factor  comes 
into  play,  sufiicient  of  itself  to  produce  serious  results.  This  factor  is  the 
psychical  shock.  In  simple  falls  upon  the  sidewalk  or  in  accidents  where 
the  victim  is  at  once  rendered  unconscious  by  a  blow  on  the  head,  this  factor 
is  not  material,  but  where  there  are  terrifying  or  distressing  circumstances 
attending  the  accident  the  emotional  disturbance  is  much  greater  than  the 
physical.  Even  to  an  onlooker  a  great  railway  accident,  with  the  cries  of 
the  injured,  the  mangled  bodies,  and  all  the  distressing  circumstances,  will 
produce  a  most  profound  psychical  disturbance.  When,  in  addition,  there  is 
the  terror  from  the  personal  danger  incurred  it  is  not  remarkable  that,  even 
without  physical  injury,  the  victim  may  be  profoundly  affected.  Beside  the 
general  emotional  disturbance  the  terror  of  the  accident  may,  as  Charcot  has 
indicated,  give  rise  to  a  mental  condition  resembling  that  of  the  hysterical 
state.  The  victim  is  dazed  with  terror ;  he  is  conscious  of  only  a  limited 
number  of  the  phenomena  of  the  external  world ;  there  is  a  clouding  of 
consciousness ;  a  limitation  of  the  field  of  consciousness.  This  condition  has 
been  thought  by  Charcot  to  be  closely  akin  to  the  somnambulic  stage  of 
hypnotism,  and,  just  as  in  the  hypnotic  state  a  slight  blow  on  the  arm  may 
give  rise  to  an  hysterical  paralysis  by  suggestion,  so,  in  this  state,  by  a  pro- 
cess of  auto-suggestion,  either  as  the  result  of  a  slight  blow  or  merely  from 
the  idea  of  injury,  hysterical  paralyses  and  other  hysterical  symptoms  may 
arise. 

Oppenheim  and  Striimpell  are  disposed  to  lay  chief  stress  upon  these 
psychical  factors  as  the  most  potent  causes.  While  they  are  of  great  impor- 
tance the  influence  of  the  physical  shock  is  also  great,  and  of  late  there  has 
been  a  tendency  to  depreciate  it.  The  psychical  factor  in  the  simple  fall  on 
a  sidewalk  is  usually  not  great,  for  it  is  an  accident  which  most  men  have 
repeatedly  experienced  without  harm ;  the  injurious  effects  are  more  proba- 
bly due  to  the  physical  shock.  When  the  victim  is  at  once  stunned  by  a 
blow  there  is  no  time  for  the  psychical  influences  to  take  effect.  In  a  rail- 
way accident,  however,  these  psychical  influences  are  of  paramount  impor- 
tance. Physical  injury  is  more  likely  to  give  rise  to  coarser  structural 
changes — traumatic  lumbago,  and  the  traumatic  scleroses ;  l)ut  when  the  in- 


140  NERVOUS  DISEASES  AXD  THEIB  TREAT2IEXT. 

jury  is  due  chiefly  to  the  psychical  disturbances  we  are  more  likely  to  find 
conditions  of  hysteria  or  neurasthenia.  In  many  cases,  however,  the  two 
factors,  physical  and  psychical,  coexist,  so  it  is  not  easy  to  say  which  exerts 
greater  influence. 

A  word  must  be  said  in  regard  to  predisposing  factors.  It  is  rare  to  find 
traumatic  nervous  affections  in  children,  especially  affections  which  have  a 
distinct  psychical  element,  such  as  hysteria  or  neurasthenia.  They  do  exist, 
however,  and  several  cases  have  come  under  my  observation  in  children  under 
fifteen  years.  Men,  too,  are  much  oftener  affected  than  Avomen,  because  they 
are  so  much  more  exposed  to  accidents.  Out  of  ninety  cases  only  twenty- 
four  were  women,  but  out  of  forty-six  eases  of  hysteria  and  neurasthenia 
eighteen  were  women,  showing,  as  might  be  expected,  that  the  psychical 
factors  are  more  potent  in  women,  and  that  accidents  occurring  to  women 
are  more  prone  to  give  rise  to  psychical  affections. 

The  hereditary  nervous  taint  Ls  of  considerable  importance  as  a  predispos- 
ing cause.  A  comparatively  slight  injury  in  the  neuropathic  may  give  rise 
to  serious  consequences,  but  the  neuropathic  taint  is  much  more  potent  as  a 
predLsposing  cause  of  hysteria  or  neurasthenia  than  as  a  cause  of  the  sclerosis. 

If  there  be  pre-existing  disease,  especially  structural  disease  of  the  nervous 
system,  trauma  may  greatly  aggravate  the  symptoms.  More  than  once  I 
have  seen  j^atients  in  the  initial  stages  of  tabes  or  paretic  dementia,  who  were 
still  able  to  attend  to  the  duties  of  life,  rendered  incapable  of  further  activity 
by  a  slight  accident  or  by  a  moderate  jDsychical  shock,  without  much  phy- 
sical injury.  The  injury  seems  capable  of  hastening  the  morbid  processes,  so 
that  the  patient  may  soon  after  become  ataxic  or  show  so  much  more  mental 
clLsturbance  as  to  require  restraint.  These  cases,  ftirthermore,  are  important, 
since,  without  careful  inquiry  into  the  previous  condition,  the  physician  might 
erroneously  ascribe  the  entire  trouble  to  the  injury.  In  tuberculosis,  and 
especially  in  sA^ohilis,  the  injury  may  act  as  an  exciting  cause  for  the  localiza- 
tion of  the  disease  in  the  brain  or  spinal  cord. 

When  once  the  injury  has  been  sustained  there  are  other  factors  which 
come  into  play  which  have  a  profound  influence  upon  the  progress  of  the 
disease.  In  most  cases  of  illness  the  patient  feels  a  natural  anxiety  as  to 
whether  he  will  recover,  and  as  to  how  soon  he  can  resume  work  and  provide 
for  himself  and  those  dependent  on  him.  This  anxiety  is  usually  greater  in 
nervous  diseases,  especially  when  they  are  chronic,  for  thepatient  often  has 
an  exaggerated  idea  of  their  seriousness,  and  is  not  familiar  with  the  probable 
outcome.  In  many  cases  of  ner^'ous  disease  the  disorder  itself  gives  rise  to 
anxiety  and  depression.  In  cases  where  a  claim  for  damages  is  involved  other 
factors  arise  which  are  even  more  injurious.  After  a  railway  accident  the  run- 
nel's for  the  accident  lawyers  sometimes  reach  the  scene  before  the  wrecking 
train  and  the  surgeons,  and,  before  the  victim's  wounds  are  dressed,  they  assure 
him  that  he  has  sustained  incurable  injury,  for  which  he  is  entitled  to  heavy 
damages,  and  that  they  can  procure  them.  From  that  time  on  the  victim  is 
harassed  with  preparations  for  a  trial.  Instead  of  the  absolute  rest  and  freedom 
fi'om  anxiety  essential  for  recovery,  he  is  exposed  not  only  to  the  natural  and 
inevitable  anxiety  and  excitement  resulting  ft-om  his  accident  and  his  injuries, 
but  to  all  the  worry  and  conftision  of  a  suit  at  law — in  itself  sufficient  to  cause 
great  distress  to  a  person  in  feeble  health.  Under  the  absurd  system  of  "  ex- 
perts" which  exists  in  this  country  he  is  made  to  undergo  repeated  examina- 
tions, often  by  men  Avho  show  manifest  bias  and  distress  him  by  treating  him  as 
a  swindler.  In  addition  the  lawyers  and  physicians,  sometimes  directly,  and 
more  often  unconsciously,  by  repeated  examinations  and  questioning's,  suggest 
symptoms,  "and  in  such  nervous  states,  as  is  well  known,  the  patient  is  very 
susceptible  to  suggestion.     This  state  of  things  continues  for  a  year  or  two 


GENERAL  MOBBII)  STATES.  141 

before  the  case  is  reached.  Theu  comes  the  trial,  with  all  its  vexations  and  de- 
lays, with  renewed  examinations  and  the  anxiety  of  appearing  in  court  as  a 
witness.  After  this  some  question  of  appeal  may  prolong  matters  for  a  year 
or  more.  During  all  this  time  it  only  too  often  happens  that  nothing  material 
is  done  in  the  way  of  treatment.  The  attending  physician  is  more  apt  to 
prepare  the  patient  for  the  trial  than  to  cure  his  ailment.  The  patient,  thus 
neglected,  cannot  aflbrd  to  get  well.  By  doing  so  he  will  prejudice  his  case, 
and,  if  he  do  not  incur  the  odium  of  a  swindlei',  he  will  at  least  receive  a 
much  smaller  award.  The  anxiety  about  the  claim  and  excitement  of  the 
examinations  and  trial,  the  neglect  of  proper  treatment,  the  evil  results  of 
suggestion,  and  the  consciousness  that  recovery  would  prejudice  his  interests 
— all  these,  kept  up  for  several  years,  naturally  have  a  most  deleterious  influ- 
ence, and  they  may  easily  convert  a  mild,  curable  trouble  into  a  severe, 
incurable  disease. 

With  the  extensive  use  of  electrical  currents  of  high  potential  a  new  source 
of  accidents  has  been  brought  into  daily  life,  and,  as  these  accidents  are  be- 
coming more  frecpient,  the  influence  of  electrical  shocks  in  causing  nervous 
affections  becomes  important.  The  symptoms  resulting  from  these  shocks  are 
similar  to  those  resulting  from  a  shock  from  lightning.  In  fatal  cases  the 
chief  changes  have  been  congestion  in  the  nervous  system  with  occasional 
ecchymoses,  and  alterations  in  the  blood,  which  is  dark  and  fluid.  There  is, 
perhaps,  some  chemical  change  in  the  blood,  and  Peterson^  thinks  that  the 
current  divides  and  disarranges  the  molecular  structure  of  the  body.  In 
some  cases  Dana'^  maintains  that  there  may  be  a  disorganizing  effect  upon  the 
nervous  tissues,  causing  paralysis  from  coarse  lesions.  Linemen,  and  others 
who  work  in  dangerous  positions,  may  be  subjected  to  severe  falls,  from  the 
fact  that  even  a  moderate  current  may  cause  a  sudden  start ;  in  other  cases 
the  strong  current  causes  severe  burns  without  any  other  symptoms.  With 
persons  unused  to  electrical  shocks  the  effect  is  chiefly  pyschical.  Electricity 
is  a  new  and  mysterious  agent.  In  the  form  of  lightning  it  is  most  awe-inspir- 
ing, and  it  has,  from  the  earliest  times,  given  rise  to  many  superstitions.  The 
numerous  fatal  accidents  from  the  currents  now  employed  have  given  rise  to 
much  discussion  in  the  press.  Hence  an  electrical  shock  has  a  most  powerful 
effect  upon  the  imagination  even  of  educated  people.  As  might  be  expected, 
the  nervous  affections  resulting  from  electrical  accidents  are  chiefly  of  a  neu- 
rasthenic or  hysterical  character.  In  cases  where  the  symptoms  could  fairly 
be  ascribed  to  the  electrical  shock  and  not  to  any  attenclant  fall  or  burn, 
nearly  two-thirds  of  those  that  I  have  seen  have  been  cases  of  hysteria — a 
much  greater  proportion  than  is  the  case  with  accidents  from  other  causes. 

Pathology.  It  is  unnecessary  to  cite  cases  showing  the  numerous  direct 
effects  of  trauma  upon  the  nervous  system.  Among  them  we  may  note 
hemorrhage,  contusion,  laceration,  and  softening,  involving  the  brain  and 
cord,  or  the  peripheral  nerves.  It  is  also  generally  admitted  that  trauma 
may  act  as  a  direct  or  as  an  exciting  cause  of  more  chronic  processes,  such  as 
new  growths  and  degenerations.  The  pathology  in  these  conditions  is  well 
recognized  and  the  symptoms  are  usually  well  defined. 

The  pathology  of  the  more  obscure  affections  is  still  very  vague.  Although 
it  has  been  much  discussed,  and  although  many  pages  have  been  written  upon 
it,  it  rests  unfortunately  upon  a  very  slender  basis  of  fact.  The  extremely 
small  number  of  autopsies,  considering  the  frequency  of  the  affections,  has, 
in  times  past,  led  certain  writers  to  doubt  the  reality,  or  at  least  the  severity, 
of  the  cases  in  question.  The  absence  of  autopsies  seemed  to  afford  proof 
that  all  cases  got  well.     The  weakness  of  this  argument,  however,  is  exposed 

1  N.  Y.  Med.  Rec,  Nov.,  1889.  .  2  ibid. 


142  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

wlien  we  consider  that,  in  spite  of  the  frequency  and  severity  of  neurasthenia 
not  of  traumatic  origin,  there  are  very  few  autopsies  in  this  disease  on  record ; 
yet  many  neurasthenic  j)atients  do  not  get  well,  and  some  of  them  must  die 
from  some  cause  or  other,  if  not  from  neurasthenia  itself. 

Erichsen  believed  that  where  an  accident  had  given  rise  to  definite  physical 
injury,  especially  fracture  of  a  bone,  the  symj)toms  of  concussion  did  not 
ajDpear,  that  the  violence  expended  itself  upon  the  bone  and  did  not  exert 
injurious  eifects  upon  the  nervous  system.  This  opinion  cannot  be  main- 
tained, for,  in  a  number  of  cases  which  have  come  under  my  own  observa- 
tion, nervous  affections  of  various  t}'pes  have  developed  as  the  result  of 
injuries  which  also  caused  fractures,  either  of  a  large  or  small  bone. 

A  certain  amount  of  work  has  been  undertaken  on  the  experimental  side 
to  show  the  nature  of  the  changes  which  may  result  from  concussion  accidents. 

Mendel,^  believing  that  hypersemia  was  an  important  feature  of  the  early 
changes  in  general  paralysis,  sought  to  excite  an  intense  chronic  hypersemia 
of  the  brain  in  dogs.  For  this  purpose  he  fastened  the  animals  on  a  revolv- 
ing table,  with  their  heads  toward  the  periphery.  Eapid  revolutions,  125  to 
130  a  minute,  continued  for  half  an  hour,  produced  punctate  hemorrhages. 
Slower  revolutions  (110)  for  six  minutes  a  day,  produced,  after  some  weeks, 
symptoms  of  general  paralysis,  and,  on  killing  the  animals,  he  found  adhe- 
sions between  the  skull,  the  meninges,  and  the  brain,  an  increase  in  the  nuclei 
and  cells  of  the  glia,  an  increase  in  the  number  of  vessels,  and  changes  in 
the  ganglion  cells.  Fiirstner^  repeated  Mendel's  experiments,  with  fewer 
revolutions  (60  to  80),  for  a  shorter  time  (one  to  two  minutes),  and  continued 
for  months.  He  found  double  primary  degeneration  of  the  lateral  columns 
and  of  a  particular  part  of  the  posterior  columns,  changes  in  the  optic  nerves, 
and  changes  in  the  brain  similar  to  those  found  by  jMendel. 

Watson^  carried  on  a  rather  elaborate  series  of  experiments,  the  aim  of 
which  was  to  show  that  concussion  accidents  were  not  likely  to  produce  injury 
of  the  spinal  cord.  He  dropped  dogs  from  a  height  of  twenty-five  feet,  hop- 
pling them  so  that  in  most  cases  the  blow  was  delivered  on  the  nates.  From 
his  experiments  he  concluded  that  concussive  accidents  never  produce  patho- 
logical changes  in  the  sj^inal  cord,  except  where  great  force  has  been  applied 
to  the  spinal  column,  and  those  cases  are  generally,  if  not  always,  complicated 
with  the  fracture  of  a  body  of  a  vertebra,  dislocation  of  the  same,  rupture 
or  stretching  of  vertebral  ligaments,  or  severe  lesions  in  other  parts  of  the 
body,  which  termmate  quickly  in  death.  The  symptoms  indicative  of  these 
morbid  conditions  are  immediately  developed,  rarely  become  intensified  by 
reason  of  morbid  changes  occurring  in  the  spinal  cord,  exceptional  cases 
being  limited  to  fractures  and  dislocations,  or  those  in  which  a  slow  hemor- 
rhage occurs,  causing  pressure  on  the  cord.  Watson's  conclusions,  however, 
are  weakened  by  the  fact  that  he  regards  such  changes  in  the  cord  as  h}^er- 
semia,  punctate  hemorrhages,  and  a  granular  appearance  of  sections,  with  in- 
distinctness of  fibres  and  a  difficulty  in  makiag  out  the  axis  cylinders,  as 
insignificant,  and  that  in  hardly  a  case  did  he  keep  his  dogs  alive  long  enough 
to  determine  whether  any  of  the  more  chronic  processes  might  develoj). 
Schmaus  *  conducted  a  series  of  experiments  on  rabbits  by  placing  a  bit  of 
Avood  over  the  spine  and  giving  it  repeated  blows  with  a  hammer.  The  ver- 
tebral canal  was  uninjured,  but  spinal  symptoms  were  produced,  and  various 
changes  were  found  in  the  cord — fine  granular  degeneration  of  the  gangbon 
cells,  swelling  and  enlargement  of  the  axis  cylinders,  foci  of  softening,  and 
fascicular  degeneration.     His  conclusions  are  as  follows  : 

1  Neurol.  Centralbl.,  May,  1884.  -  Arch.  f.  Psych,  xix.,  438, 

3  Experimental  Study  of  Diseases  Arising  from  Severe  Concussions. 

4  Virchow's  ArcMy,  csxii.,  326. 


GENERAL  MORBID  STATES.  143 

1.  There  is  a  direct  traumatic  necrosis  of  fibres — cases  Avith  positive  ana- 
tomical lesions. 

2.  More  fibres  have  died  than  we  can  recognize — cases  with  marked  clinical 
symptoms  and  slight  anatomical  changes. 

3.  The  fibres  may  be  merely  fatigued — rapidly  fatal  cases,  with  negative 
lesions,  and  cases  that  recover. 

4.  The  fatigue  of  the  fibres  may  go  on  to  their  death — cases  with  gradual 
beginning  and  positive  anatomical  lesions. 

6.  Gliosis — termination  in  tumor  formation. 

These  experiments,  although  interesting  and  to  some  extent  suggestive,  are 
by  no  means  conclusive.  Neither  the  rotation  employed  by  Mendel  and 
Fiirstner,  nor  the  concussion  experiments  of  Watson  or  Schmaus,  reproduce 
very  closely  the  conditions  that  most  commonly  bring  about  morbid  mani- 
festations in  man.  Furthermore,  the  psychical  factor,  which  undoubtedly 
plays  a  great  part  in  many  of  the  cases  that  occur  in  man,  has  no  part  in 
such  experiments. 

Human  pathology  aflfords  some  information  with  regard  to  the  possible 
effects  of  trauma  upon  the  nervous  system.  At  the  autopsies  of  several 
persons  killed  at  a  great  railway  accident  at  Charenton,  Vibert^  found  very 
abundant  punctate  hemorrhages  in  the  upper  part  of  the  body,  and  he  sug- 
gests that  they  arose  from  lesions  of  the  nervous  centres.  AVilligk''  found  in 
one  case  dilatation  of  the  finest  vessels,  with  infiltration  into  the  perivascular 
spaces,  and  degeneration  of  the  coats  of  the  vessels.  Changes  in  the  lateral 
columns  have  been  found  after  death,  in  patients  who  had  suffered  from  "  con- 
cussion," by  Dumesnil  and  Petel,^  and  also  by  Edes,*  Avho  has  called  attention 
to  the  occurrence  of  symptoms  of  spastic  paraplegia  in  certain  cases.  Gowers^ 
also  has  found,  in  a  case  where  paraplegia  developed  some  days  after  the  in- 
jury, subacute  myelitis  in  the  thoracic  region,  chiefly  in  the  white  columns 
and  greatest  in  the  pyramidal  tract. 

Sperling  and  KronthaP  have  reported  a  case  showing  melancholia,  head- 
ache, mental  impairment,  muscular  weakness,  and  circulatory  disturbances,  in 
which,  after  death,  they  found  pronounced  arterio-sclerosis,  Avith  spots  of  slight 
degeneration  in  the  Avhite  matter  of  the  cord,  hemorrhage  into  the  cord,  and 
degeneration  of  ganglion  cells  in  one  portion  of  the  cord.  Both  cerebral  and 
spinal  bloodvessels  Avere  sclerosed.  Bernhardt  and  KronthaF  report  another 
case,  showing  symptoms  of  hystero-neurasthenia,  where  the  patient  committed 
suicide  by  hanging.  The  cord,  which  alone  AA^as  examined,  shoAA'^ed  dissemi- 
nated foci  Avhich  stained  more  deeply.  Here  the  glia  was  increased,  and  some 
axis  cylinders  were  lost ;  the  vessel-walls  Avere  much  thickened.  Both  these 
cases  showed  arterio-sclerosis  and  spots  of  slight  degeneration  in  the  AA'hite 
substance  of  the  cord.  Friedmann^  found  in  the  brain  extreme  hypersemia, 
dilatation  of  the  smaller  vessels,  Avith  infiltration  of  their  sheaths  and  pro- 
liferation of  endothelial  cells,  and  hyaline  degeneration  of  the  vessel-walls. 
Similar  changes  were  found  in  the  pia,  and  the  brain  tissue  was  invaded  by 
lymph  cells. 

It  must  also  be  noted  here  that  Van  Gieson,®  in  an  elaborate  study  of  por- 
tions of  cortex  excised  in  operations  for  traumatic  epilepsy,  found  a  focus  of 
local  irritation  with  chronic  leptomeningitis,  and,  in  addition,  degeneration 
of  the  ganglion  cells  and  neuroglia  hyperplasia,  with  some  increase  of  capil- 
laries. 

1  Etude  medico-legale  sur  les  blessures,  etc. 

2  Vierteljahrschr.  f.  d.  prakt.  Heilk.,  cxxviii.,  19.  s  Arch,  de  Neurol.,  Jan.  1885. 

4  Brit.  Med.  and  Surg.  Journ.,  Sept.,  1882. 

5  Manual  of  Diseases  of  the  Nervous  System,  2d  ed.,  i.,  591. 

6  Neurol.  Centralbl..  1889,  No.  11.  "<  Ibid.,  1890,  No.  4. 

8  Arch.  f.  Psych.,  xxiii.  ^  gtarr :  Brain  Surgery,  p.  78. 


144  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Tlie  interpretation  of  tliese  autopsies  is  still  vague.  Oppeulieim^  holds  that  the 
degeneration  in  Kronthal's  cases  was  merely  the  result  of  the  arterio-sclerosis, 
and  he  thinks  that  neither  these  cases  nor  Friedmann's  can  fairly  be  cited  to 
establish  the  pathology  of  the  traumatic  neuroses.  Friedmann,  however, 
maintains  that  the  source  of  the  trouble  in  most  of  the  cases  is  vasomotor. 
The  concussion  gives  rise  to  a  tendency  to  frequent  fluxions  with  angemia,  the 
vasomotor  regulating  apparatus  is  weakened,  and  the  nutrition  of  the  vessel- 
walls  and  their  resisting  power  is  at  last  imjDaired.  Clevenger^  has  attempted, 
without  any  definite  pathological  evidence,  to  refer  the  symptoms  ia  many  of 
these  cases  to  injury  of  the  sympathetic  system  and  the  consequent  vasomotor 
changes. 

The  notion  of  functional  diseases  as  distiuct  from  organic — that  is,  of  dis- 
ease due  to  no  structural  change  iu  the  diseased  organ — is  fast  becoming 
obsolete.  We  are  estabHshing  the  pathological  changes  of  epilepsy,  chorea, 
neuralgia,  paralysis  agitans,  and  other  aflTections  once  classed  as  functional. 
"Spinal  concussion,"  paralysis  due  to  molecular  disturbances  in  the  cord 
without  structural  changes,  has  no  place  in  modern  pathology.  "  Cerebral 
concussion  "  is  equally  obsolete.  In  any  fatal  case  of  brain  injury  that  is 
properly  examined  structural  changes  can  be  found.  In  neurasthenia,  hys- 
teria, and  certain  allied  affections  the  notion  of  "functional  disease"  still 
holds  sway  in  many  muids. 

In  hysteria  the  symptoms  are  chiefly  of  cerebral  origiu,  and  Me}Tiert^  and 
Bastian,*  among  others,  have  attempted  to  apply  the  ordinary  rules  of  local- 
ization to  hysterical  anaesthesia  and  paralysis.  For  many  years  attempts 
have  been  made  to  refer  both  affections  to  alterations  in  the  blood-supply  of 
the  affected  parts,  and  especially  to  vasomotor  disturbances.  In  many  cases 
of  traumatic  neurasthenia  and  hysteria  there  are  profound  disturbances  of 
the  circulatory  system — a  rapid  pulse,  palpitation,  impaired  circulation,  car- 
diac distress,  flushings,  etc. — which,  in  connection  with  the  scanty  pathological 
evidence,  would  favor  the  theory  of  a  vasomotor  affection.  This  theory  of 
vasomotor  disturbance,  although  not  improbable,  has  little  positive  evidence 
as  yet  in  its  favor,  so  that  we  must  regard  it  as  still  undetermined. 

Although  still  in  the  very  untrustworthy  domaiu  of  speculative  pathology, 
I  cannot  dismiss  this  subject  without  reference  to  certain  experiments  which 
seem  to  be  of  great  significance  as  pointing  out  the  way  for  future  research. 
In  an  elaborate  study  of  the  changes  due  to  functional  activity  in  nerve-cells, 
Hodge^  has  found  that  in  normal  fatigue  the  nuclei  decrease  iu  size,  assume 
an  irregular,  jagged  outline,  stain  darker,  and  lose  their  open,  reticulate  ap- 
pearance ;  the  cell-protoplasm  shrinks  in  size,  and  shows  vacuolization  in  the 
spinal  ganglia,  or  enlargement  of  the  peri-cellular  lymph-space  in  the  cere- 
brum and  cerebellum,  and  has  a  lessened  power  to  reduce  osmic  acid ;  and 
the  nuclei  of  the  cell-capsule,  where  there  is  a  capsule,  decrease  in  size.  Normal 
fatigue  has  a  close  kinship  with  neurasthenia,  and  it  is  not  improbable  that,  in 
the  latter  affection,  we  may  find  changes  in  the  nerve-celLs  of  a  similar  though 
of  a  more  pronounced  type. 

Reasoning  from  analogy,  therefore,  it  seems  probable  that  in  the  so-caUed 
functional  affections  we  have  at  first  ceUular  changes  resembling  those  de- 
scribed by  Hodge.  These  may  give  rise  to  degenerative  changes  similar  to 
those  described  by  Schmaus,  or'to  secondary  vascular  disturbances,  leading  in 
the  severer  and  "more  chronic  cases  to  more  pronounced  and  more  diffused 
sclerotic  processes.     Such  a  pathology  is  as  yet  largely  speculative,  but  it 

1  Op.  cit.,  2d  ed.,  p.  176.  2  Op.  cit.,  p.  277. 

3-  Centralbl.  f.  Nervenheilk.,  1889,  No.  12. 

4  Hysterical  or  Functional  Paralysis.  ^  Journal  of  Morphol.,  vu.,  95. 


GENERAL  MORBID  STATES.  145 

agrees  with  tlie  few  data  that  we  have,  and  it  indicates  the  jDOSsibilities  of 
serious  and  irremediable  changes  in  chronic  cases. 

Preliminary  Symptoms.  In  the  majority  of  cases  there  are  certain  symp- 
toms due  immediately  to  the  trauma,  which  are  common  to  all  affections, 
and  may  be  briefly  described  here. 

In  a  part  of  the  cases,  especially  when  the  head  has  been  injured  and  the 
physical  violence  has  been  great,  the  patient  is  at  once  rendered  unconscious, 
regaining  consciousness  after  some  interval.  The  unconsciousness  is  due  to 
direct  injury  of  the  brain,  probably  contusion.  With  more  serious  injury  the 
return  to  consciousness  is  naturally  delayed,  and  serious  symptoms  will  be 
manifest  when  the  patient  comes  to  himself.  In  such  cases  it  often  happens 
that  the  patient  has  no  memory  of  the  accident  or  of  events  immediately 
preceding  it.  kSuch  a  condition  is,  of  course,  more  often  found  in  cases  where 
there  has  been  definite  injury  to  the  skull  or  its  contents,  such  as  fracture  or 
cerebral  hemorrhage. 

In  other  cases  the  symptoms  are  those  of  ordinary  surgical  shock — j^^Ho^? 
faintness,  vertigo,  a  weak  and  rapid  pulse,  coldness  of  the  extremities,  nausea, 
vomiting,  etc.  The  faintness  may  go  on  to  actual  syncoj^e,  and  the  memory 
of  events  that  happen  during  this  period  is  much  impaired.  This  condition 
may  last  for  several  hours. 

In  other  cases  the  symptoms  of  shock  are  slight  or  absent,  but  the  patient 
is  thrown  into  a  peculiar  nervous  state.  He  is  apparently  dazed,  he  performs 
various  actions  correctly  yet  in  a  sort  of  automatic  way,  and  he  has  no  sub- 
sequent consciousness  of  his  acts.  He  may  also  forget  events  that  happen 
immediately  before  the  accident.  This  condition  is  closely  akin  to  the  som- 
nambulic state  of  hypnotism,  and  its  importance  for  the  development  of 
suggestion  has  already  been  mentioned. 

In  other  cases  still,  the  patient  is  not  aw^are  of  the  injury  received ;  he  may 
experience  some  slight  pain,  and  feel  a  trifle  dazed  or  faint  for  a  moment ;  he 
then  revives  and  goes  on  with  his  duties  ;  in  a  railway  accident  he  will  relieve 
the  injured,  carry  them  from  the  wreck,  and  do  many  similar  acts.  After  a 
varying  interval  symptoms  develop.  The  symptoms  of  neurasthenia  and 
hysteria  are  apt  to  come  on  suddenly :  after  the  patient  gets  home  and  is  free 
from  excitement  he  may  break  down  in  a  fit  of  hysterical  weeping,  or  pass  a 
sleepless  night,  and  the  next  day  begin  to  complain.  In  other  cases,  especially 
with  the  scleroses,  the  symptoms  are  of  more  gradual  onset.  Local  injuries 
may  cause  temporary  disturbance,  and,  not  until  the  patient  recovers  from 
them,  do  serious  symptoms  manifest  themselves.  There  is  seldom  an  interval 
of  more  than  two  or  three  days  free  from  any  morbid  symptoms,  but  it  may 
be  a  number  of  weeks  before  they  become  sufficiently  pronounced  to  disturb 
the  patient  materially  or  to  demand  the  interference  of  a  physician. 

In  rare  cases  pronounced  mental  symptoms  appear  soon  after  the  injury. 
Most  commonly  there  is  a  condition  of  extreme  nervous  excitement,  insomnia, 
restlessness,  anxiety,  morbid  terrors,  laughing,  crying,  etc.  In  a  few  cases 
the  symptoms  are  even  more  pronounced,  and  a  condition  of  actual  delirium 
may  ensue,  usually  taking  the  form  of  acute  confiisional  insanity  with  hallu- 
cinations. Thomsen'  has  reported  a  case  under  the  name  of  "  acute  railway 
brain  "  where,  immediately  after  an  accident,  there  were  maniacal  symptoms, 
with  absolute  and  complete  ansesthesia,  confusion,  and  delusions  of  persecu- 
tion ;  later  the  maniacal  symptoms  disappeared,  the  ansesthesia  was  less  com- 
plete, but  the  man  became  lachrymose,  hysterical,  hypochondriacal,  de- 
pressed, irritable,  and  unable  to  work  on  account  of  headache  and  weakness. 

1  Berlin,  klin.  Wochenschr.,  Aug.  1887. 
10 


146 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


TRAUMATIC    LUMBAGO.     (Strain  of  the  Muscles  of  the  Back.) 

Although  not  properly  an  affection  of  the  nervous  system,  traumatic  lum- 
bago may  be  described  with  the  traumatic  nervous  affections,  because  it  is  a 
very  common  complication  of  such  affections,  and  because  it  formerly  gave 
rise  to  erroneous  theories  as  to  the  nature  of  some  of  these  affections.  The 
pain  and  stiffness  in  the  back  which  it  causes  have  often  been  referred  to  dis- 
eases of  the  spinal  cord. 

The  accompanying  diagram  (Fig.  40)  shows  clearly  the  size  of  the  mus- 
cular mass  which  is  attached  to  the  vertebral  column  in  the  lumbar  region, 

Fig.  40. 


Horizontal  section  through  the  body  at  the  umbilicus.  (After  Braune.)  The  double  line  marks 
the  boundary  of  the  section.  A.  Cauda  equina.  B.  Cartilage  between  the  third  and  fourth  lumbar 
vertebrae.    C.  Erector  spinse.    D.  Psoas.    E.  Quadratus  lumborum. 

but  it  does  not  show  the  complexity  of  the  tissues  which  make  up  this  mass, 
which  includes  tendons,  ligaments,  fascise,  and  small  bloodvessels  and  nerves, 
as  well  as  muscular  substance. 

Traumatic  lumbago  is  due  to  physical  causes,  and  it  may  arise  either  from 
a  direct  blow  upon  the  back  or  from  violence  which  leads  to  a  twisting  or 
wrenching  of  the  trunk.  It  is,  therefore,  especially  common  in  railway  acci- 
dents ancl  collisions,  where  the  victim  is  tossed  like  a  shuttlecock  back  and 
forth  between  the  seats.  Where  the  physical  injury  has  been  severe  the 
victim  usually  shows  the  ordinary  signs  of  surgical  shock,  or  he  may  even 
lose  consciousness.  Rarely  he  may  think  himself  at  first  uninjured,  the 
symptoms  developing  after  a  few  hours. 

The  striking  feature  of  traumatic  lumbago  is  pain  in  the  back.  The  pain 
is  usually  moderate  in  severity,  and  seldom  becomes  sharp  or  lancinating 
while  the  patient  is  at  rest.  Any  attempt  at  movement,  how^ever,  increases 
the  pain.  The  muscles  are  consequently  kept  by  reflex  action  in  a  state  of 
tonic  spasm.  The  patient  moves  slowly  and  deliberately,  in  order  to  avoid 
any  jar,  the  back  is  held  stiff,  and  when  he  stoops  there  is  little  or  no  bend- 
ing of  the  spine  ;  he  turns  the  head,  but  he  avoids  any  twisting  of  the  trunk  ; 
he  often  walks  with  his  hand  upon  the  back,  protecting  and  supporting  the 
painful  part.  Other  muscles  are  apparently  affected.  The  importance  of  the 
vertebral  muscles  in  fixing  the  spine  and  affording  a  firm  basis  for  other  move- 
ments is  seldom  fully  appreciated,  but  it  is  very  great,  and,  as  the  vertebral 


GENERAL  MORBID  STATES. 


147 


muscles  cannot  be  moved  without  pain,  the  limbs  cannot  act  with  their  full 
strength,  because  they  require  the  co-ordinated  simultaneous  action  of  the 
vertebral  muscles  to  afford  support  for  their  extreme  contraction.  The  legs, 
and,  to  a  lesser  degree,  the  arms,  are  therefore  weak.  Furthermore,  as  the 
vertebral  muscles  can  no  longer  act  properly,  the  action  of  the  abdominal 
muscles  is  impaired,  and  the  expulsive  movements  are  less  well  performed,  so 
that  defecation  and  micturition  are  no  longer  performed  naturally.  There  is 
a  sense  of  greater  effort,  and  it  seems  as  if  a  greater  strain  were  required.  It 
is  harder,  too,  to  perform  the  last  ex]3ulsive  movements,  so  that  there  may  be 
a  little  dribbling  of  urine.  There  is  never,  however,  any  involuntary  dis- 
charge of  urine  or  feces  or  any  true  incontinence. 

The  attitude  and  bearing  of  the  patient  are  characteristic,  from  his  effort 
to  avoid  any  jar,  bend,  or  twist  of  the  spine.  (Fig.  41.)  If  he  be  made  to 
bend  forward,  or  to  one  side,  the  rigidity  becomes  more  manifest,  and  expres- 

FlG.  41. 


Attitude  of  a  patient  with  traumatic  lumbago.    (Dercum.) 

sions  of  pain  are  at  once  elicited.  In  the  severer  cases  the  pain  may  be  so 
great  as  to  cause  redness  or  pallor  of  the  face,  an  outcry,  an  outburst  of  sweat 
on  the  forehead,  faintness,  or  a  quickened  or  weaker  pulse.  If  the  spine  be 
rotated  or  jarred  by  any  method,  as  by  the  physician  clasping  his  hands  over 
the  patient's  head  and  pulling  down  suddenly,  the  pain  is  even  greater.  The 
erector  spinse  muscles  may  be  felt  tense  and  firm  to  the  touch.  There  is  no 
special  sensitiveness  of  the  skin,  and  the  tenderness  is  usually  more  marked 
over  the  muscles  by  the  side  of  the  spine  than  over  the  spine  itself.  If  the 
tenderness  be  at  all  marked,  firm  pressure  on  the  tender  spot  will  cause  an 
increase  in  the  rapidity  of  the  pulse,  and  other  manifestations  of  pain. 
(Mannkopf  )^     Sensibility  is  unimpaired.     The  knee-jerk  is  somewhat  exag- 


1  Centralbl.  f.  Nervenheilk.,  1889,  No.  12. 


148  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

gerated,  the  movement  is  quick,  but  the  excursion  is  short,  as  if  held  in  check. 
The  jar  causes  pain,  and  thus  inhibits  the  movement.  There  may  be  other 
evidences  of  exaggeration  of  the  reflexes,  such  as  front-tap  contraction,  but 
the  reflexes  are  not  exaggerated  beyond  normal  limits,  and  are  not  greater 
than  we  often  see  as  a  result  of  painful  conditions. 

In  addition  to  these  symptoms  there  may  be  various  general  symptoms  due 
to  the  pain  and  confinement,  such  as  loss  of  appetite,  constipation,  and  the 
like.  Owing  to  the  clifiiculty  of  getting  into  a  comfortable  position,  and  to 
the  pain  on  any  slight  movement,  sleep  is  very  apt  to  be  disturbed,  and  the 
general  health  may  suffer  in  consequence. 

Traumatic  lumbago  is  not  often  an  independent  affection.  It  is  much 
more  frequently  seen  as  a  complication  in  various  forms  of  traumatic  nervous 
diseases,  where  it  may  obscure  the  clinical  picture  and  add  to  the  difficulty  of 
diagnosis.     In  most  instances,  however,  its  presence  can  easily  be  detected. 

The  diagnosis  is  not  difficult.  Careftil  examination  will  reveal  any  surgical 
aflfection,  such  as  fracture,  dislocation,  or  spinal  caries.  Is'euralgia  is  attended 
by  a  more  acute,  shooting  pain,  often  increased  on  motion,  but  confined  to 
certain  nerve  distributions.  Examination  may  reveal  Valleix's  points,  but 
the  muscular  rigidity  and  tenderness  are  less  pronounced. 

In  some  cases  of  hysteria  and  neurasthenia  there  is  very  great  pain  in  the 
back,  usuallv  described  in  much  more  emphatic  terms  than  the  pain  of  trau- 
matic lumbago.  The  patient  says  that  a  knife  is  sticking  into  the  back,  that 
the  spine  seems  to  be  opening  and  shutting,  and  uses  other  extravagant  ex- 
pressions. Motion  and  jarring  aggravate  this  pain,  too,  so  that  the  reflex 
spasm  of  the  erector  spinje  muscles  may  be  present.  The  pain  is  usually 
rather  higher  up  than  the  pain  of  traumatic  lumbago,  or,  at  any  rate,  it 
shoots  up  the  spine  to  become  connected  with  the  "  pain  at  the  base  of  the 
brain  "  so  often  complained  of.  The  spinous  processes  themselves  become 
extremely  tender  to  the  touch,  but  the  muscles  by  the  side  of  the  spine  are 
less  sensitive.  A  slight  touch  usually  causes  more  pain  than  deej)  pressure. 
The  two  conditions  may  coexist,  the  "  spinal  irritation  "  of  neurasthenia  being 
associated  with  lumbago. 

The  pathology  of  lumbago  is  quite  unknown.  It  is  assumed  that  we  have 
tearing  of  certain  muscular  or  ligamentous  fibres,  which  is  certainly  most 
probable.  In  some  cases  there  may  have  been  a  slight  dislocation  of  the 
vertebrae,  or,  more  frequently,  probably,  an  arthritis  of  some  of  the  inter- 
vertebral articulations. 

In  injuries  involving  the  neck  and  the  upper  part  of  the  spine  we  may  find 
similar  svmptoms  in  that  region.  In  such  cases  the  arms,  as  might  be  ex- 
pected, show  greater  weakness  than  the  legs,  and  there  are  often  symptoms 
suggesting  some  injury  or  disturbance  of  the  brachial  plexus. 


TRAUMATIC    NEURASTHENIA. 

One  of  the  most  frequent  eflects  of  severe  injury  upon  the  nervous  system 
is  the  production  of  a  state  of  nervous  weakness  or  nervous  exhaustion — 
neurasthenia.  In  about  one-third  of  all  the  cases  of  traumatic  nervous  dis- 
ease coming  under  my  own  observation  I  have  been  led  to  consider  this  state 
of  nervous  weakness  as  the  chief  trouble ;  but  it  often  exists  in  connection 
with  other  affections.  In  any  case  of  serious  disease,  no  matter  Avhat  its 
nature  or  its  origin,  we  are  apt  to  see  a  condition  of  neurasthenia  as  one 
manifestation  of  general  asthenia,  although  in  many  of  these  cases  the  ner- 
vous weakness  is  not  especially  prominent.  So,  too,  in  the  majority  of  trau- 
matic cases  a  condition  of  neurasthenia  is  apt  to  supervene  or  to  coexist. 


GENERAL  MORBID  STATES.  149 

Consequently  it  becomes  a  difficult  matter  to  define  its  importance  and  to 
differentiate  cases  of  pure  neurasthenia  from  neurasthenia  associated  with 
other  forms  of  nervous  disease. 

The  causes  of  neurasthenia  are  various.  Non-traumatic  neurasthenia  may 
arise  from  both  physical  and  psychical  causes ;  it  may  develop  as  a  result  of 
acute  infectious  diseases,  gastric  disorders,  or  uterine  affections,  or  it  may  be 
due  to  grief,  anxiety,  or  mental  strain ;  often,  indeed,  the  physical  and  psy- 
chical factors  may  be  combined.  The  same  is  true  of  traumatic  neurasthenia. 
In  the  stress  that  has  lately  been  laid  on  the  psychical  factor  in  the  etiology 
of  traumatic  nervous  affections  the  physical  factor  has  been  somewhat 
slighted.  Neurasthenia  may  follow  an  ordinary  fall  on  a  slippery  sidewalk, 
or  down  two  or  three  steps,  where  there  has  been  no  special  psychical  dis- 
turbance ;  but  the  most  severe  and  pronounced  cases  usually  arise  where  the 
psychical  factors  are  greater.  Some  of  the  severest  cases  are  to  be  seen  in 
the  survivors  of  great  railway  accidents,  who  may  have  suffered  very  little 
physical  injury.  The  symptoms  are  often  much  influenced  by  the  psychical 
factors.  Neurasthenia  may  also  develop  secondarily  as  the  result  of  the 
physical  suffering  from  other  injuries,  especially  when  associated  with  the 
causes  of  anxiety  and  worry  already  referred  to. 

Von  Hosslin^  thinks  that  only  persons  with  a  predisposition  to  neuroses 
suffer  from  traumatic  neurasthenia,  but,  in  many  cases,  no  evidence  of  pre- 
disposition can  be  found.  The  victims  had  previously  good  nervous  organiza- 
tions, with  no  history  of  inherited  or  acquired  nervous  taint.  This  is  Avhat 
we  might  expect,  for  neurasthenia  is  the  most  readily  acquired  form  of 
nervous  weakness,  and  it  can  hardly  be  considered  a  type  of  degeneration. 
The  essential  elements  of  traumatic  neurasthenia  are  the  same  as  those  of 
other  forms  of  neurasthenia.  The  weakened  nervous  system  usually  shows 
no  definite  loss  of  function,  but  it  is  incapable  of  persistent  and  prolonged 
effort.  While  the  patient  may  perform  many  acts  apparently  as  well  as  ever, 
they  are  done  at  a  greater  cost  than  in  health,  the  subsequent  exhaustion  is 
more  profound,  and  a  week's  suffering  may  pay  for  an  hour's  effort.  With 
this  the  power  of  persistent  mental  and  physical  application  is  diminished. 
The  neurasthenic  cannot  perform  the  ordinary  daily  routine  of  life,  or  do  any 
work  requiring  persistent  and  constant  application.  The  powers  which  at 
first  seem  normal  are  soon  exhausted. 

The  second  element  in  traumatic  neurasthenia  is  that  of  irritability,  often 
manifested  as  irritable  weakness ;  the  nervous  system  responds  to  weaker 
stimuli,  and  stimuli  which  are  scarcely  noticed  in  health  give  rise  to  un- 
pleasant or  distressing  effects.  This  combination  of  an  unduly  irritable  ner- 
vous system,  with  incapacity  for  protracted  effort,  is  characteristic  of  all 
forms  of  neurasthenia. 

The  mental  symptoms  vary  greatly.  In  cases  due  to  physical  causes  they 
are  less  pronounced,  but  in  cases  due  to  psychical  causes  they  may  become 
one  of  the  most  marked  and  distressing  features  of  the  disease.  The  com- 
monest and  most  persistent  symptoms  are  nervousness  and  irritability.  The 
patient  starts  at  a  sound  ;  the  slamming  of  a  door  distresses  him  ;  every  slight, 
unusual  noise  makes  him  start ;  he  is  fretful  and  fault-finding  ;  his  children, 
of  whom  he  was  once  devotedly  fond,  he  dreads  to  have  near  him  lest  their 
noise  disturb  him  ;  if  he  is  able  to  be  about  he  can  no  longer  endure  the  petty 
annoyances  of  life  ;  he  is  captious,  querulous,  and  irritable  ;  he  can  no  longer 
get  on  comfortably  with  his  fellows  ;  in  short,  he  presents  the  familiar  picture 
of  the  complaining,  irritable,  nervous  invalid.  In  cases  due  to  railway  acci- 
dents the  victim  often  has  a  peculiar  dread  of  railways ;  the  whistle  of  tlie 

1  Miiller's  Handbuch  der  Neurasthenie,  p.  62. 


150  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

locomotive  and  the  noise  of  the  train  may  cause  alarm,  and  he  dreads  to  get 
into  a  train  to  take  a  journey. 

In  many  cases  mental  dej)ression  is  a  very  marked  feature.  This  depres- 
sion is  most  frequently  personal,  referring  to  the  j)atient's  chances  for  re- 
covery ;  he  is  often  hypochondriacal.  The  introspection,  common  to  all 
neurasthenic  patients,  leads  him  to  dwell  on  his  symptoms,  to  exaggerate  his 
slightest  ills,  and  to  look  with  gloom  and  apprehension  on  the  future.  With 
this  may  be  coupled  the  depression  that  comes  from  fear  of  financial  embar- 
rassment or  the  dread  of  absolute  penury.  Some  patients,  however,  are  re- 
markably brave  in  combating  their  ill-feelings ;  they  force  their  illness  into 
the  background,  make  light  of  their  symptoms  as  much  as  they  can,  and  pre- 
serve a  calm,  hopeful  demeanor  through  it  all,  understanding  the  severity  of 
their  symptoms,  yet  requiring  close  questioning  before  they  will  tell  half  their 
real  sufferings.  The  depression  may  vary  greatly  in  intensity,  some  patients 
experiencing  sudden  waves  of  intense  depression  which  come  upon  them 
suddenly  and  last  for  a  considerable  time. 

In  addition  to  these  two  striking  symptoms  of  irritability  and  depression, 
other  mental  symptoms  are  also  seen.  The  spirit  of  doubt  and  hesitancy  is 
not  uncommon.  Every  task,  even  writing  a  letter,  seems  Herculean,  and  it 
is  only  after  much  effort  that  the  patient  can  bring  himself  to  undertake  it. 
When  it  is  done  there  may  be  questionings  and  doubtings  as  to  its  proper 
performance.  Certain  insistent  and  dominant  ideas  may  assert  themselves, 
such  as  are  seen  in  the  milder  forms  of  the  insanity  of  doubt.  The  patient  is 
anxious  and  apprehensive ;  he  dreads  solitude,  the  dark,  a  crowd,  or  railway 
trains,  but  the  dread  is  often  more  fi'om  association  or  from  the  fear  of  im- 
pending calamity  to  himself;  the  intention  psychoses,  such  as  agoraphobia, 
are  rare. 

The  mental  powers  are  somewhat  impaired.  The  power  of  persistent 
mental  application,  as  has  been  said,  is  diminished.  Attention  and  appre- 
hension are  weakened.  In  the  great  majority  of  cases  the  patient  is  incapable 
of  doing  anything  very  long ;  he  rarely  reads  for  more  than  a  few  minutes  at 
a  time,  and  does  not  care  to  listen  to  reading  much  more  than  that.  Few 
patients  read  over  one  hour  in  the  twenty-four,  and  that  not  consecutively. 
In  a  part  of  the  cases  this  is  due  to  the  fact  that  reading  tires  the  eyes  or  in- 
creases the  headache.  The  judgment  is  seldom  accurate ;  the  patient  can 
neither  think  nor  work  so  well,  but  the  memory  is  not  much  impaired.  Often, 
from  pain,  the  patient  may  demand  absolute  rest,  and  therefore  he  may  seem 
apathetic.  True  apathy,  however,  is  of  graver  significance,  and,  when  asso- 
ciated with  pronounced  loss  of  memory  and  actual  mental  imj^airment,  it 
points  to  more  marked  changes  in  the  brain. 

Emotional  distvirbances  are  common.  One  of  the  victims  of  a  railway 
accident,  whom  I  once  saw,  after  working  at  the  wreck  attending  the  injured, 
came  home  quietly,  told  his  story  calmly,  and  then  burst  into  tears — the  first 
manifestation  of  a  profound  psychical  shock.  Many  neurasthenics  are  prone 
to  shed  tears  wdien  any  unpleasant  or  distressing  subject  is  brought  to  their 
attention,  and  some  show  rapid  transitions  from  tears  to  laughter. 

One  of  the  gravest  and  most  distressing  symptoms  is  insomnia.  In  neuras- 
thenia from  physical  injury  it  is  less  severe,  but  in  neurasthenia  from  psychical 
shock  it  may  form  one  of  the  chief  subjects  of  complaint.  The  patient  dreads 
to  go  to  bed  at  all,  and,  although  sleepy,  he  cannot  get  to  sleep.  At  times 
the  insomnia  is  due  to  the  pain  which  comes  from  any  unguarded  movement ; 
at  other  times  it  is  due  to  extreme  restlessness  or  to  the  psychical  shock.  When 
sleep  comes  it  is  attended  with  bad  dreams,  often  referring  to  the  accident, 
but  always  of  a  distressing  character. 

Sensory  Symptoms.     One  of  the  chief  symptoms  of  traumatic  neuras- 


GENERAL  MORBID  STATES.  151 

theuia  is  pain.  The  pain  is  located  chiefly  in  the  back,  extending  thence  to 
the  head  or  other  parts  of  the  body.  In  non-traumatic  neurasthenia  the  pain 
is  most  frequently  situated  in  the  uj)per  part  of  the  spine  and  in  the  back 
of  the  head,  and  we  find  a  tender  region  between  the  shoulder-blades  or  even 
higher  up.  Spinal  rigidity  is  rare.  In  traumatic  neurasthenia,  however,  the 
chief  seat  of  pain  is  in  the  lumbar  region.  In  the  majority  of  cases  there  is 
traumatic  lumbago,  with  the  characteristics  already  described  ;  but  the  coex- 
istence of  neurasthenia  intensifies  all  the  symptoms.  The  pain  is  more  intense, 
and  often  shoots  all  over  the  body ;  neuralgia  is  a  common  complication  ;  the 
patient  may  describe  the  feelings  in  most  graphic  ways,  as  if  an  electric 
battery  were  moving  up  and  down,  as  if  the  spine  were  pulled  apart,  or  as  if 
a  red-hot  iron  were  thrust  into  it.  In  other  cases  the  pain  is  duller  and  of  a 
more  dragging  character.  In  a  few  cases,  especially  if  the  injury  be  higher  up 
on  the  spine,  the  pain  is  above  the  lumbar  region. 

In  addition  to  the  pain  there  is  pronounced  hypersesthesia.  The  vertebrae 
and  the  adjacent  parts  become  exceedingly  sensitive,  not  only  to  deep  pres- 
sure, but  also  to  a  light  touch.  Sometimes  the  sensitiveness  may  exist  only 
for  deep  pressure,  sometimes  only  for  touch.  Touching  or  pressing  the  tender 
part  is  usually  attended  by  an  increase  in  the  pulse-rate.  Headache  is  com- 
mon, and  is  increased  by  excitement  or  mental  application.  It  is  rather 
more  common  in  the  back  of  the  head,  the  "  pain  at  the  base  of  the  brain," 
and  often  is  of  great  severity.  The  pain  in  the  back  and  head  may  incaj^aci- 
tate  the  patient  for  days,  demanding  absolute  rest,  quiet,  and  darkness. 

Pains  in  other  parts  of  the  body  are  not  uncommon.  Many  of  them  are 
of  a  neuralgic  character.  If  there  have  been  a  blow  on  any  portion  of  the 
body,  this  region  is  apt  to  be  the  starting  point  of  pain. 

Hypersesthesia  is  another  common  sensory  disturbance.  The  hypersesthesia 
of  the  back  has  already  been  mentioned,  but  it  may  extend  over  the  whole 
body  or  over  definite  portions.  The  nervous  system,  responding  to  weak 
stimuli,  may  suffer  pain  from  conditions  that  would  hardly  be  noticed  in 
health.  Coarse  clothing,  rumpled  bedclothes,  hard  seats,  and  the  like,  may 
give  rise  to  actual  pain.  The  hypersesthesia  may  extend  to  the  special  senses ; 
strong  scents,  noises,  and  bright  lights  increase  the  headache  or  the  sense  of  dis- 
comfort. Parsesthesia  of  different  sorts,  tingling,  burning,  flushing,  crawling, 
and  the  like,  are  common.  Ansesthesia  does  not  occur.  If  we  find  any  form 
of  anaesthesia  we  may  conclude  that  there  is  some  more  serious  disturbance 
of .  the  nervous  system. 

Of  symptoms  referable  to  the  special  senses,  the  visual  disturbances  are  of 
the  greatest  importance.  It  may  be  said  of  these,  as  of  other  neurasthenic 
symptoms,  that  symptoms  of  deficit  are  not  often  met  with.  Asthenopia 
is  the  chief  trouble.  In  most  cases  central  vision  is  unimpaired  unless  there 
be  errors  of  refraction,  but  the  visual  power  is  soon  weakened,  and  it  may 
rapidly  fall  off"  if  the  tests  be  too  long  contiiuied.  The  condition  of  the 
visual  field  is  of  great  interest.  In  many  cases,  as  in  shown  in  Fig.  42,  it  is 
not  contracted  at  all.  Von  Hosslin^  thinks  it  is  usually  very  nearly  normal, 
and  that  the  retention  of  a  normal  visual  field  is  of  extreme  value  in  dis- 
tinguishing between  neurasthenia  and  hysteria.  It  is  a  tempting  hypothesis 
to  claim  that  a  contracted  field  shows  a  greater  disturbance  of  the  nervous 
system  and  a  more  profound  impairment  of  function.  It  is  certain,  too,  that 
symptoms  of  deficit  are  more  common  in  hysteria  than  in  neurasthenia,  and 
contraction  of  the  field  must  be  regarded  as  such  a  symptom ;  while  rapid 
exhaustion,  rather  than  deficit,  is  a  characteristic  of  neurasthenia.  Neverthe- 
less, Lowenfeld''  and  Wilbrand  and  Sanger  find  contracted  fields  in  neuras- 

'  Op.  cit.,  p.  117.  2  Neurasthenie  und  Hysterie,  p.  150. 


152 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


tlienia,  and  Fig.  43,  from  a  patient  who  presented  distinct  neurasthenic 
symptoms  without  other  hysterical  stigmata,  shows  a  distinct,  though  not  very 
great,  contraction  of  the  field. 


Fig.  42. 


Normal  visual  field  in  traumatic  neurasthenia.    (Personal  observation.) 
Fig.  43. 


0°    18(f 


Contracted  visual  field  in  traumatic  neurasthenia.    (Personal  observation.) 

Various  German  observers  (Forster,'  Konig,  Wilbrand  and  Sanger)  have, 
lately  called  attention  to  a  condition  often  observed  in  the  visual  field  of 
neurasthenics,  which  indicates  the  fatigue  which  is  so  ea.^ily  induced  in  these 
conditions.  If  the  field  be  tested  from  the  periphery  to  the  centre,  and  then 
outward  from  the  centre  to  the  periphery,  the  second  field  will  be  found  to  be 
the  smaller.  fShifting  type,  Verschiebuugst}';[)us.)  This  is  due  to  the  fact 
that  the  peripheral  portions  of  the  field  speedily  become  fatigued.  A  ready 
method  of  detecting  this  fatigue  of  the  peripheral  portions  of  the  field  has 
been  described  by  Wilbraud  and  Sanger.^  (Fig.  44.)  The  testing  object  is 
moved  along  the  horizontal  meridian  of  the  j^erimeter  from  the  temporal  side 
to  the  nasal.  At  0  the  object  first  appears  on  the  temporal  side,  and  at  1  it 
disappears  on  the  nasal  side.     It  is  at  once  moved  back  over  the  same  me- 


1  Wilbrand  und  Saenger,  op.  cit.,  p.  15. 


2  Op.  cit.,  p.  10. 


GENERAL  MORBID  STATES. 


lb[ 


ridian  to  the  temporal  side,  where  it  will  be  found  to  disappear  at  some  point 
nearer  the  centre,  as  2.  It  is  then  moved  back  in  the  same  way  to  the  nasal 
side,  when  it  disappears  at  3,  and  so  on.  Another  method,  described  by 
Forster,  has  been  called  by  Schiele'  the  diametral  method.     The  object  is 


Fig.  44. 


Ready  test  for  contraction  of  the  visual  field  from  fatigue.    (Wilerand.) 

moved  in  on  all  the  meridians  of  the  temporal  field,  across  to  the  nasal  field, 
and  the  points  of  appearance  and  disappearance  are  noted.  This  may  give  a 
field  similar  to  that  inclosed  by  the  unbroken  line  in  Fig.  46.  After  a  period 
of  rest  the  process  is  repeated  on  the  meridians  of  the  nasal  field,  and  a  field 

Fig.  45. 


Contraction  of  the  visual  field  from  fatigue.    Diametral  method.    (Wilbrand.) 

similar  to  that  inclosed  by  the  dotted  lines  may  be  observed.  The  limitation 
of  the  field  on  the  side  toward  which  the  object  is  moved  is  due,  of  course,  to 
the  speedy  exhaustion  of  the  retina.  Tests  made  in  these  various  Avays  thus 
afibrd  a  very  trustworthy  indication  of  the  easily  induced  fatigue  of  the 
retina.  It  is  needless  to  say  that  such  tests  require  the  use  of  the  perimeter. 
In  addition  to  these  sensory  symptoms  referable  to  the  eyes  there  are  also 

1  Arch.  f.  Augenheilk.,  xvi. 


154  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

certain  indications  of  motor  weakness.  On  closure  of  the  lids  it  may  often 
be  noted  that  the  closure  is  incomplete,  and  that  the  lids  constantly  quiver. 
The  pupils  are  often  large,  and  react  to  very  slight  stimuli ;  at  times,  when 
light  is  thrown  on  them,  they  contract  at  once  and  then  dilate  again,  even 
though  the  light  is  still  thrown  on  them,  contracting  and  dilating  by  turns. 
This  may  happen  independently  of  light  or  accommodation.  Where  there 
has  been  slight  hypermetropia  or  astigmatism,  compensated  by  the  muscles  of 
accommodation,  the  patient  will  complain  of  a  failure  of  vision,  due  to  the 
weakness  of  the  muscles  of  accommodation,  which  has  been  first  developed 
by  the  injury.  Insufficiency  of  some  of  the  external  muscles  of  the  eye,  espe- 
cially the  internal  recti,  may  also  be  noted,  but  there  is  never  any  paralysis. 

Aural  symptoms  are  less  pronounced.  The  chief  complaint  is  of  auditory 
hypersesthesia.  Even  the  slightest  noise  in  some  cases  seems  to  aggravate  the 
headache  and  the  various  pains,  while  loud,  sudden  noises,  such  as  the  slam- 
ming of  a  door,  prove  very  distressing.  Some  patients,  too,  are  peculiarly 
susceptible  to  sounds  of  a  certain  character.  One  man  under  my  observa- 
tion, who  was  much  disturbed  by  noise,  could  still  listen  to  music  of  a  certain 
character,  but  he  could  not  bear  to  hear  singing  by  a  soprano  voice,  or  to  sing 
himself  any  high  notes,  although  he  could  sing  and  enjoy  singing  in  the  lower 
register.  Baginsky^  has  found  that  perception  of  the  whispered  voice  and  of 
the  tuning-fork  was  diminished  in  some  cases,  and  that  the  sound  of  the  fork 
was  not  so  well  perceived  by  bone-conduction.  This  he  ascribes  to  a  central 
cause,  although  he  does  not  absolutely  exclude  labyrinthine  affections.  Dis- 
turbances of  smell  and  taste  have  also  been  noted,  chiefly  in  the  form  of 
hypereesthesia,  the  patient  being  much  disturbed  by  certain  odors  or  tastes. 

Motor  Symptoms.  The  motor  disturbances  of  neurasthenia  resemble  in 
many  respects  the  sensory.  Symptoms  of  absolute  deficit,  such  as  paralysis,  do 
not  occur,  but  symptoms  of  weakness  are  very  common.  In  traumatic  neu- 
rasthenia muscular  weakness  is  the  rule.  In  some  non-traumatic  cases,  where 
the  symptoms  are  chiefly  cerebral  (cerebrasthenia),  Lowenfeld  claims  that  the 
muscular  strength  may  be  unimpaired  ;  but  that  must  be  rare,  and  in  trau- 
matic cases  wholly  exceptional.  The  degree  of  muscular  weakness  may  vary 
greatly,  from  inability  to  walk  across  the  room  to  merely  an  impaired  power 
to  walk  long  distances.  The  gait  may  present  nothing  unusual,  unless,  as  is 
often  the  case,  there  be  also  a  traumatic  lumbago,  ■\^'llen  the  characteristic 
features  of  that  condition  are  added.  In  some  cases  the  condition  of  spinal 
tenderness  ("spinal  irritation"  of  old  writers)  may  lead  the  patient  to  take 
similar  precautions  against  sudden  movements  or  jars.  The  gait  may  be  slow, 
guarded,  feeble,  and  somewhat  uncertain  from  weakness,  but  there  is  no  true 
ataxia.  When  asked  to  stand  with  the  eyes  closed  and  the  feet  close  together 
it  may  be  noted,  first,  that  it  is  difficult  to  make  him  close  the  eyes  abso- 
lutely, and,  second,  that  there  may  be  considerable  swaying,  although  never 
so  pronounced  as  in  tabes. 

In  many  cases  there  is  manifestly  diminished  muscular  strength,  as  shown 
by  the  dynamometer,  but  in  other  cases  the  weakness  is  manifested  rather  by 
the  lack  of  endurance.  The  dynamometer  needle  can  be  forced  up  to  the 
average  point,  but  it  cannot  be  kept  there  long ;  the  patient  can  put  up  as 
heavy  a  dumb-bell  as  ever,  but  he  cannot  hold  it  up  as  long ;  if  the  curve 
of  muscular  work  be  taken  on  a  registering  apparatus  it  may  rise  nearly  as 
high,  but  it  will  fall  oflT  much  more  rapidly.  Oppenheim^  has  emphasized  a 
condition  which  must  have  often  been  noted  before,  and  which  is  not  uncom- 
mon, where,  although  the  patient  apparently  makes  a  profound  effort,  and 
calls  many  muscles  into  play,  the  effect  of  the  movement  is  but  slight.     It 

1  Lowenfeld,  op.  cit.,  p.  151.  -  Op.  cit.,  p.  148. 


GENERAL  MORBID  STATES  155 

often  suggests  the  attempt  to  make  a  brave  show  of  effort  without  accomplish- 
ing anything,  and  hence  it  is  erroneously  regarded  as  indicative  of  simulation, 
but  Oppenheim  rightly  regards  it  as  due  to  a  loss  of  memory  of  the  requisite 
division  of  motor  impulses  in  order  to  execute  a  given  movement. 

The  quivering  of  the  eyelids  has  already  been  mentioned.  In  some  cases 
we  may  also  note  a  fine  tremor  of  the  lips,  and,  more  especially,  of  the  hands. 
This  is  never  very  marked  in  ordinary  neurasthenia,  and  it  does  not  impair 
the  finer  movements  of  the  hands  very  materially.  It  may  show  itself  some- 
what in  the  handwriting,  and  it  is  then  more  marked  at  the  end  of  a  letter 
than  at  the  beginning. 

Reflexes.  As  might  naturally  be  expected  from  the  nature  of  neuras- 
thenia, the  reflex  activity,  as  a  rule,  is  everywhere  exaggerated.  This,  how- 
ever, is  less  noticeable  in  the  skin  reflexes  than  in  the  deep  reflexes ;  in  fact, 
the  former  are,  as  a  rule,  not  much  exaggerated.  The  exaggeration  of  the 
deep  reflexes  is  seen  most  markedly  in  the  knee-jerk.  Not  only  is  the  kick 
more  vigorous  when  tested  in  the  usual  way,  but  the  knee-jerk  may  be  elic- 
ited in  various  ways  not  usual  in  health.  Thus  a  movement  may  be  elicited 
by  striking  the  tendon  of  the  quadriceps  above  the  patella,  or  by  striking  the 
broad  upper  part  of  the  tibia.  If,  while  the  leg  is  extended  and  relaxed,  the 
finger  be  placed  over  the  upper  edge  of  the  patella  and  the  patella  be  drawn 
downward  toward  the  foot,  and  if  then  the  finger  be  struck  a  sharp  blow 
with  a  percussion  hammer  in  the  direction  of  the  traction,  a  twitch  of  the 
quadriceps  may  be  obtained  (patellar  twitch).  Gowers'  front-tap  contraction 
is  often  present,  but  a  true  patellar  or  ankle  clonus  is  not  found ;  on  testing 
for  them  the  muscles  may  respond  by  several  contractions,  but  not  by  persistent, 
rhythmical  clonus.  The  reflexes  never  diflTer  on  the  two  sides.  In  some  cases, 
especially  when  there  is  coexisting  traumatic  lumbago,  the  knee-jerk  has  the 
characteristics  already  described ;  it  is  short  and  quick,  and  the  excursion 
seems  suppressed ;  the  attempt  to  elicit  it  apparently  causes  pain,  probably 
from  the  slight  jar. 

Trophic  Disturbances  and  Electrical  Changes.  The  trophic  dis- 
turbances in  traumatic  neurasthenia  are  of  slight  importance.  The  chief 
change  to  be  noted  is  the  change  in  weight,  which  is  usually  dej^endent  upon 
the  condition  of  the  appetite  and  digestion.  Other  changes  seldom  occur. 
The  hair  may  fall  out  or  turn  gray,  the  skin  may  become  dry,  or  there  may 
be  profuse  sweating,  but  such  symptoms  are  rare. 

Changes  in  the  electrical  excitability  of  muscles  and  nerves  have  been  but 
little  studied.  Rumpf  ^  has  claimed  that  in  the  later  stages  of  some  of  the 
traumatic  affections  there  is  a  quantitative  reduction  in  the  galvanic  excita- 
bility of  motor  nerves,  kathodic  closure  contraction  requiring  a  current  of 
four  to  ten  milliamperes,  instead  of  one  or  two.  This  has  not  been  confirmed 
by  other  observers,  and  in  the  healthy  subject  I  have  frequently  found  that 
a  stronger  current  than  two  milliamperes  is  required  to  produce  contrac- 
tions. Rumpf  also  claimed  that  after  faradization  of  a  nerve  trunk  the 
contraction  was  followed  by  large  fascicular  and  fibrillary  contractions  last- 
ing several  seconds,  another  point  which  most  subsecjuent  oliservers  have 
failed  to  confirm.  If  this  be  true,  however,  it  is  of  some  value  as  indicating 
the  increased  irritability  of  the  nerve  trunks.'*  Mann  has  claimed  recently 
that  in  various  forms  of  "  functional "  brain  diseases,  including  neurasthenia 
and  the  so-called  traumatic  neuroses,  there  was  a  diminution  of  the  electrical 
resistance  of  the  head.  By  placing  a  large  electrode  (5  to  10  centimeters) 
on  the  back  of  the  neck  and  a  similar  one  on  the  forehead,  and  using  a  few 
cells,  he  found  that  normally  the  resistance  was  from  4000  to  6000  S.  E.,  but 

1  Deutsche  med.  Wochen.,  1890,  No.  9.  -  Berlin,  klin.  Wochenschr.,  1893. 


156  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

that  in  the  traumatic  neuroses  it  fell  to  1500  and  2500  S.  E.  Basile^  has  also 
found  similar  diminution  of  resistance  in  the  spinal  region  in  cases  of  so-called 
spinal  neurasthenia.  If  this  reduction  in  resistance  be  confirmed  it  may  per- 
haps be  explained  by  supposing  that  the  vasomotor  disturbances,  which  are  not 
uncommon,  have  given  rise  to  an  increased  cutaneous  blood-supply,  and  thus 
to  a  lessened  cutaneous  resistance.  Qualitative  changes  and  degenerative 
reactions  do  not  occur. 

Kespiratory  and  Circulatory  Disturbances.  The  respiratory  dis- 
turbances in  traumatic  neurasthenia  are  of  slight  consequence.  A  rapid 
respiration  and  slight  dyspnoea  on  exertion  are  very  common,  but,  as  a  rule, 
they  are  to  be  referred  to  cardiac  irregularities.  A  weakness  of  respiration 
associated  with  general  weakness  is  of  course  common.  This  may  manifest 
itself  in  the  voice,  which  is  often  low  and  feeble,  conversation  requiring  much 
efiort,  and  occasionally  being  attended  with  sighing  or  gasping  for  breath.  In 
one  of  my  own  cases,  where  neurasthenic  symptoms  were  prominent,  there 
was  a  curious  gasp  or  sob  in  the  breath  as  the  patient  spoke,  a  catch,  as  if 
the  effort  caused  great  pain,  yet  really  not  due  to  pain.  Such  spasmodic 
respiratory  disturbances  however,  are  rare. 

The  circulatory  disturbances  are  of  great  importance,  and,  as  has  been 
noted  in  the  section  on  pathology,  they  probably  have  some  bearing  on  the 
nature  of  the  affection.  One  of  the  striking  features  of  traumatic  neuras- 
thenia is  the  rapidity  of  the  pulse.  In  twenty-five  cases  it  ranged  from  72  to 
140,  the  average  rate  being  95,  and  in  only  three  cases  did  it  fall  below  80.  In 
many  cases  the  pulse  is  weak,  irregular,  or  intermittent.  Any  slight  exertion 
or  excitement  will  send  it  up  to  150  or  more.  This  rapidity  of  pulse  is  not 
the  temporary  quickening  often  seen  in  nervous  patients  from  dread  of  an 
examination  or  fear  of  detection  of  simulation ;  such  a  quickening  is  merely 
a  transitory  affair,  and  very  soon  subsides ;  but  the  increased  rapidity  in  trau- 
matic neurasthenia  is  permanent  and  is  to  be  found  on  repeated  examinations. 
In  a  few  cases,  after  this  rapidity  has  continued  for  a  year  or  more,  it  has 
been  observed  that  hypertrophy  and  dilatation  of  the  heart  set  in  and  that 
insufiiciency  of  the  valves  developed  with  the  visual  symptoms  (Oppenheim). 

Various  subjective  symptoms  may  be  referred  to  the  heart.  Palpitation, 
shortness  of  breath,  pain  in  the  prsecordium,  and  the  feelings  of  distress  that 
so  often  accompany  nervous  disturbances  of  the  heart,  are  common.  At  times 
this  distress  may  increase  to  severe  paroxysms  of  cardiac  anxiety,  but  this  is, 
in  my  experience,  rare.  Oppenheim  has  noted  arterio-sclerosis  in  a  number 
of  cases,  and  this  has  been  found  by  Kronthal  in  the  two  autopsies  already 
cited. 

Symptoms  of  defective  or  irregular  circulation  are  also  frequent.  The 
extremities  are  cold,  and  it  may  be  harder  to  keep  the  patient  comfortably 
warm.  At  times  the  skin  may  be  so  congested  as  to  be  quite  cyanotic,  and 
Kriege^  has  noted  symj)toms  of  Raynaud's  disease.  In  addition  to  this, 
patients  often  complain  of  flashes  of  heat,  flushings,  congested  feelings,  rush 
of  blood  to  the  head,  etc.  Slight  irritation  may  lead  to  persistent  redness  of 
the  skin.  Occasionally  there  may  be  profuse  perspiration,  so  that  the  ex- 
tremities are  cold  and  clammy. 

Digestive  Disturbances.  Digestive  disturbances  are  common,  but  they 
seldom  dominate  the  picture.  The  commonest  symptom,  as  in  other  forms 
of  neurasthenia,  is  more  or  less  loss  of  appetite.  This  is  often  due  in  part  to 
an  absolute  disinclination  for  food,  and  in  part  to  a  dread  of  the  distress 
which  the  ingestion  of  food  may  cause.  In  a  few  cases  there  is  inability  to 
retain  any  solid  food,  and  the  patient  is  obliged  to  live  on  small  amounts  of 

1  Neurol.  Central.,  1884,  p.  118.  -  Arch,  of  Psych,  xxii,  241. 


GENERAL  MORBID  STATES.  157 

some  prepared  liquid  food,  such  as  beef  extracts  or  partly  digested  milk. 
lu  other  cases  the  stomach  can  retain  food  fairly  well,  but  there  is  consider- 
able distress  after  eating,  a  sensation  of  a  weight  in  the  stomach,  gastric 
pains,  eructations,  flatulence,  or  occasionally  pyrosis.  Partly  from  muscular 
weakness,  partly  from  inactivity,  constipation  is  not  infrequent ;  in  a  few 
cases  there  may  be  nervous  diarrhosa.  As  a  result  of  the  diminished  amount 
of  food  and  the  imperfect  digestion  the  bodily  nutrition  not  infrequently 
suffers. 

Urinary  Symptoms.  There  is  rarely  any  disturbance  either  of  the  urine 
or  of  micturition  in  uncomplicated  neurasthenia.  Many  patients  complain 
either  of  an  imperative  need  of  making  water  as  soon  as  the  desire  comes,  or 
of  slowness  or  Aveakness  in  emptying  the  bladder.  In  most  cases  this  is  due 
to  a  complicating  lumbago.  General  weakness  may  lead  to  some  enfeeble- 
ment  of  the  stream  and  perhaps  to  a  slightly  imperfect  expulsion  ;  there  may 
be  a  slight  dribbling  after  the  act,  but  there  is  never  any  real  retention  or 
incontinence. 

The  urine  itself  shows  few  changes.  In  rare  cases  the  amount  may  be 
increased  or  the  need  of  passing  it  may  be  more  frec^uent.  Hyperacidity, 
phosphaturia  and  oxaluria  have  been  noted  by  some  writers,  but  their 
significance  is  not  great.  Glycosuria  is  rare,  but  it  has  been  observed  by 
Eisenlohr  and  Oppenheim.'  Albuminuria  is  also  a  rare  symptom  which 
has  occasionally  been  noted.  Transitory  albuminuria  may  occur  in  health, 
as  is  well  known,  but  a  permanent  albuminuria,  unless  it  be  due  to  some 
foreign  cause,  such  as  coexisting  nephritis,  would  probably  exist  only  in 
those  cases  where  there  is  passive  congestion  of  the  kidney  from  the  enfeebled 
heart — at  least  such  was  the  probable  explanation  in  the  only  case  in  my 
own  experience  where  albuminuria  occurred. 

Sexual  Symptoms.  In  the  majority  of  the  cases  of  traumatic  nervous 
disease  where  there  is  any  claim  for  damages  much  stress  is  usually  laid  upon 
the  impairment  of  the  sexual  functions.  For  obvious  reasons,  the  sexual 
power  cannot  well  be  tested  by  the  examining  physician,  and  we  can  decide 
definitely  as  to  permanent  impotence  only  where  there  are  definite  symptoms 
of  disease  of  the  spinal  cord  destroying  or  inhibiting  the  sexual  centre.  The 
sexual  power,  however,  is  influenced  greatly  by  the  physical  condition  and 
by  many  psychical  causes,  so  that  it  might  well  be  expected,  when  such 
etiological  factors  are  present  as  have  been  mentioned  above,  and  when  the 
general  health  is  suffering  from  any  form  of  disease,  that  the  sexual  power 
would  be  lost  or  else  much  impaired.  This  loss  or  impairment,  however,  is 
not  necessarily  permanent,  and  unless  there  be  a  cord  lesion  it  will  usually 
disappear  with  the  restoration  to  health. 

In  traumatic  neurasthenia  the  disturbance  of  the  sexual  function  is  also 
manifested,  as  might  be  expected,  by  symptoms  of  irritable  weakness  and  of 
exhaustion.  In  the  milder  cases  one  may  see  too  frequent  pollutions  or 
premature  ejaculation;  but,  as  a  rule,  there  is  a  distinct  failure  of  power; 
desire  is  usually  much  impaired,  and,  as  a  rule,  desire  and  power  both  dis- 
appear entirely. 

In  women  disturbances  of  menstruation  are  not  uncommon.  The  physical 
concussion  in  any  traumatic  case  may  lead  to  local  disturbances,  especially 
uterine  disj^lacements,  or  in  pregnant  women  it  may  cause  abortion.  Such 
disturbances  in  themselves  may  give  much  trouble  and  may  aggravate  the 
condition.  In  other  cases,  owing  to  the  general  hyperesthesia,  there  may  be 
increased  pain  at  the  menstrual  period  and,  not  infrequently,  great  irregu- 
larity in  the  occurence  of  the  function.     There  may  be  a  cessation  of  the 

1  Op.  cit.  p.  174. 


158  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

menses  for  several  months,  or  proftise  flowing  at  the  periods.  It  must  be 
borne  in  mind  that  an  injury  may  start  up  troublesome  symptoms  from  a  pre- 
existing uterine  fibroid  that  previously  has  been  unnoticed.  In  other  cases 
menstruation  is  unaffected,  and  conception,  pregnancy  and  parturition  may 
go  on  normally. 

TBAUMATIC    HYSTERIA. 

As  StriimpelP  has  shown,  hysteria  must  be  reckoned  as  a  more  advanced 
stage  in  the  j^rocess  of  disintegration  of  the  nervous  system  than  neuras- 
thenia, although  not  necessarily  so  grave  a  condition.  It  is  characterized  by 
more  profound  symptoms  :  where  neurasthenia  shows  only  a  weakness  hysteria 
may  show  an  absolute  deficit,  as  in  paralysis ;  where  neurasthenia  may  show  an 
increasing  motor  excitability,  hysteria  may  show  distinct  motor  discharges,  as 
in  convulsions.  There  is,  however,  no  distinct  line  of  division  between  the 
cases.  In  the  majority  of  neurasthenics  we  may  note  the  emotional  instability 
once  thought  characteristic  of  hysteria,  and  in  any  collection  of  cases  we  find 
that  the  boundary  between  the  two  morbid  states  cannot  be  distinctly  drawn. 
Neurasthenic  symptoms  are  often  to  be  found  in  cases  that  present  distinct 
symptoms  of  hysteria.  This  is  not  to  be  wondered  at,  for  neither  neuras- 
thenia nor  hysteria  can  be  regarded  as  definite  diseases,  but  rather  as  morbid 
states  of  the  nervous  system,  due  chiefly  to  cerebral  disturbances,  and 
generally  considered  to  be  chiefly  mental  affections. 

The  essential  characteristics  of  neurasthenia  have  already  been  mentioned. 
The  definition  of  hysteria  is  much  less  easy.  It  is  something  more  than  a 
disease  of  representation  or  ideation,  or  of  reduplication  of  personality  or  of 
limitation  of  the  field  of  consciousness.  Perhaps  the  best  definition  is  that 
recently  elaborated  by  Janet  :'■*  "  Hysteria  is  a  mental  disease  belonging  to 
the  considerable  group  of  diseases  of  degeneracy ;  it  has  only  very  vague 
physical  symptoms,  consisting  especially  in  a  general  diminution  of  nutrition  ; 
it  is  characterized  especially  by  moral  symptoms,  the  chief  symptom  being  an 
enfeeblement  of  the  faculty  of  psychological  synthesis,  a  limitation  of  the  field 
of  consciousness.  A  certain  number  of  elementary  phenomena,  sensations 
and  images,  cease  to  be  perceived  and  seem  suppressed  from  personal  per- 
ception ;  these  constitute  the  stigmata.  From  this  there  follows  a  tendency  to 
the  permanent  and  complete  division  of  personality,  to  the  formation  of 
several  groups  of  phenomena  independent  of  one  another.  These  symptoms 
of  psychological  facts  alternate  with  one  another  or  coexist,  which  gives 
rise  to  attacks,  somnambulism,  or  unconscious  acts.  In  short,  this  defect  of 
synthesis  favors  the  formation  of  certain  parasitic  ideas  which  are  completely 
developed  independently  of  the  control  of  personal  consciousness,  and  are 
manifested  by  the  most  varied  disturbances,  apparently  purely  physical — that 
is  to  say,  they  are  manifested  by  hysterical  attacks." 

It  will  be  seen  that  Charcot's  theory,  mentioned  above — that  traumatic 
hysteria  is  developed  by  auto-suggestion,  the  patient  being  in  a  somnambulic 
state,  a  theory  afterward  made  more  general  by  Moebius,^  who  held  that 
hysteria  was  a  disease  of  representation,  is  applicable  to  only  a  part  of  the 
phenomena.  Janet,  Jolly,*  Oppenheim,^  and  others  have  shown  that  beside 
the  fixed  ideas  which  may  well  give  rise  to  certain  symptoms,  there  are  other 
conditions  which  demand  some  other  explanation,  such  as  the  symptoms 
which  persist  when  the  subject  no  longer  thinks  of  them,  the  attacks,  som- 
nambulism, etc. 

1  Spec.  Pathologie  u.  Therapie  ;  seventh  edition.  2  gtat  mental  des  hysteriques. 

3  Centralb.  fur  Nervenheilkunde,  Feb.,  1888. 

*  Berlin,  kl.  Wochenschr.,  1892,  No.  34.  6  charite  Annalen.  1889. 


GENERAL  MORBID  STATES.  159 

Hysteria  is  distinctly  less  common  in  America  than  it  is  in  France.  The 
pronounced  stigmata,  hemianjesthesia,  contraction  of  the  visual  field,  etc.,  are 
not  very  common  in  the  clinics  for  nervous  diseases  in  this  country  with 
which  I  have  been  familiar,  except  among  the  Russian  and  Polish  Jews,  and 
the  typical  attacks  of  grand  hysteria  are  distinctly  rare.  Traumatic  hysteria 
is  relatively  more  common.  About  twenty  per  cent,  of  all  cases  of  traumatic 
nervous  disease  of  which  I  have  record  have  been  classed  as  hysterical,  but 
this  is  a  very  liberal  percentage,  as  many  doubtful  cases  have  been  included. 

Heredity  seems,  in  the  cases  that  have  come  under  my  own  observation, 
to  be  of  less  importance  in  the  etiology  of  traumatic  hysteria  than  in  the 
idiopathic  forms,  but  Bataille,'  Charcot  and  others  have  laid  much  stress 
upon  an  hereditary  taint.  Dana'^  has  found  traumatic  hysteria  to  be  less 
common  in  women  than  in  men.  Such  has  not  been  my  own  experience. 
Thirteen  out  of  twenty-five  cases  of  traumatic  hysteria  under  my  own  obser- 
vation occurred  among  women,  yet,  as  I  have  said  before,  less  than  one-third 
of  all  cases  of  traumatic  nervous  disease  that  I  have  seen  have  been  women. 

In  the  majority  of  cases  of  traumatic  hysteria  other  symptoms  have  been 
noted,  such  as  have  already  been  described  as  neurasthenic — headache,  back- 
ache, insomnia,  depression,  a  rapid  pulse,  dyspepsia,  nervousness,  irritability 
and  incapacity  for  protracted  effort.  To  these  are  added  the  special  stigmata 
of  hysteria.  In  other  words,  we  rarely  meet  with  hysteria  of  a  pure  type, 
it  is  usually  combined  with  neurasthenic  symptoms — hystero-neurasthenia. 

The  mental  symptoms  of  traumatic  hysteria  differ  considerably  from  those 
of  ordinary  hysteria.  The  old  ideas  that  the  hysterical  patient  is  a  deliber- 
ate, conscious  liar,  simulator  and  poseur  can  no  longer  be  admitted.  The 
apparently  voluntary  theatrical  demonstrations,  exaggerations  and  misstate- 
ments have  been  shown  to  be  merely  the  results  of  unconscious  suggestion, 
often  arising  from  hallucinations,  and  as  little  blameworthy  as  the  delusions 
of  the  paranoiac.  The  characteristic  feature  of  the  hysterical  mind  is  its 
exaggerated  suggestibility ;  to  the  suggestions  that  arise  from  other  people  or 
from  the  patient's  own  dreams,  to  hallucinations  and  morbid  ideas  in  general, 
may  be  traced  many  of  the  phenomena  presented  by  the  hysterical,  esj^ecially 
the  ideas  and  actions  which,  in  old  times,  were  attributed  to  demoniacal 
possession,  and  in  our  day  are  still  too  often  regarded  as  affectations  or  false- 
hoods. 

In  traumatic  hysteria,  however,  the  suggestibility,  the  modifications  of 
personality,  the  exaggeration  of  the  ego,  the  posing,  and  the  divisions  of  jDcr- 
sonality,  catalepsy,  trance,  double  consciousness,  and  the  like,  seldom  pre- 
dominate. As  has  already  been  said,  the  great  majority  of  cases  are  associated 
with  neurasthenia,  and,  as  Charcot^  has  shown,  the  mental  symptoms  of 
neurasthenia  are  the  first  to  show  themselves,  especially  in  the  male,  and  they 
may  remain  dominant  throughout.  Charcot  speaks  of  this  step  as  a  "  period 
of  neurasthenic  preparation."*  We  note  the  irritability,  the  depression,  the 
aversion  to  society,  the  introspection,  the  hesitancy,  the  inability  for  pro- 
tracted mental  effort,  and  the  occasional  emotional  instability,  already 
described.  The  insomnia  and  the  bad  dreams  also  exist.  Later  on,  but 
comparatively  rarely,  however,  the  hallucinations  of  hysteria  may  become 
manifest. 

From  the  clinical  point  of  view,  the  hysterical  stigmata  are  of  the  first 
importance  in  the  diagnosis  of  hysteria  and  in  differentiating  it  from  neuras- 
thenia and  other  conditions,  so  that  they  must  be  first  described. 

Sensory  Stigmata.     Anxesthesia.     Anaesthesia  in  some  form  is  one  of 

1  Traumatisme  et  Nevropathie.  2  System  of  Legal  Medicine,  ii.,  335. 

3  Lecons  du  Mardl,  1888-18S9, 

*  Gilles  de  la  Tourette.    Traite  de  I'hysterie,  p.  548. 


160 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  commonest  stigmata  of  hysteria.  Tactile  sensibility  is  most  frequently 
impaired.  The  tactile  sensibility  is  most  easily  tested  by  touching  the 
skin  lightly  with  the  finger-tip  or  a  camel's-hair  brush,  the  patient's  eyes 
being  blindfolded  or  closed  by  the  thumb  and  finger  of  the  examiner's 
other  hand.  The  various  sesthesiometers,  which  try  to  show  at  what  distance 
the  patient  can  distinguish  two  points  from  one,  have  comparatively  little 
value.  The  degree  of  anaesthesia  may  vary  greatly.  In  a  fatal  case  of 
hystero-neurasthenia  with  hemianaesthesia  the  patient  could  distinguish  the 
lightest  touch  on  the  anaesthetic  side ;  but  it  was  not  felt  so  distinctly  as  on 
the  other  side.  There  are  all  varieties  between  this  and  anaesthesia  so  abso- 
lute that  the  patient  can  feel  no  sort  of  sensory  stimulus,  not  even  the  stimu- 
lus of  the  strongest  faradic  current  conveyed  through  a  single  needle-pointed 
electrode. 

Fig.  46. 


Hysterical 


Hemianaesthesia,  with  hyperalgesic  zones.    (Personal  observation.) 


The  distribution  of  the  anaesthesia  may  vary  very  greath^  General  anaes- 
thesia as  a  permanent  stigma  is  very  rare,  Briquet'  finding  it  only  four 
times  in  two  hundred  and  forty  cases.  The  commonest  form,  in  my  experi- 
ence, is  hemianaesthesia,  which  may  be  complete  or  partial  (Figs.  46  and  47). 
As  a  rule,  hemianaesthesia  is  sharply  limited  at  the  meridian  line,  but  the 
boundary  may  be  a  little  to  one  side.  Briquet  regards  the  disseminated 
islets  of  anaesthesia,  of  which  a  remarkable  specimen  is  shown  in  Fig.  48,  as 
the  commonest  form ;  but  I  have  rarely  encountered  it,  either  in  traumatic 
or  non-traumatic  cases.  A  fourth  form  is  the  geometrical  anaesthesia  (Fig. 
49),  which  may  involve  various  segments  of  the  body,  covering  them  like  a 
stocking,  a  glove,  a  sleeve,  or  a  helmet.  This  distribution  of  anaesthesia  has 
been  shown  by  Charcot  and  Horsley''^  to  be  characteristic  of  cortical  anaes- 
thesia, and  in  hysteria  we  never  find  anaesthesia  limited  to  the  distribution  of 
any  special  nerve  or  sets  of  nerves. 


1  Gilles  de  la  Tourette.    Op.  cit.,  p.  126. 


Trans.  Am.  Cong.  Phys.  Surg.,  1888 


GENERAL  MORBID  STATES. 


161 


Head'  has  recently  attempted  to  divide  hysteria  into  two  forms,  a  psychical 
form,  Avhere  the  anaesthesia  follows  natural  lines,  as  in  the  geometrical  an^es- 


FlG.  47 


Islets  of  ^^  Anaesthesia.    (Pitres.) 


1  Brain,  svi  ,  1. 
U 


162 


NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 


thesia  already  described,  and  the  cerebro-spinal  form,  ^here  the  pain  and 
temperature  senses  especially  are  lost  in  the  early  stages  in  areas  correspond- 
ing to  the  spinal  segmentation.  In  the  psychical  form  the  skin  reflexes  are 
retained,  and  the  visual  field  contracted.  In  the  cerebro-spinal  form  the 
reverse  occurs.  This  latter  form  Head  considers  to  have  a  worse  prognosis, 
and  to  be  more  likelv  to  be  confused  vrith  disseminated  sclerosis. 


Geometrical 


Anaesthesia.    (Personal  observation.) 


The  an&esthesia  may  be  of  var^dng  extent.  In  some  cases  the  deeper  parts 
are  involved,  and  the  anaesthesia  extends  to  the  mucous  membranes ;  there  is 
a  loss  of  sensibility  to  all  forras  of  stimulation,  pain,  temperature,  etc.,  and 
the  sensibility  of  the  muscles  and  joints  is  impaired.  In  other  cases  there  is 
anaesthesia  only  to  certain  forms  of  stimuli — partial  or  dissociated  anaesthesia. 
The  commonest  form  of  partial  anaesthesia  that  I  have  noted  has  been  the 
loss  of  sensibility  to  pain  (analgesia),  the  sensibility  to  touch  remaining 
normal.  There  may  also  be  a  loss  of  sensibility  to  temperature  ( thermo- 
ansesthesia ),  or  loss  of  sensibility  to  electricity — electro-anesthesia,  which  is 
merely  a  form  of  analgesia.  In  fact,  analgesia  may  be  estimated  more 
exactly  by  placing  a  wire  brush,  or,  better,  Erb's  sensory  electrode,  to 
different  parts  of  the  skin,  applying  the  faradic  current,  and  noting  the 
coil  distance  at  which  the  first  sensation  of  pain  appears.  Analgesia  may, 
however,  be  most  readily  determined  by  pricking  with  a  pin.  Thermo- 
aneesthesia  may  be  tested  by  tubes  filled  with  warm  and  cold  water,  or  by 
metal  cylinders  warmed  and  cooled.  Goldscheider'  has  given  very  elaborate 
methods  for  testing  the  temperature  sense,  Avhich,  however,  demand  much 
time  and  patience.     His  tests,  however,  may  be  of  use  in  doubtiiil  cases. 

These  various  forms  of  sensory  disturbance  are  apt  to  be  pretty  constant, 
but  thev  iliav  suddenlv  chana-e,  and  thev  mav  he  modified  in  various  wavs. 


Archiv  f.  Psrch.,  xviii. 


GENERAL  MORBID  STATES. 


163 


In  cases  of  liemian^estliesia,  for  instance,  the  anesthesia  may  be  transferred 
to  the  other  side  of  the  body  by  the  application  of  a  magnet  or  of  certain 
metals.  It  is  probable,  however,  that  this  transfer  is  due  solely  to  sug- 
gestion, for  recent  researches  have  cast  grave  doubts  on  the  possibility  of 
any  influence  being  exerted  by  these  agents  where  suggestion  was  absolutely 
excluded. 

In  many  of  the  forms  of  hysterical  anaesthesia  the  special  senses  may  also 
be  involved.  In  hemiansesthesia  it  is  not  unusual  to  have  a  loss  of  taste  on 
the  corresj)onding  half  of  the  tongue,  of  smell  in  the  corresponding  nostril, 
of  hearing  in  the  corresponding  ear,  and  of  vision  in  the  corresponding  eye. 
In  hysterical  deafiiess,  which  may  be  of  varying  intensity,  it  has  been  found 
that,  as  might  have  been  expected,  the  trouble  was  of  central  origin,  as 
indicated  by  Rinne's  test.  In  this  test  the  tuning-fork,  which  has  been 
made  to  vibrate,  is  placed  upon  the  mastoid.  When  the  patient  no  longer 
hears  the  sound  it  is  moved  in  front  of  the  ear.  In  deafness  of  central 
origin  the  sound  is  heard  again  when  conducted  through  the  air ;  but  in 
deafness  from  disease  of  the  middle  or  external  ear  it  is  heard  longer  by  bone- 
conduction. 

The  most  important  disturbance  of  the  special  senses  is  that  of  vision. 
After  excluding  the  cases  of  impairment  of  vision,  Avhere  there  are  errors  of 
refraction,  there  are  some  cases  Avhere  there  is  complete  amaurosis,  usually  in 
the  eye  on  the  ansesthetic  side.  In  the  majority  of  cases,  however,  there  is 
not  complete  amaurosis,  but  a  concentric  limitation  of  the  visual  field,  often 
most  marked  on  the  anaesthetic  side  (Fig.  50).     In  the  cases  that  have  come 

Fig.  50. 


,30°  150 


Irregular  contraction  of  the  visual  field  in  one  eye  in  traumatic  hj-steria.    (Personal  observation.) 


under  my  own  observation  this  limitation  of  the  field  has  not  been  very 
great,  but  in  some  cases  it  is  extreme,  as  shown  in  Fig.  51.  With  the  con- 
traction of  the  field  may  often  be  noted  a  change  in  the  relation  of  the  color 
fields.  Normally,  the  area  in  which  blue  can  be  detected  is  the  greater ;  red 
next,  and  green  the  smallest.  These  fields  may  also  be  contracted,  and  the 
field  for  red,  for  instance,  may  be  greater  than  that  for  blue.  The  percep- 
tion of  certain  colors  may  be  impaired  (dyschromatopsia),  or  the  perception 
of  color  may  be  wholly  lost  (achromatopsia). 

It  is  a  matter  of  great  importance,  in  view  of  the  frequent  claims  that  the 
patient  is  a  malingerer,  to  bear  in  mind  that  these  sensory  disturbances  of 
hysteria,  the  anaesthesia  and  the  amaurosis,  are  purely  psychical  in  character, 


164 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


and  that,  in  sjDite  of  the  actual  inabilit}^  of  the  patient  to  feel  or  to  see,  it 
can  be  demonstrated  that  she  actually  does  feel  and  see.  Pitres'  has  shown 
quite  conclusively  that  hysterical  amaurosis  exists  only  on  vision  with  the 
affected  eye.  If,  for  example,  the  left  eye  be  blind  and  a  screen  be  placed 
vertically  between  the  two  eyes  parallel  to  the  axis  of  vision,  the  patient, 
with  the  right  eye  closed,  sees  nothing ;  and,  with  the  left  eye  closed,  reads 
letters  only  on  the  right  of  the  screen  ;  but,  with  both  eyes  open,  she  may 
read  the  letters  across  the  page,  including  those  to  the  left  of  the  screen, 
which  could  be  seen  only  by  the  left  eye.  Janet^  has  also  shown  by  some 
interesting  experiments,  confirmed  in  this  country  by  Prince,^  and  by  my  own 
observation,  that  in  cutaneous  anaesthesia  the  patient  actually  feels  a  touch. 
If  the  auEesthetic  part  be  touched  or  pricked  while  the  patient  is  blindfolded 

Fig.  51. 


Marked  contraction  of  both  visual  fields  in  hysteria.    (Gilles  de  la  Tourette.) 

she  does  not  feel  it ;  but  if,  later,  the  patient  be  hypnotized,  or  if  her  "  hidden 
self"  be  cjuestioned  by  means  of  automatic  writing,  she  will  repeat  accurately 
where,  and  how  many  times,  she  was  touched.  One  of  my  own  patients  with 
a  marked  diminution  of  color-sense  in  one  eye  saw  colors  plainly  with  that 
eye  when  a  prism  was  used  in  such  a  way  as  to  give  crossed  images.  The 
right  eye  being  affected,  she  saw  the  colors  of  the  left-hand  image  correctly, 
although  actually  seen  with  the  right  eye.  In  the  same  case,  with  complex 
ansesthesia  and  loss  of  muscular-sense  in  one  hand,  the  patient  could  still 
wink  and  grasp  my  hand  with  her  hand  when  her  eyes  were  closed.  Such 
cases  are  of  much  importance  in  the  study  of  the  nature  of  hysteria,  but  they 
are  also  of  great  importance  as  proving  the  great  liability  to  error  of  those 
who,  ignorant  of  hysterical  peculiarities,  are  prone  to  find  simulation  in  every 
case. 

It  is  important  to  determine  whether  the  definite  sharply-defined  anaesthesia, 
either  in  the  form  of  hemianaesthesia  or  geometrical  anaesthesia,  is  pathogno- 
monic of  hysteria.  It  is  beyond  a  doubt  that  in  the  great  majority  of  cases 
where  we  find  such  a  distribution,  especially  if  associated  Avith  contracted 
visual  fields,  the  case  is  hysteria ;  but  the  researches  of  Thonxsen  and  Oppen- 
heim*  have  yet  to  be  contradicted,  and  they  have  found  that  hemiauaesthesia 
may  occur  in  other  affections.  Contracted  visual  fields  are  not  always  due  to 
hysteria.  They  are  seen  in  the  early  stages  of  optic  atrophy  and  in  various 
nervous  afifections. 


1  Larsons  clin.  sur  I'hysterie,  i.,  193. 

8  Bos-ton  Medical  and  Surgical  Journal. 


2  L'Automatisme  psychologique. 
*  Arch.  f.  Psych.,  xv. 


GENERAL  MORBID  STATES. 


165 


Hypercesthesia.  H}']3ersestliesia,  or,  to  speak  more  correctly,  hyperalgesia, 
since  there  is  usually  increased  sensitiveness  to  pain  rather  than  an  in- 
creased sensitiveness  to  touch,  is  not  uncommon.  In  some  cases  it  may 
take  the  place  of  anaesthesia,  and  may  be  distributed  in  the  same  way,  but 
it  is  more  commonly  limited  to  certain  regions.  If  the  injury  has  implicated 
any  special  region  it  may  exist  in  that  region,  and  it  may  exaggerate  or 
prolong  the  tenderness  due  to  the  local  disturbances  caused  by  the  physical 
injury.  It  is  thus  often  seen  in  the  hysterical  joint  affections,  which  will  be 
described  later.  In  other  cases  the  hyperesthesia  develops  spontaneously, 
and  is  manifested  with  some  constancy  in  certain  regions,  forming  the  so-called 
hyperaesthetic  zones.  Of  the  relation  of  these  zones  to  hysterical  attacks  I 
will  speak  later.  The  most  constant  seat  of  the  zones  is  in  the  ovarian  region 
(Charcot's  "ovarie"),  but  they  are  not  uncommon  in  the  epigastrium,  over 
the  vertebrae,  near  the  breast,  and  occasionally  elsewhere.  Fig.  46  shows 
their  distribution  in  one  case.  Another  important  form  of  hypersesthesia  is 
the  well-known  clavus  or  localized  intense  pain  in  hysterical  headache.  The 
tenderness  over  the  vertebrae  is  allied  to  the  "  irritable  spine"  of  neurasthenia, 
and  it  may  also  be  associated  with  traumatic  lumbago.  The  reality  of  the 
hypersesthesia  may  often  be  demonstrated  by  the  increase  in  the  frequency  of 
the  puLse  when  pressure  is  applied.  In  some  instances  a  light  touch  seems  to 
produce  more  pain  than  deep  pressure.  Pitres^  has  described  a  rare  symptom, 
haphalgesia,  where  the  contact  of  certain  metals  caused  great  pain. 

Motor  Symptoms.  Paralysis.  In  traumatic  hysteria  absolute  paralysis 
is  less  common  than  anaesthesia.  Muscular  weakness,  however,  similar  to  that 
described  in  neurasthenia,  and  local  paresis,  is  not  uncommon.  The  distribu- 
tion of  the  paralysis  may  vary  very  greatly. 
In  traumatic  cases  hemiplegia  and  monoplegia 
are  the  commonest  forms.  It  is  character- 
istic of  hysterical  hemiplegia  that  the  leg  is 
dragged  stiffly  up  to  the  sound  leg,  instead 
of  being  circumducted,  as  in  hemiplegia,  from 
cerebral  hemorrhage  (Fig.  52).  The  face  is 
not  involved,  but  a  spasm  of  the  muscles  on 
the  other  side  of  the  face  may  suggest  facial 
paralysis.  In  the  same  way  there  may  appar- 
ently be  in  rare  cases  a  paralysis  of  the  sixth 
nerve,  or  external  ophthalmoplegia ;  but  Gilles 
de  la  Tourette,^  on  careful  analysis,  has  shown 
that  in  most  of  these  cases  the  trouble  is  not 
a  real  paralysis,  but  a  spasm.  It  is  of  impor- 
tance to  note  here  that  in  these  apparent 
oculo-motor  paralyses  the  voluntary  move- 
ments only  are  affected,  the  eye  moving  nor- 
mally in  unconscious  movements. 

It  is  a  valuable  diagnostic  feature  in  hyster- 
ical pax'alysis  when  the  paralysis  is  also  asso- 
ciated with  anaesthesia.    The  paralysis  may  be      ^  .,   ^        ..    ,    .,,  .  ,.    , 

„         .  -  .  -r  11  Gait  of  a  patient  with  traumatic  bys- 

tiaccid  or  spastic.     In  rare  cases,  as  has  been  ^^^^^^  hemiplegia.   (Personal  observa- 

noted  by  various  French  observers,  there  may  tion.) 

be  muscular  atrophy  with  the  paralysis,  not 

merely  the  atrophy  of  disuse,  but  also  atrophy  with  electrical  changes. 

Hysterical  paralysis  is  never  limited  to  the  distriljution  of  a  single  nerve ; 
but,  like  all  cerebral  paralyses,  it  affects  definite  movements  or  groups  of 


Fig.  52. 


1  Op.  cit.,  i.,  65. 


2  Op.  cit.,  p.  415. 


166  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

movements.  It  may  attack  a  limb  in  segmental  fashion,  like  ansesthesia,  or 
it  may  affect  only  certain  movements.  Bremer^  has  reported  a  case  of  hys- 
terical astasia-abasia  attributed  to  a  very  slight  accident.  The  patient  in 
such  cases  can  move  the  limbs  perfectly  well  while  in  bed,  with  good  strength 
and  good  co-ordination,  but  he  is  wholly  unable  to  stand  or  walk.  In  some 
cases,  while  unable  to  walk,  patients  can  hop  on  one  foot,  or  walk  with  a 
tragic  stride,  or  in  some  pecviliar  way. 

Contractions.  Hysterical  contractions  are  often  associated  with  paralysis, 
but,  except  in  the  hysterical  joints,  they  are  not  common  in  traumatic  cases. 
French  writers  describe,  as  not  uncommon,  the  "  diathesis  of  contracture," 
where  a  comparatively  slight  irritation  (a  bandage,  a  blow  on  the  muscle  or 
nerve,  the  application  of  the  faradic  current,  the  magnet,  or  metals)  may 
produce  a  pronounced  contraction  of  the  limb.  Such  a  condition,  however, 
is  distinctly  rare  in  hysteria  as  seen  in  this  country.  When  contracture 
occurs  it  is  apt  to  be  well-marked,  unlike  the  very  slight  rigidity  on  passive 
movement  sometimes  seen  in  the  early  stages  of  hemiplegia. 

Tremor.  It  is  only  in  comparatively  recent  years  that  tremor  has  been 
recognized  as  an  important  symptom  in  hysteria,  but  Charcot'  has  shown  that 
it  is  common  in  men,  and  more  especially  in  hysteria  of  traumatic  origin. 
The  tremor  may  be  persistent  or  paroxysmal,  general  or  localized,  slight  or 
pronounced,  and  of  variable  rhythm.  DutiP  has,  in  fact  classified  them 
according  to  the  rapidity  of  the  rhythm,  but  Charcot  classifies  them  accord- 
ing to  the  character  of  the  tremor.  Tremors  which  are  exaggerated  by 
voluntary  movements  may  be  slow  (three  to  six  a  second)  or  rapid  (eight  to 
nine  or  more  a  second).  The  former  often  resembles  the  tremor  of  senility 
or  of  paralysis  agitans ;  the  latter  is  like  the  tremor  of  exophthalmic  goitre, 
or  alcoholism.  Another  class  of  tremors  may  or  may  not  exist  during  repose, 
but  they  are  true  intention  tremors,  movement  increasing  the  amplitude  of 
the  vibrations  rather  than  their  rapidity ;  this  resembles  the  tremor  of  dis- 
seminated sclerosis  and  of  mercurial  poisoning.  In  the  cases  of  hysterical 
tremor  that  have  come  under  my  own  observation  this  seems  to  be  the  com- 
monest form.  It  is  sometimes  seen  associated  with  paralysis,  in  the  para- 
lyzed limb. 

Spasm.  In  addition  to  the  contractures  and  tremors  not  uncommon  in 
hysteria,  we  may  also  note  various  forms  of  spasm  in  the  traumatic  cases  as 
well  as  the  non-traumatic  forms — the  various  forms  of  tic,  the  anomalous 
choreic  movements,  which  have  been  described  as  electric,  rhythmic,  and 
saltatory  chorea,  saltatoiy  reflex  spasm,  paramyoclonus  multiplex,  and  the 
like.  These  conditions,  however,  are  distinctly  rare  in  traumatic  hysteria, 
and  do  not  differ  from  similar  conditions  in  non-traumatic  hysteria,  which  is 
described  in  detail  in  Chapter  III. 

The  Hysterical  Attack.  The  sti-iking  feature  of  the  hysterical  attack 
is  the  spasmodic  seizure,  which  may  assume  the  form  of  the  severe  hyster- 
ical convulsion  with  its  classical  stages  of  epileptiform  convulsions,  con- 
tortions and  grand  movements,  plastic  poses  and  passionate  attitudes  and 
delirium.  Motor  spasm,  however,  is  not  an  essential  feature  of  the  attack. 
In  the  broadest  sense  the  hysterical  attack  may  inckide  the  paroxysms  of 
laughing  and  crying,  the  spasmodic  coughs  and  other  respiratory  disturb- 
ances, attacks  of  vertigo,  cardiac  anxiety,  and  the  like.  The  ordinary  con- 
vulsive attack  seldom  manifests  the  various  periods  of  the  grand  attack.  It 
is  often  preceded  by  some  irritability,  and  it  may  manifest  itself  after  some 
emotional  disturbance.     The  attack  is  often  preceded  by  unpleasant  sensa- 

1  Journal  of  Nervous  and  Mental  Disease,  January,  1893. 

2  Progr^s  med.,  1889, 1890.  3  Nouv.  Icon,  de  la  Salpetrifere,  1890, 1891. 


GENERAL  MORBID  STATES.  167 

tions,  such  as  palpitation,  headache,  vertigo,  gastric  distress,  or  the  familiar 
globus ;  and  it  may  be  of  varying  intensity,  from  a  slight  weakness  or  faint 
feeling  with  tremor,  up  to  a  pronounced  convulsion  with  exaggerated  and 
disturbed  movements.  In  the  majority  of  cases  there  is  probably  some  slight 
clouding  of  consciousness,  which  may  go  on  to  absolute  loss  of  consciousness. 
The  classical  attack  is  extremely  rare  in  this  country  in  any  form  of  hysteria, 
and  the  attack  in  any  form  plays  a  very  subordinate  part  in  traumatic  hys- 
teria. Charcot  and  other  French  observers  have  noted  the  severe  attacks, 
with  pronounced  convulsions,  the  arc  du  cercle,  and  similar  manifestations 
in  a  number  of  cases.  Pitres'  found  the  attack  less  common  in  male  hysteria, 
occurring  in  only  seven  out  of  thirty-one  cases,  while  of  sixty-nine  women 
fifty-six  had  attacks.  In  the  cases  of  traumatic  hysteria  seen  in  this  country, 
however,  I  have  never  found  the  classical  attack  with  its  four  periods,  nor 
even  the  severe  convulsion,  and  in  less  than  ten  per  cent,  of  the  cases  of 
hysteria  was  there  anything  that  could  be  regarded  as  even  a  mild  attack. 

The  relation  of  the  attacks  to  the  so-called  zones  is  extremely  interesting. 
In  many  cases  it  has  been  found  that  pressure  over  certain  regions  is  sufiicient 
to  give  rise  to  an  attack,  and  these  regions  are  called  hysterogenous  zones. 
These  zones  are  apt  to  correspond  with  the  hypersesthetic  areas  already  de- 
scribed, and  their  most  common  seat  is  in  the  ovarian  region,  over  the  spine, 
under  the  breasts,  and  in  the  epigastrium.  Fig.  46,  although  showing  merely 
hypersesthetic  areas  and  not  hysterogenous  zones,  shows  the  favorite  location 
of  these  zones.  Charcot  long  ago  demonstrated  that  pressure  over  the  ova- 
rian region  might  also  cut  short  an  hysterical  convulsion.  Further  research 
has  shown  that  there  may  be  various  " hystero-frenic  zones"  in  other  parts  of 
the  body,  but  they  are  less  often  seen  than  hysterogenous  zones.  In  trau- 
matic hysteria  in  this  country  such  zones  are  rare,  and  pressure  on  the  hyper- 
sesthetic areas  has  in  no  case  under  my  own  observation  produced  any  symp- 
toms except  those  indicative  of  pain,  such  as  an  increase  in  the  pulse,  faint- 
ness,  sweating,  flushing,  etc. 

Hysterical  Joint  Affections.  The  hysterical  joint  affections,  first  de- 
scribed by  Brodie,'''  are  usually  of  traumatic  origin.  They  seem  rather  less 
common  than  other  forms  of  traumatic  hysteria,  and  are  much  more  common 
in  women  than  in  men.  Out  of  seventy  cases  rejDorted  by  Charcot,^  the  knee 
was  affected  in  over  one-half,  and  the  hip  in  over  one-fourth.  The  striking 
symptom  of  an  hysterical  joint  affection  is  pain,  which  may  be  severe  when 
the  joint  is  at  rest,  and  always  becomes  severe  on  any  attempt  to  move  the 
joint,  and  also  on  any  pressure  about  the  joint.  The  pain  may  be  confined 
to  the  joint,  or  it  may  extend  to  parts  above  and  below.  In  addition  to  the 
pain  there  is  often  pronounced  hyperalgesia,  sometimes  being  very  marked  in 
the  skin  covering  the  joint,  and  sometimes  extending  to  the  soft  parts  sur- 
rounding it.  This  tenderness  is  usually  much  greater  than  the  tenderness  of 
the  joint  itself;  the  ends  of  the  bones  may  be  pressed  together  with  much 
less  pain  than  is  caused  by  handling  the  soft  parts.  In  some  cases  the  hyper- 
algesic  region  may  be  bounded  by  an  ansesthetic  area.  With  the  pain  and 
tenderness  comes  disability.  The  patient  cannot  move  the  joint  on  account 
of  pain,  and  with  the  pain  there  is  often  weakness.  The  tenderness  on  motion 
gives  rise  to  a  reflex  spasm,  so  that  there  is  often  a  pronounced  contraction  of 
the  muscles  about  the  joint ;  in  the  hip,  for  instance,  we  may  observe  an  ap- 
parent contraction,  with  adduction  and  rotation  inwards.  In  rare  cases  there 
may  be  some  muscular  atrophy.     In  a  few  cases  the  joint  may  be  swollen. 

It  is  probable  that  in  many  cases  of  hysterical  joint  affection  there  is  at 

1  Op.  cit.,  i.,  207.  2  Lectures  Illustrative  of  Certain  Local  Affections. 

3  Legons  sur  les  maladies  du  systeme  nerveux,  iii.,  370. 


168  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

first  some  trifling  lesion  in  or  about  the  joint  which  gives  rise  to  pain.  As 
any  attempt  at  moving  the  joint  gives  rise  to  pain,  the  ideas  of  motion  and 
pain  become  so  firmly  associated  that  finally  the  idea  of  motion  may  be  suf- 
ficient to  give  rise  to  the  idea  of  pain,  even  after  the  physical  source  of  pain 
has  disapjjeared.  Prince^  has  shown  that,  by  introducing  the  idea  of  some 
unusual  motion  in  the  joint,  the  new  motion,  which  has  never  been  associated 
with  any  idea  of  pain,  may  be  performed  without  pain,  and  that  thus  the 
morbid  association  may  gradually  be  broken  up. 

Hysterical  joint  afiections  are  apt  to  be  obstinate,  and  they  may  last  for 
years.  Casas  that  recover  may  suffer  from  relapses.  The  diagnosis  must  de- 
pend on  the  presence  of  other  hysterical  symptoms,  the  absence  of  swelling, 
the  character  of  the  pain  and  tenderness,  and  the  influence  of  psychical 
factors.  Charcot  has  claimed  that  antesthesia  by  ether  or  chloroform  will  at 
once  cause  the  rigidity  and  contraction  to  disappear,  and  that  this  is  a  valu- 
able diagnostic  criterion,  but  it  must  be  remembered  that  anesthesia  will  also 
cause  the  contraction  and  rigidity  to  disappear  in  the  early  stages  of  actual 
arthritis,  although  they  persist  in  the  later  stages,  so  that  the  distinction  is  by 
no  means  absolute. 

Reflexes.  The  examination  of  the  reflexes  in  traumatic  hysteria  usually 
gives  valuable  confirmatory  evidence  of  the  conditions  existing.  Where 
there  is  ansesthe-ia  the  skin  reflexes  are  either  diminished  or  wholly  absent  in 
the  anaesthetic  region,  even  in  cases  which  in  other  respects  correspond  to  the 
"psychical  form"  of  hysteria  described  by  Head.  The  tendon  reflexes  are, 
as  a  rule,  exaggerated,  as  they  are  in  neurasthenia.  In  the  majority  of  cases 
of  hysterical  paralysis,  and  occasionally  in  simple  anaesthesia,  the  reflexes  are 
greater  in  the  affected  part,  but  in  a  few  instances  of  hysterical  hemiplegia 
they  have  been  found  more  marked  on  the  unaffected  side.  The  loss  of  the 
pharyngeal  reflex  is  often  noted,  and  it  is  important  in  diagnosis. 

The  other  symptoms  of  traumatic  hysteria  are  of  less  importance.  Trophic 
disturbances  are  not  very  common.  Muscular  atrophy  may  be  associated 
with  hysterical  paralysis  or  with  the  joint  affections,  usually  the  simple 
atrophy  from  disuse,  but,  more  rarely,  a  degenerative  atrophy  with  the  de- 
generative reactions.  The  electrical  changes  mentioned  under  neurasthenia, 
as  described  by  Rumpf  and  others,  apply  to  hysteria  as  well  as  to  neuras- 
thenia, but  their  value,  as  has  been  said,  is  still  uncertain.  (Edema,  includ- 
ing the  "  blue  oedema  "  described  by  Charcot,  and  various  cutaneous  changes 
may  occur  in  traumatic  hysteria ;  but  they  are  rare,  and  do  not  differ  ft-om 
similar  conditions  observed  in  the  non-traumatic  form.  In  one  case  the  hair 
over  a  limited  area  on  the  scalp  which  had  been  the  seat  of  severe  pain 
began  to  grow  out  white,  and  when  the  patient  came  under  my  obsei-vation 
about  an  inch  at  the  root  of  the  hair  was  white,  the  rest  of  the  hair  being 
dark.  It  became  entirely  white,  and  then  turned  back  to  the  natural  color 
in  the  same  way. 

Respiratory  and  circulatory  disturbances  resemble  those  of  neurasthenia 
ah'eady  described.  In  one  case,  observed  by  one  of  my  colleagues,  there  was 
extremely  rapid  respiration,  120  to  180  a  minute.  This  persisted  for  some 
time,  and  then  was  temporarily  cured  after  praying  in  a  certain  church. 
The  rapid  pulse  and  the  circulatory  weakness  are  very  common. 

The  digestive  disturbances  in  traumatic  hysteria  are  also  like  those  of  neur- 
asthenia. The  typical  hysterical  anorexia  and  A'omiting  are  rarely  seen,  but 
the  loss  of  appetite  may  be  great,  and  in  a  few  cases  the  stomach  can  retain 
but  little  food. 

We  seldom  see  the  anuria  or  polyuria  so  often  descrilied  and  occasionally 

1  Journ.  Xerv.  and  Ment.  Dis.,  May,  1S91 


GENERAL  MORBID  STATES.  1G9 

met  with  in  uou-traumatic  hysteria.  As  a  rule  the  urinary  symptoms  are 
similar  to  those  described  in  neurasthenia,  and  are  of  comparatively  slight 
significance.  Gilles  de  la  Tourette  and  Cathelineau^  have  found  in  non-trau- 
matic hysteria  without  attacks  that  the  urine  was  normal  as  to  amount  and 
solid  constituents.  After  an  attack,  however,  the  amount  of  urine  passed  in 
the  next  twenty-four  hours  is  not  increased,  but  somewhat  diminished,  the 
solid  constituents  (urea  and  phosphates)  are  one-third  diminished,  and  rela- 
tion between  the  earthy  and  alkaline  phosphates,  which  is  normally  one  to 
three,  rises  from  one  to  two,  or  even  to  equality. 


THE   "TRAUMATIC  NEUROSES." 

In  view  of  the  great  prominence  which  this  term  has  recently  acquired  in 
all  discussions  of  the  subject  since  the  publication  of  Oppenheim's  mono- 
graph, it  is  necessary  to  devote  a  brief  space  to  a  consideration  of  it. 

Striimpell  '■  states  that  in  a  part  of  the  cases  the  trauma  has  merely  a  local 
action,  and  the  nervous  symptoms  which  result  from  it  are  also  localized  in 
the  arm,  the  leg,  etc.  For  such  cases  he  uses  the  term  "  local  traumatic  neu- 
rosis." Under  this  head  he  classes  the  local  hypersesthesias,  anaesthesias, 
paralyses,  contractures,  and  the  hysterical  joint  affections,  excluding,  of 
course,  any  affections  due  to  material  lesions  of  the  peri23heral  nerves.  As 
Striimpell  himself  admits  that  these  cases  are  all  local  manifestations  of 
hysteria,  which  is,  of  course,  a  general  disease,  the  justification  of  the  term 
seems  questionable. 

It  is  somewhat  different  with  the  "  general  traumatic  neuroses"  which  he 
describes,  and  which  have  been  more  fully  studied  by  Oppenheim.^  Accord- 
ing to  the  latter,  nervous  symptoms  may  develop  either  immediately  after  an 
injury  or  after  an  interval  of  some  weeks  or  months.  The  earliest  symptoms 
are  usually  subjective  in  character ;  pain,  especially  at  the  seat  of  injury,  and 
often  increased  on  motion  ;  irritability,  anxiety,  and  timorousness.  Later  on 
the  mental  symptoms  increase  until  the  patient  falls  into  an  hypochondriacal- 
melancholic  state,  with  anxiety  and  abnormal  irritability.  This  is  often  ac- 
companied by  insomnia.  The  intelligence  is  usually  not  much  impaired,  but 
it  may  be  considerably  affected.  Vertigo  and  faintness  are  common,  and 
convulsive  seizures  and  other  sj)asmodic  conditions  may  occur.  Tremor  is 
oftezi  seen,  and  other  conditions,  such  as  convulsive  tic,  muscular  spasms, 
chorea,  reflex  epilepsy,  etc.,  sometimes  develop. 

Motion  is  often  affected.  This  may  be  due  in  part  to  the  inhibiting  in- 
fluence of  pain,  but  there  is  generally  an  actual  paresis.  The  paresis  .may 
take  a  generalized  form,  or  the  form  of  hemiplegia,  paraplegia,  or  monoplegia. 
Paralyses  limited  to  a  given  nerve  distribution  are  never  seen.  The  paralysis 
usually  differs  in  some  respects  from  paralysis  from  gross  lesions.  There  may 
be  an  increased  tension  of  the  muscles,  but  this  differs  from  the  contractures 
following  gross  lesions.  The  tendon  reflexes  are  often  exaggerated,  but  never 
absent.  Muscular  atroi:)hy  and  degenerative  reactions  are  rare.  Paralysis  of 
any  individual  cranial  nerve  is  almost  never  met  with,  but  motions  which  de- 
mand the  harmonious  activity  of  different  muscular  groups  are  often  impaired. 
The  speech  may  be  affected,  but  the  affection  is  more  akin  to  stuttering ; 
aphasia  and  simple  disturbances  of  articulation  are  never  seen.  The  pu})ils 
may  be  unequal,  but  they  are  rarely  immobile. 

Sensory  disturbances  are  common,  but  they  never  follow  the  disti'ibution 
of  the  peripheral  nerves  or  of  the  spinal  segments,  and  they  are  often  asso- 

1  La  nutrition  dans  I'hystSrie.  -  Berliner  klin.,  No.  3.  s  Op.  cit. 


170  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ciated  with  disturbances  of  the  special  senses,  especially  with  contraction  of 
the  field  of  vision. 

Vasomotor  disturbances  are  very  common.  The  vesical  functions  are 
usually  not  much  impaired,  but  there  may  be  retention  or  incontinence. 
There  is  usually  loss  of  sexual  power.  The  skin  reflexes  may  be  increased, 
but  they  are  usually  diminished  or  lost,  especially  in  the  anaesthetic  areas. 

The  heart  is  very  often  abnormally  excitable,  and  this  may  rarely  lead  to 
disease  of  the  heart,  dilatation,  and  valvular  insufficiency.  These  conditions, 
however,  do  not  differ  very  materially  from  those  already  described  in  the 
preceding  sections,  or  in  the  sections  to  follow.  Striimpell  considers  that  the 
traumatic  neuroses  are  chiefly  hysteria  and  neurasthenia,  or  the  mixed  form, 
hystero-neurasthenia,  but  he  considers  that  trauma  often  gives  them  a  some- 
what distinct  type,  and  he  retains  the  word  as  a  convenient  term.  Oppen- 
heim  also  admits  frankly  that  there  may  be  a  pure  traumatic  hysteria,  a  pure 
traumatic  neurasthenia,  but  that  there  are  mixed  forms,  hystero-neurasthenia, 
often  complicated  with  other  neuroses  and  psychoses,  and  that  there  are  also 
obscure  affections  due  to  more  material  changes  in  the  central  nervous  sys- 
tem. For  all  these,  therefore,  he  would  employ  the  term  traumatic  neuroses 
as  a  convenient,  although  not  strictly  definite  term. 

Other  writers  since  then,  with  less  knowledge,  have  adopted  the  term  and 
have  come  to  regard  traumatic  neurosis  almost  as  a  distinct  disease,  like 
exophthalmic  goitre.  This  must  be  regarded  as  a  mistake.  Others  still  have 
objected  so  strongly  to  the  use  of  the  term  that  there  has  arisen  a  mass  of 
controversial  literature  on  the  subject,  with  the  rather  unfortunate  result  of 
weakening  Oppenheim's  position  as  to  the  genuineness  and  severity  of  the 
affections.  Just  as  some  men  thought  that,  by  proving  that  there  was  no 
spinal  concussion,  they  could  disprove  the  existence  of  all  these  affections,  so 
others,  by  showing  that  there  was  no  "traumatic  neurosis,"  have  slighted  the 
real  troubles.  Upon  the  Avhole,  the  introduction  of  the  term  has  had  a  bad 
influence.  It  has  tended  to  check  the  differentiation  of  the  various  obscure 
traumatic  nervous  affections,  and  it  has  substituted  a  general  term  for  particu- 
lar terms,  which  always  leads  to  confusion.  Hysteria,  neurasthenia,  chorea, 
neuralgia,  epilepsy,  might  all  be  classed  as  neuroses,  and  they  all  may  at  times 
be  of  traumatic  origin,  but  it  is  better  to  employ  the  more  precise  terms  when- 
ever possible.  It  is  often  very  difficult  to  say  whether  a  case  is  to  be  regarded 
as  neurasthenia,  hysteria,  or  some  form  of  cerebral  or  spinal  sclerosis  ;  as  we 
have  ah'eady  seen,  the  transition  forms  between  hysteria  and  neurasthenia  are 
frequent,  but,  whenever  possible,  the  more  precise  classifications  should  be 
employed. 

TRAUMATIC    SCLEROSIS. 

In  the  section  on  pathology  I  have  given  the  anatomical  evidence  upon 
which  the  claim  that  some  of  these  obscure  traumatic  affections  are  due  to  defi- 
nite structural  changes  in  the  central  nervous  system  rests.  From  that  section 
it  will  be  seen  that  the  evidence  is  still  very  slight.  We  must  admit  that  in 
traumatic  epilepsy  the  injury  probably  produces  a  neuroglia  sclei'osis ;  in 
some  cases  injuries  may  give  rise  to  certain  lesions  in  the  spinal  cord,  either 
subacute  myelitis  or  degenerative  areas,  chiefly  in  the  lateral  columns. 

It  is  also  generally  accepted  that  trauma  may  give  rise  to  definite  structural 
changes  from  direct  violence,  contusion,  or  crushing  of  the  nervous  tissues, 
hemorrhage ,  sand  even  infectious  proceses,  with  no  discoverable  cutaneous 
wound.  In  various  germ  diseases  the  injury  may  make  the  part  a  place  of 
diminished  resistance,  and  it  may  then  become  a  favorite  seat  for  develop- 
ment of  the  infectious  process. 


GENERAL  MORBID  STATES.  171 

The  majority  of  authors,  furthermore,  admit  trauma  as  one  of  the  causes 
of  various  degenerative  processes  and  of  tumor  formations.  The  evidence  of 
this  is  somewhat  obscure,  owing  to  the  fact  of  the  very  insidious  development 
of  the  degenerative  diseases,  the  possibilitj^  of  their  previous  unsuspected  exist- 
ence, and  of  other  undiscovered  etiological  factors,  and  the  like ;  but,  never- 
theless, cases  of  disseminated  sclerosis,  diffuse  myelitis,  progressive  spinal 
muscular  atrophy,  tabes,  and  new^  growths  are  reported  by  the  best  observers, 
w^here  trauma  seems  to  form  the  only  cause. 

Notwithstanding  the  unsatisfactory  character  of  the  pathological  evidence 
there  are  a  good  many  cases,  some  of  them  resulting  fatally,  where  the  symp- 
toms do  not  fall  under  the  rubric  of  neurasthenia  or  hysteria.  These  cases 
point  to  a  general  disturbance  in  the  cerebro-spinal  system,  and  occasionally 
they  present  symptoms  which  are  usually  regarded  as  due  to  more  definite 
structural  changes  in  the  nervous  system  than  we  expect  to  find  in  hysteria 
or  neurasthenia.  Out  of  one  hundred  and  nine  cases  coming  under  my  own 
observation,  t-sventy-three  have  been  considered  to  be  due  to  such  conditions. 
The  symptoms,  as  wall  be  seen  from  what  follow^s,  resemble  very  much  the 
symptoms  in  the  affections  previously  described,  but  the  condition  is  much 
more  serious,  and  in  many  cases  other  symptoms  are  added  which  resemble 
those  of  disseminated  sclerosis.  Dana,'  who  describes  these  cases  under  the 
term  of  the  grave  traumatic  neurosis,  inclines  to  a  belief  that  there  are  definite 
structural  changes  in  the  central  nervous  system,  but  he  admits  wdth  justice 
that  it  is  impossible  to  draw'  the  line  sharply  betw'een  them  and  the  cases  of 
neurasthenia  and  hysteria. 

In  the  etiology  of  theses  cases  the  psychical  factor  is  less  prominent,  but 
the  physical  factor  dominates,  and  the  physical  concussion  often  outweighs 
any  possibilities  of  suggestion.  In  one  case  resulting  fatally,  after  a  period 
of  a  number  of  months,  a  man  was  caught  in  machinery  and  received  phy- 
sical injuries  sufficient  to  break  several  small  bones  ;  a  woman  was  dragged 
in  a  railway  collision,  her  head  and  back  bumping  over  the  sleepers ;  she  re- 
ceived injuries  which  resulted  fatally  after  a  period  of  twenty-one  months  ; 
another  man,  while  on  a  railway  train,  was  struck  by  a  bridge,  the  blow  in- 
flicting a  severe  scalp  wound  and  causing  unconsciousness  for  a  number  of 
hours.  In  other  cases  the  physical  force  of  the  action  was  so  great  as  to 
cause  loss  of  consciousness. 

The  symptoms  are  usually  of  gradual  onset,  unless  there  be  an  initial 
period  of  unconsciousness.  One  of  the  most  constant  symptoms,  especially 
with  injuries  involving  the  head,  is  headache.  This  is  constant,  not  usually 
very  severe,  but  occasionally  exhibiting  paroxysms  of  more  intense  pain. 
The  pain  is  often  localized  at  the  seat  of  the  injury,  and  it  may  be  associated 
with  local  hjiDcrsesthesia  and  tenderness.  If  not  at  the  seat  of  the  injury  it 
is  apt  to  be  frontal  or  vertical ;  we  seldom  see  the  intense  "  pain  at  the  base 
of  the  brain  "  shooting  down  the  back  of  the  neck  and  spine.  With  the 
headache  there  is  often  vertigo,  and  in  some  cases  of  injury  to  the  head  the 
headache  and  vertigo  form  the  chief  symptoms. 

The  mental  symptoms  are  usually  pronounced.  The  patient  is  dull  and 
apathetic.  He  takes  little  interest  in  what  is  going  on  about  him  or  even  in 
his  owai  affairs.  If  a  claim  for  damages  be  pending  he  even  takes  little  in- 
terest in  that ;  he  sits  listlessly  about,  unable  to  occupy  himself  in  any  way  ; 
he  is  incapable  of  any  process  of  mental  effort ;  his  powers  of  attention  and 
apprehension  are  slight ;  his  memory  is  very  poor  ;  he  objects  to  any  inter- 
ference ;  is  morose,  silent  and  depressed.  His  friends  note  a  profound  change 
in   his   character.     The   nervousness,    excitability,  and  introspectiveness  of 

1  System  of  Legal  Medicine,  ii.,  331. 


172 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


neurasthenia  are  conspicuous  by  their  absence.  Actual  delusions  and  hallu- 
cinations are  rare.  The  sleep  is  usually  very  poor  and  is  broken  by  bad 
dreams,  especialiy  by  dreams  of  impending  disaster. 

With  regard  to  the  special  senses,  the  smell  and  taste  are  often  blunted  and 
sometimes  lost.  Auditory  symptoms  are  not  very  important.  Tinnitus  is  a 
common  symptom,  and  the  hearing  may  be  diminished,  with  symptoms  indi- 
cating a  lesion  in  the  labyrinth  or  nerve.  Schultze^  thinks  that  symptoms 
of  Meniei'e's  disease  are  common.  Only  in  one  case  have  I  noted  absolute 
deafaess  of  probable  nervous  origin.  The  ocular  symptoms  are  of  much 
greater  importance.  Strabismus  is  rare,  but  nystagmus  is  more  common. 
Inequality  of  the  pupils  sometimes  occurs,  and  in  several  cases  I  have  noted 
thej  irritability  of  the  pupils  to  light.  Dilatation  and  contraction  of  the 
pupils  are  rare.  Diplopia  has  been  complained  of  by  a  number  of  patients, 
and  in  one  of  my  own  cases  which  terminated  fatally  there  was  monocular 
diplopia,  which  is  more  often  an  hysterial  symptom,  and  which  I  have  also 
noted  in  traumatic  neurasthenia.  Failure  of  vision  is  not  an  uncommon 
symptom,  sometimes  with  no  errors  of  refraction  and  no  change  in  the  frmdus. 
A  few  cases  are  on  record  where  there  was  optic  atrophy,  but  none  have  come 
under  my  own  observation.  In  a  considerable  number  of  cases  there  has 
been  a  peripheral  contraction  of  the  field  of  vision,  usually  not  of  a  very 
high  degree,  as  shown  in  Fig.  53. 

Fig  53. 


Contraction  of  the  visual  field  in  traumatic  sclerosis.    (Personal  observation.) 

Sensory  Symptoms.  Sensory  disturbances  are  common  in  this  class  of 
affections,  but  they  are  by  no  means  constant.  In  some  cases  the  most  care- 
fiil  tests  wall  reveal  nothing,  except,  perhaps,  local  tenderness  at  the  seat  of 
the  injury  or  in  the  back,  where  it  is  often  due  to  a  complicating  traumatic 
lumbago.  More  fi'equently  there  is  a  distinct  loss  of  sensibility.  This  takes 
the  form  of  diminished  tactile  sensibility,  but  the  sensibility  to  pain  and 
temperature  and  the  muscular  senses  may  also  be  involved.  A  diminution 
of  sensibility  to  pain  and  temperature,  with  normal  tactile  sensibility,  is 
rare ;  it  probably  occurs  only  in  hysteria  and  in  certain  cord  affections  simu- 
lating syringomyelia,  as  in  hemorrhage  about  the  central  canal.  The  dimi- 
nution of  sensibility  does  not  usually  amount  to  absolute  anaesthesia,  and  it 
seldom  has  the  distributions  described  under  hysterical  anaesthesia.  There 
is  usually  a  pretty  general  hypo-sesthesia,  which  is  most  marked  in  the  legs. 


1  Art.  cit. 


GENERAL  MORBID  STATES.  173 

but  it  does  not  follow  the  distribution  of  augesthesias  from  lesions  of  the  spinal 
segments.  There  is  seldom  any  definite  line  of  division  between  the  hypo- 
sesthesia  and  the  normally  sensitive  parts,  but  they  shade  into  each  other 
very  gradually.  The  head  is  seldom  involved.  This  form  of  anaesthesia  is  of 
interest  with  reference  to  Head's  views  as  to  a  cerebro-spinal  type  of  hysteria, 
which  may  be  akin  to  disseminated  sclerosis,  but  it  does  not  strictly  corre- 
spond to  the  anaesthesia  that  he  describes. 

Motor  Symptoms.  Oculo-motor  symptoms  have  already  been  described. 
Paralysis  is  rarely  seen,  and,  when  met  with,  it  is  indicative  of  some  focal 
lesion  of  the  brain  or  cord.  Ordinarily  there  is  a  general  motor  weakness,  not 
amounting  to  definite  paralysis,  but  involving  both  arms  and  legs.  The  gait 
is  usually  slow  and  feeble,  and  has  often  the  characteristic  features  which 
complicating  lumbago  may  give  to  it.  It  is  also  not  infrequently  uncertain, 
and  the  patient  may  stagger  somewhat,  but  there  is  no  real  ataxia  or  spas- 
ticity. When  the  patient  stands  with  the  eyes  closed  there  is  often  a  pro- 
nounced swaying.  The  arms  are  weak,  the  grip,  perhaps,  not  exceeding  ten 
kilogrammes ;  all  movements  are  slow,  difficult,  and  uncertain,  and  there  is 
often  a  distinct  tremor  of  the  hands,  which  in  some  instances  may  amount  to 
a  pronounced  intention  tremor.  This  tremor  may  show  itself  very  markedly 
in  the  handwriting,  Fig  54.  The  movements  of  the  face  are  seldom  affected, 
but  a  fibrillary  tremor  of  the  lips  and  tongue  is  quite  common. 

Fig.  54. 


Handwriting  of  patient  with  traumatic  sclerosis  before  and  after  the  injury,  showing  intention 
tremor.    (Personal  observation.) 

Convulsive  conditions  are  seldom  seen.  If  convulsive  attacks  or  tempo- 
rary lapses  of  consciousness  occur,  they  point  to  a  neuroglia  sclerosis,  and  the 
case  must  be  regarded  as  one  of  traumatic  epilepsy.  Such  cases  are  consid- 
ered in  another  chapter.     They  are  to  be  distinguished  from  hysterical  attacks. 

Muscular  atrophy  and  electrical  changes  seldom  occur  ;  occasionally  there 
is  some  general  wasting,  but  not  a  degenerative  atrophy. 

Reflexes.  The  skin  reflexes  are  diminished  when  there  is  anaesthesia, 
but  only  in  the  ansesthetic  region.  The  tendon  reflexes  vary ;  most  com- 
monly they  are  exaggerated,  in  rare  cases  even  to  the  production  of  clonus, 
but  occasionally  they  may  be  absent. 

Other  symptoms  are  not  very  remarkable,  and  they  resemble  those  already 
described  under  neurasthenia.  The  cardiac-vascular  disturbances  are  much 
like  those  of  neurasthenia,  but  increase  in  the  pulse-rate  is  less  frequent,  and 
symptoms  referable  to  the  heart's  action,  palpitation,  cardiac  distress,  etc., 
are  not  so  often  seen.  The  appetite  is  often  poor,  nausea  and  vomiting  are 
rather  more  frequent,  and  in  some  cases  the  control  of  the  anal  sphincter  is 
diminished.  Constipation  is  quite  common.  Vesical  symptoms  are  rather 
moi'e  pronounced  ;  it  is  not  uncommon  for  patients  to  complain  that  it  re- 
quires a  greater  eflfort  to  empty  the  bladder,  and  that  there  is  more  or  less 
dribbling  of  urine  after  the  act ;  but  retention  and  incontinence  are  rare. 
The  sexual  j)owers  are  always  diminished.  There  is  usually  a  pi'etty  con- 
stant failure  of  nutrition  and  a  loss  in  weiffht. 


174 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


TRAUMATIC    SPINAL    SCLEROSIS. 

The  spinal  cord,  as  will  be  seen  from  the  accompanying  diagram,  Fig  55, 
is  deeply  seated  in  the  interior  of  the  body ;  it  is  carefully  suspended  in  a 
strong  but  flexible  bony  case,  is  stayed  by  the  ligamentum  denticulatum  and 
the  spinal  nerves,  and  is  protected  by  its  membranes,  a  cushion  of  fluid  and 
fatty  tissue.  Any  blow  on  the  spinous  processes  would  naturally  be  trans- 
mitted through  the  laminae  to  the  bodies  of  the  vertebrse.  It  is  therefore  not 
strange  that  many  writers  have  maintained  that  it  was  impossible  for  injury 
to  affect  the  cord  unless  there  were  direct  violence  sufficient  to  cause  fracture 
or  dislocation  of  the  vertebrae,  contusion,  or  crushing  of  the  cord,  or  spinal 
hemorrhage.  Such  injuries  give  rise  to  definite  symptoms  of  focal  or  trans- 
verse lesion  of  the  cord,  which  are  discussed  in  another  chapter. 

Fig.  55. 


Horizontal  section  of  the  body  tlirough  the  eighith  thoracic  vertebra.    (After  Bkaune.) 
A.  Spinal  cord.    B.  Body  of  the  eighth  thoracic  vertebra. 


In  the  section  on  pathology  reference  has  been  made  to  the  experimental 
and  pathological  evidence  from  which  it  seems  probable  that  in  some  cases 
after  severe  injury  there  may  develop  morbid  processes  in  the  cord  itself,  of 
slow  onset,  without  any  injury  to  the  surrounding  parts,  and  localized  chiefly 
in  the  white  matter  in  the  lateral  columns.  The  clinical  evidence  of  such 
conditions  is  even  stronger. 

The  old  term  of  spinal  concussion,  which  was  once  in  general  use  for  all 
these  conditions,  has  been  generally  abandoned  by  neurologists.  There  is, 
however,  a  condition  which  might  almost  merit  the  term.  In  a  few  rare  cases 
paraplegia,  sensory  disturbances,  loss  of  control  of  the  bladder  or  rectum, 
loss  of  knee-jerk,  etc.,  have  developed  immediately  after  a  severe  blow  on  the 
spine.  These  symptoms  have  disappeared  entirely  in  a  few  hours  or  days. 
In  such  cases  a  disturbance  in  the  cord  seems  the  most  probable  explanation ; 
but  the  nature  of  this  disturbance  is  still  hypothetical.  The  most  plausible 
explanations  are  Schmaus's  theory  of  a  fatigue  of  the  fibres,  vasomotor 
changes,  or  slight  meningeal  hemorrhage.  It  may  be  borne  in  mind  that  the 
lower  part  of  the  cord  is  supplied  with  blood  chiefly  by  the  branches  from 
the  inter-vertebral  arteries.  It  is  not  impossible  that  a  severe  blow  may  lead 
to  a  vasomotor  paralysis  of  those  vessels.  The  hypothesis  of  fatigue  of  the 
fibres  seems,  however,  more  probable. 


GENERAL  MORBID  STATES.  175 

In  the  cases  where  there  are  definite  pathological  lesions,  such  as  have  been 
mentioned,  the  symptoms  are  usually  of  gradual  onset.  The  patient  appar- 
ently recovers  from  the  injury,  although  there  is  usually  a  feeling  as  if  he 
were  not  cjuite  the  same  as  before.  The  sj^iual  trouble  may,  however,  be 
complicated  with  some  local  injury  or  traumatic  lumbago.  As  the  symptoms 
develop  the  motor  symptoms  usually  predominate.  The  patient  notices  a 
gradual  loss  of  power  in  the  legs,  attended  with  a  certain  amount  of  stiffness. 
He  walks  with  short,  scuffling  steps,  and  with  some  unsteadiness,  often  requir- 
ing support.  The  gait  is  much  like  that  of  spastic  paralysis.  There  may  be 
a  little  wasting  of  the  muscles  in  one  or  both  legs,  but  it  is  general,  and  is 
not  attended  with  degenerative  reactions.  The  skin  reflexes  are  not  often 
affected,  but  the  tendon  reflexes  are  much  exaggerated,  and  clonus  may  often 
be  found.  There  is  often  some  inco-ordination,  but  it  is  not  very  marked. 
There  is  often  swaying  when  the  eyes  are  closed.  The  weakness  in  the  legs 
may  increase  to  complete  paraplegia. 

The  sensory  symptoms  are  not  usually  so  pronounced.  Pain  in  the  back, 
except  as  a  result  of  traumatic  lumbago,  is  rare.  Pains  in  the  legs,  which  may 
be  sharp  and  lancinating  like  those  of  tabes,  are  not  uncommon.  Parsesthesise 
of  various  sorts,  prickling,  burning,  crawling,  etc.,  are  often  complained  of. 
Anaesthesia  is  not  constant,  and  selclom  is  pronounced.  Anaesthesia  in  limited 
areas  corresponding  to  the  distribution  of  the  spinal  segments  is  not  met  with. 
There  is  most  commonly  a  diminution  of  sensibility  in  all  its  forms,  some- 
times more  marked  in  one  leg  than  in  the  other ;  absolute  anaesthesia  is  much 
rarer.     Partial  anaesthesia  is  also  extremely  rare. 

There  is  generally  difficulty  in  passing  water,  which  may  reach  the  point 
of  retention  or  incontinence ;  more  commonly  there  is  great  straining  with 
some  dribbling  after  the  act,  and  occasional  imj)erative  desire  to  micturate. 
Constipation  is  common,  ancl  the  patient  has  to  strain  greatly  at  stool ;  feces 
may  accumulate  in  the  rectum,  and  evacuation  is  imperfect ;  one  patient 
complained  that  he  had  to  use  an  enormous  amount  of  paper  to  clean  himself 
after  a  stool.  Incontinence  of  feces  is  a  later  symptom.  Impotence  is  a 
frequent  symptom,  but  priapism  is  seldom,  if  ever,  seen. 

As  has  already  been  said,  the  majority  of  authors  admit  that  various 
degenerative  affections  of  the  cord,  notably  progressive  spinal  muscular 
atrophy,  may  be  due  to  injury,  but  these  affections  are  discussed  in  the 
appropriate  chapters. 

Diagnosis.  The  diagnosis  of  traumatic  nervous  affections  presents  problems 
of  a  peculiar  difficulty.  Not  only  do  we  have  to  determine  the  character  of 
an  obscure  nervous  affection,  but  also,  on  account  of  the  claims  for  damages 
that  so  often  arise,  we  must  decide  whether  there  be  any  disease  at  all,  or 
whether  the  patient  be  merely  a  simulator. 

Neither  of  these  points  can  be  determined  wdthout  a  thorough  and  com- 
plete examination  of  the  patient  by  the  most  exact  methods  of  research. 
Such  an  examination  demands  care  and  patience.  It  requires  much  time,  and, 
occasionally,  it  is  necessary  to  make  repeated  observations.  In  doubtful 
cases  it  may  even  demand  opportunities  for  prolonged  observation,  which  can 
be  afforded  only  by  residence  in  a  hospital.  Only  when  an  examination  has 
been  made  by  a  trained  bacteriologist  can  we  be  certain  as  to  the  presence  or 
absence  or  nature  of  any  germs.  It  is  equally  true  that  in  these  cases  no 
opinion  is  of  any  value  unless  it  is  made  by  a  man  thoroughly  familiar  with 
nervous  diseases  and  with  the  methods  employed  in  their  diagnosis.  We 
cannot  judge  of  the  traumatic  nervous  affections  unless  we  are  familiar  with 
all  the  various  phenomena  presented  by  patients  with  neurasthenia,  hysteria, 
and  other  mental  and  nervous  diseases  not  of  a  traumatic  origin. 


176  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

In  the  differential  diagnosis  of  the  affections  which  have  ah-eadv  been 
described,  it  is  first  of  all  necessary  to  eliminate  the  possibility  of  the  exist- 
ence of  any  focal  lesion  of  the  brain  or  cord,  any  systemic  affection  of  the 
cord,  or  any  disease  of  the  peripheral  nerves.  This  can  usually  be  done  by 
a  consideration  of  the  symj)toms  of  thase  affections  and  by  a  careful  exami- 
nation. Traumatic  lumbago,  as  has  been  said,  is  a  frequent  complication, 
and  it  usually  can  be  readily  detected  by  pain  in  the  back,  which  is  increased 
on  movement,  by  the  local  tenderness  of  the  muscles  and  their  rigidity. 
Traumatic  neurasthenia  presents  the  characteristic  symptoms  of  headache^ 
depression,  insomnia,  incapacity  for  protracted  effort,  irritability,  backache, 
muscular  weakness,  nervous  dyspepsia,  vasomotor  disturbances,  rapid  pulse, 
exaggerated  knee-jerks,  "shifting"  type  of  contraction  of  the  visual  field, 
together  with  the  absence  of  the  hysterical  stigmata  and  any  indications  of 
focal  or  systemic  disease.  The  diagnosis  of  hysteria  must  be  based  chiefly 
upon  the  discovery  of  the  hysterical  stigmata  already  described,  especially 
the  aneesthesia  and  the  contracted  visual  fields.  As  has  ah'eady  been  said, 
these  two  symptoms  cannot  be  regarded  as  pathognomonic  of  the  hysterical 
condition  ;  but,  in  the  majority  of  cases,  a  careful  study  of  the  symptoms 
ah'eady  described  will  render  the  diagnosis  of  hysteria  comparatively  easy. 

It  is  important  to  distinguish  between  the  hysterical  attacks  and  epileptic 
seizures,  both  of  which  may  be  of  traumatic  origin.  In  most  cases  there  can 
be  no  confusion,  but  in  some  cases  the  distinction  is  by  no  means  easy.  In 
hysteria  the  patient  is  not  apt  to  fall  so  as  to  hurt  himself,  the  tongue  is 
rarely  bitten,  consciousness  is  not  so  completely  lost,  there  is  rarely  involun- 
tary discharge  of  urine  or  feces ;  if  the  attacks  be  frequently  repeated  there 
is  no  rise  of  temperature.  The  urine  is  said,  by  Gilles  de  la  Tourette  and 
Cathelineau,  to  show  certain  characteristics  already  described. 

As  the  very  existence  of  the  traumatic  scleroses  is  still  in  dispute,  the 
diagnosis  is  by  no  means  easy.  The  history  of  a  severe  physical  injury,  the 
graver  character  of  the  symptoms,  the  mental  failure,  muscular  weakness, 
the  general  hypo-sesthesia,  and  the  physical  symptoms  will,  on  continued 
observation,  give  rise  to  the  suspicion  that  there  is  a  graver  disturbance  than 
simjDle  neurasthenia.  A  confusion  with  hysteria  is  much  less  likely  if  due 
weight  be  laid  upon  the  hysterical  stigmata.  If,  in  addition,  there  be  optic 
atrophy,  nystagmus,  intention  tremor  without  definite  signs  of  hysteria,  im- 
mobile pupils,  loss  of  knee-jerk,  degenerative  reactions,  and  the  like,  the 
suspicions  will  become  confirmed. 

The  diagnosis  of  traumatic  spinal  sclerosis  is  a  simpler  matter ;  the  para- 
paresis, spastic  conditions,  bladder  symptoms,  sensory  disturbances,  and  exag- 
gerated tendon  reflexes  are  at  once  suggestive  of  disease  of  the  cord,  and 
careful  observation  will  enable  the  physician  to  eliminate  mental  and  cerebral 
disturbances. 

There  has  been  much  discussion  of  late  as  to  the  possibilities  of  simulation. 
We  must,  of  course,  admit  that  there  are  many  men  who  will  do  am-thing 
but  work  in  order  to  get  money ;  and,  consequently,  there  must  be  many 
men  who  would  gladly  simulate  disease  if,  by  so  doing,  they  could  get  a 
large  sum  for  damages  from  aiiy  corporation.  It  is  unfortunately  true  that 
there  are  a  certain  number  of  lawyers  and  physicians  who  would  join  these 
men  in  such  an  attempt.  It  is,  however,  a  harder  thing  to  believe  that  such 
men,  even  when  coached  by  such  physicians,  who  are  seldom  very  learned 
men,  can  successfully  and  persistently  simulate  the  conditions  akeady  de- 
scribed. It  is  a  singular  fact  that  until  recently  very  few  neurologists  have 
maintained  that  simulation  was  at  all  frequent,  and  the  men  who  claimed  that 
it  was  frequent  have  been,  for  the  most  part,  railway  surgeons,  who  have  had 
but  little  familiaritv  with  nervous  diseases.     Witliin  a  few  vears,  as  has  been 


GENERAL  MOBBIB  STATES.  177 

said,  a  number  of  German  neurologists  have  maintained  that  successful  simu- 
lation was  common,  and  that  from  one-fourth  to  one-third  of  all  cases  pre- 
senting claims  for  damages  or  injuries  were  fraudulent.  Schultze,'  however, 
who  has  been  one  of  the  leading  supporters  of  this  opinion,  in  a  second  series 
of  cases  found  ten  per  cent,  (instead  of  thirty-tlii'ee,  as  in  his  first  sei'ies), 
which  he  believed  to  be  simulated ;  and  it  is  also  worthy  of  note  that  very 
few  cases  of  alleged  simulation  have  been  published  by  neurologists,  and 
most  of  them  which  have  been  published  have  not  been  able  to  stand  careful 
criticism.  In  my  own  experience,  although  I  have  often  met  with  cases 
which  were  said  to  be  fraudulent,  I  have  usually  found  evidence  to  j)rove  the 
existence  of  disease.  In  less  than  3  per  cent,  of  the  cases  was  I  led  to 
believe  in  simulation.  The  majority  of  neurologists  in  this  country  admit 
that  simulation  is  very  rare,  although  exaggeration  Ls  not  uncommon. 

The  simulator  is  apt  to  present  striking  symptoms,  and  his  efforts  are  usually 
too  much  exaggerated,  and  so  incongruous  as  to  be  detected  at  once.  No  one 
familiar  with  nervous  diseases  can  be  deceived  in  him.  All  his  symptoms 
are  very  much  in  evidence ;  they  do  not  have  to  be  sought  for.  It  is  also 
impossible  to  keep  the  attention  fixed  on  any  one  subject  for  more  than  a 
very  brief  time ;  if  the  attention  must  be  fixed  on  a  number  of  different  sub- 
jects at  once,  as,  for  example,  when  a  man  must  feign  a  contracted  visual 
field,  anaesthesia,  paralysis,  and  the  like,  the  attention  must  inevitably  be 
easily  disturbed,  and  the  expert  can  very  soon  catch  the  simulator  off  his 
guard  and  expose  his  deception. 

In  the  majority  of  cases  that  come  under  observation  the  morbid  symp- 
toms must  be  sought  for ;  they  are  not  brought  forward  by  the  patient  him- 
selfj  and  he  is  often  unaware  of  their  existence.  It  is  not  uncommon,  for 
example,  for  a  patient  to  say  he  has  no  trouble  with  his  vision,  yet,  on 
examination,  we  find  a  slight  contracture  of  the  visual  field ;  another  may 
have  normal  sensibility  to  touch,  with  complete  loss  of  sensibility  to  pain. 

Careflil  examination  will  usually  disclose  symptoms  unfamiliar  to  the  laity, 
and  often  unrecognized  by  the  patient  himself,  and  it  will  usually  reveal  other 
symptoms,  which  have  distinctly  an  objective  character.  The  examiner 
must  be  familiar  with  the  mental  characteristics  of  nervous  patients,  the  ten- 
dency to  exaggerate,  the  variations  that  often  occur  in  their  general  condi- 
tion or  in  individual  symptoms,  and  the  seeming  contradictions  that  these 
symptoms  may  present.  Some  striking  examples  of  this  have  already  been 
mentioned  in  the  section  on  hysteria  with  reference  to  hysterical  amblvopia 
and  hysterical  ansesthesia.  In  hysteria  and  neurasthenia,  too,  it  is  not 
uncommon  for  the  symptoms  to  vary  from  day  to  day,  and  even  from  hour 
to  hour. 

To  the  person  familiar  with  mental  diseases  the  mental  symptoms  presented 
in  most  cases,  such  as  have  already  been  described,  are  easily  recognized ; 
but  to  the  casual  observer  they  are  not  very  striking.  That  they  can  be 
successflilly  simulated  by  the  average  patient  seems  impossible.  Prolonged 
observation  will  usually  show  the  genuineness  of  the  patient's  mental  con- 
dition. 

Examination  of  the  eyes  will  usually  give  definite  objective  evidence  of 
some  disturl^ance.  Strabismus,  immobile  pupils,  and  nystagmus  cannot  be 
feigned,  but  they  are  rare.  Concentric  limitation  of  the  visual  field  is  much 
more  common,  and  most  authorities  agree  that  it  is  not  possible  to  simulate 
this  condition  and  keep  the  same  limits  to  the  field  under  repeated  testings. 
If  perimeters  of  different  diameters  be  used,  and  the  fields  then  agree,  the 
possibilities  of  simulation  are  practically  excluded. 

1  Dentsch.  Zeit.  f.  Nervenheilk,  i.,  445. 
12 


178  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  sensory  symptoms  also  have  a  distinct  objective  vakie.  It  is  not 
practicable  for  a  simulator  to  tell  whether  a  touch  be  on  one  side  or  the  other 
of  a  given  line,  especially  if  that  line  pass  horizontally  about  the  body  or  a 
limb,  or  if  it  pass  through  the  less  sensitive  parts  of  the  body ;  hence,  if 
there  be  a  shai'ply  defined  anaesthesia,  constant  in  its  limitations,  it  is  un- 
doubtedly genuine.  The  simulator,  moreover,  will  seldom  adopt  the  more 
unusual  forms  of  anaesthesia,  such  as  the  loss  of  sensibility  to  pain  with 
retained  sensibility  to  touch,  or  the  slight  blunting  of  the  tactile  sense. 
Moreover,  when  a  sudden  and  very  painful  stimulus,  such  as  may  be  con- 
veyed, for  example,  by  an  extremely  strong  current  from  the  induction  coil 
through  a  needle  point,  is  applied  to  any  region  of  the  body,  especially  the 
more  sensitive  regions,  when  the  simulator  is  off  his  guard,  it  is  impossible 
for  him  to  refrain  from  some  manifestation  of  pain  ;  there,  at  least,  will  be 
certain  muscular  contractions  or  a  quickening  of  the  pulse.  This  was  shown 
very  strikingly  by  Pitres.^  A  man  endeavored  to  feign  disease,  one  of  the 
symptoms  being  anaesthesia.  He  had  previously  earned  his  living  by  appear- 
ing as  the  anaesthetic  man  in  a  show,  Avho  thrust  pins  into  himself  without 
any  manifestations  of  pain.  The  unexpected  application  of  very  painful 
stimuli  revealed  his  simulation  at  once. 

The  increase  of  the  pulse-rate  on  pressure  over  the  painful  region  is  ob- 
jective evidence  of  tenderness,  which  is  of  great  value.  Paralysis  with 
atrophy  or  with  contracture  can,  of  course,  not  be  simulated ;  no  voluntary 
contraction  of  the  muscles  is  at  all  like  the  rigidity  of  contracture  seen  in 
certain  forms  of  paralysis.  Careful  examination  of  an  alleged  paralyzed 
limb,  especially  if  the  patient  himself  be  put  through  certain  peculiar  move- 
ments, and  if  the  limb  be  moved  about  in  different  ways,  will  readily  detect 
the  existence  of  voluntary  control  of  the  muscles. 

Although  a  tremor  can  be  feigned  under  certain  conditions,  especially  if 
the  limbs  be  given  a  certain  amount  of  support,  if  the  limbs  be  unsupported 
it  is  impossible  to  continue  a  tremor  with  any  definite  rhythm,  and  the  irregu- 
larities in  the  rhythm  and  in  the  degree  of  excursion  of  the  limbs  can  at  once 
be  detected. 

The  circulatory  symptoms,  which  have  already  been  described,  are  of  fre- 
quent occurrence,  and  they  can,  of  course,  be  readily  detected.  I  have 
already  spoken  of  the  distinction  between  the  nervous  increase  of  the  pulse 
of  the  person  coming  under  examination  and  the  persistent  increase  so  com- 
mon in  these  conditions.  Bladder  symptoms  are  usually  not  of  a  very  strik- 
ing character.  If  there  be  distinct  incontinence  it  can  often  be  detected  by 
carefully  drying  the  parts  with  absorbent  cotton  and  then  noting  if  the  urine 
escape  drop  by  drop.  This,  of  course,  is  a  distinct  proof  of  the  genuineness 
of  the  symptoms. 

Many  neurasthenic  and  hysterical  patients,  no  matter  what  the  cause  of 
their  trouble,  will  exaggerate  their  symptoms.  This  is  equally  true  in  trau- 
matic cases,  whether  there  be  a  claim  for  damages  or  not ;  l3ut  it  must  be 
borne  in  mind  that  many,  in  fact  the  majority  of  patients  with  traumatic 
nervous  affections  who  have  a  claim  for  damages,  are  more  deeply  interested 
in  their  personal  sufferings  than  in  any  claim  which  they  may  have.  The 
tendency  to  exaggerate  can  readily  be  detected  by  the  man  familiar  with 
nervous  diseases  and  with  human  nature,  by  a  comparison  between  the  com- 
plaints and  the  physical  condition,  and  by  applying  the  personal  equation. 
Several  careful  observers,  who  have  had  the  opportunity  of  examining  all  the 
claimants  for  damages  for  certain  railway  corporations,  have  assured  me  that 
the  percentage  of  deliberate  simulation  was  rare,  and  that  the  attempts  at 

1  Op.  cit.,  i.,79. 


GENERAL  MORBID  STATES.  179 

simulation  were  always  gross  exaggerations.  I  believe  myself  that  the  claim 
of  the  frequency  of  simulation  is  more  often  due  to  the  ignorance  of  the 
physician  than  to  any  attempt  to  deceive  on  the  part  of  the  patient. 

Prognosis.  The  prognosis  of  the  affections  described  is  of  extreme  impor- 
tance, yet  it  is  involved  in  much  obscurity,  and  it  is  by  no  means  easy  to 
determine.  In  view  of  the  immense  importance  which  prognosis  has  in  so 
many  medico-legal  cases  it  is  by  no  means  remarkable  that,  on  the  one 
hand,  some  men  conclude  that  the  great  majority  of  cases  recover  completely, 
and  that  other  men  hold  out  gloomy  predictions  as  to  dementia,  paralysis, 
and  death.  It  is  ^^robable  that  a  large  proportion  of  the  cases,  taking  all 
cases  as  they  come,  if  they  could  be  placed  under  proper  conditions  imme- 
diately after  the  injury,  would  do  well.  Unfortunately  few  cases  are  placed 
under  such  conditions ;  instead  they  are  put  under  the  worst  possible  condi- 
tions, and  kept  there  for  years. 

Traumatic  lumbago,  when  uncomplicated,  is  apt  to  be  rather  an  obstinate 
affection,  persisting  for  several  months,  and  leaving  its  victim  with  a  weak 
back  ;  the  symptoms  being  liable  to  occur  at  any  slight  strain  or  cold.  When 
comjDlicated  with  other  nervous  affections,  especially  under  debilitating  con- 
ditions, it  lasts  much  longer.  In  rare  instances  it  may  persist,  causing  annoy- 
ance and  some  disability  for  years ;  in  one  case  under  my  observation  it  lasted 
for  twenty-eight  years.  Here  there  was  probably  some  more  deeply  seated 
trouble,  such  as  a  chronic  arthritis  of  the  vertebral  articulations. 

The  prognosis  of  traumatic  neurasthenia  is  better  than  that  of  the  other 
traumatic  nervous  affections.  A  certain  proportion  of  cases  get  well  if  they 
can  be  placed  under  proper  conditions.  As  in  all  forms  of  neurasthenia, 
however,  the  process  of  recovery  is  slow  and  tedious,  and  it  must  always  be 
measured  by  months  and  sometimes  by  years.  The  prognosis  in  all  forms  of 
neurasthenia  must  vary  with  the  duration  of  the  trouble,  and  as  the  conditions 
in  many  of  the  traumatic  cases  are  bad,  as  has  already  been  shown,  it  is  obvi- 
ous that  the  prognosis  must  also  be  unfavorable.  When  any  case  of  neuras- 
thenia has  continued  under  unfavorable  conditions  which  tend  to  aggravate 
it,  without  treatment,  for  two  or  three  years,  the  chances  of  recovery  are 
greatly  diminished.  The  chances  of  complete  recovery  in  any  case  of  neur- 
asthenia that  has  existed  over  three  years  are  slight.  The  patient  may  make 
a  partial  recovery,  and  perhaj)s  be  able  to  resume  his  accustomed  work,  but 
he  has  less  endurance,  his  trouble  is  apt  to  recur  after  comparatively  slight 
strains,  he  is  nervous  and  irritable,  his  sleep  is  less  sound,  his  judgment  is  not 
quite  so  good,  he  has  tendencies  toward  headaches  and  digestive  disturbances, 
he  gets  on  less  smoothly  with  his  fellows,  trifles  annoy  him,  and,  instead  of 
being  a  capable  business  man  and  a  genial  companion,  he  is  apt  to  be  a  nerv- 
ous, querulous,  disagreeable  person — a  "  damaged  man."  The  casual  observer 
seeing  him  at  his  wonted  tasks  says  that  he  is  Avell,  but  his  intimate  friends 
and  the  neurologist  can  detect  the  change  brought  about  by  the  accident. 
More  than  one  case  of  traumatic  neurasthenia  can  be  cited  where  there  was 
never  any  claim  for  damages,  but  where  the  symptoms  have  persisted  ten, 
fifteen,  or  twenty  years,  causing  various  disturbances,  from  a  mere  change  of 
disposition  and  diminished  endurance  to  complete  disability. 

Even  in  severe  cases,  if  treatment  be  instituted  promptly,  there  is  a  fair 
chance  of  recovery  after  a  number  of  months,  but  when  the  condition  has 
lasted  a  long  time  it  is  probable  that  the  changes  in  the  brain  become  greater, 
and  that  the  cells  cannot  be  restored  to  their  normal  condition.  Many  cases, 
even  after  a  lapse  of  several  years,  may  make  a  partial  I'ecovery,  which, 
under  the  excitement  and  stimulus  of  an  award  of  damages  and  the  relief 
from  the  anxiety  of  litigation,  seems  at  first  very  great ;  l)ut  afterward  there  is 
a  relapse,  and  the  patient  is  seldom  fully  restored  to  liealth.     A  consideral)le 


180  NERVOUS  DISEASES  AjSW  THEIR  TREATMENT. 

number  of  cases  persist  partly  clLsabled  and  semi-invalids,  and  others  still  re- 
main complete  invalids  for  life. 

The  prognosis  of  traumatic  hysteria  is  better  and  worse  than  that  of  neur- 
asthenia. The  individual  symptoms  of  hysteria  are  capable  of  complete  and 
sometimes  sudden  cure,  whence  many  have  believed  that  the  condition  itself 
was  cured.  Hysteria,  however,  is  on  the  whole  a  graver  condition  than  neur- 
asthenia, and  it  is  to  be  borne  in  mind  that  when  once  a  patient  becomes 
hysterical  the  condition  is  apt  to  become  permanent,  although  the  individual 
symptoms  may  be  relieved.  Although  the  paralysis,  contractures,  or  anaes- 
thesia may  wholly  disappear,  nevertheless  the  patient  remains  in  an  hysterical 
condition,  and  the  same  symptoms,  or  others  even  graver,  may  recur  fi'om  the 
slightest  cause.  Moreover,  in  traumatic  cases,  we  usually  have  to  do  with  a 
combination  of  the  two  affections.  The  same,  therefore,  holds  true  of  hys- 
teria as  Avas  said  of  neurasthenia ;  a  few  cases,  if  put  promptly  under  treat- 
ment, may  recover  completely  after  an  interval  of  a  number  of  months,  as 
Dercum^  has  shown  ;  the  majority  continue  in  a  condition  of  partial  invalid- 
ism. It  must  not  be  forgotten,  too,  that  in  rare  cases  both  hysteria  and  neur- 
asthenia may  terminate  fatally. 

The  prognosis  of  the  traumatic  scleroses  does  not  diifer  from  that  of  other 
forms  of  sclerosis ;  these  cases  gradually  grow  worse,  and  finally  succumb,  if 
not  to  the  disease,  to  intercurrent  affections. 

Including  all  patients  who  have  nervous  disturbances  after  injury,  in  many 
cases,  of  course,  the  trouble  is  sKght,  and  they  recover  completely.  Such 
cases  are,  however,  less  frequently  seen  by  the  neurologist.  In  cases  which 
present  pronounced  symptoms  of  nervous  disease  the  prognosis  must  be 
regarded  as  grave.  Out  of  fifty  consecutive  medico-legal  cases  that  I  have 
seen  I  have  known  of  the  death  of  four  from  the  nervous  disease  within  six 
years  after  the  injury,  and  of  many  of  the  cases  I  have  no  present  knowl- 
edge. Page^  has  tried  to  show  that  most  cases  recover  speedily  after  dam- 
ages are  paid,  but  his  statistics  do  not  inspire  confidence,  and  most  neurologists 
recognize  that  the  majority  of  severe  cases  never  make  a  complete  recovery. 

Treatment.  Every  case  of  traumatic  nervous  disease  ought  to  be  put  under 
systematic  and  thorough  treatment  from  the  beginning.  In  the  section  on 
etiology  I  have  shown  that  this  was  seldom  done  in  the  medico-legal  cases, 
but  that,  on  the  contrary,  treatment  was  neglected,  and  that  many  factors  were 
introduced  which  tended  to  aggravate  the  condition  and  to  render  it  clu'onic. 
If  proper  treatment  were  promptly  instituted  the  prognosis  would  be  mate- 
rially improved  and  many  patients  would  doubtless  recover  who  now  remain 
invalids.  Unfortunately,  proper  treatment  is  often  not  feasible,  even  in  cases 
where  there  is  no  litigation.  The  patient  may  not  be  able  to  aflbrd  the  ex- 
pense of  a  prolonged  and  thorough  course  of  treatment,  or,  if  he  be  only 
partly  disabled,  being  a  wage-earner  he  Avill  feel  that  he  cannot  afford  to  give 
up  the  time  requisite  for  treatment,  but  he  will  insist  on  keeping  on  with  his 
business  and  doing  the  best  he  can. 

In  medico-legal  cases  the  opportunities  for  proper  treatment  are  rare.  Xo 
course  can  be  more  at  variance  with  any  reasonable  therapeutics  than  to  sub- 
ject a  case  of  severe  neurasthenia  or  hysteria  to  repeated  examinations  by 
different  experts,  not  for  the  benefit  of  the  patient,  but  to  satisfy  the  lawyers 
and  to  make  a  numerical  showing  of  experts  before  a  jury ;  to  keep  the 
patient  harassed  by  excitement  and  vexations  of  a  trial ;  to  accuse  him  of 
fraud  ;  to  carry  him  to  court,  perhaps  upon  a  stretcher,  to  be  cross-examined 
and  held  up  to  the  view  of  an  intelligent(? )  jury,  who  are  to  decide  upon  the 
genuineness  of  his  complaints,  the  character  of  his  disease,  and  his  chances 
for  recovery. 

1  Alienist  and  Neurol.,  Oct.  1893.  -  Art.  cit. 


GENERAL  MORBID  STATES.  181 

In  most  of  the  affections  which  have  been  described  the  treatment  requisite 
Ls  the  rest-cure,  which,  in  all  sevei^e  cases,  must  be  carried  out  in  all  it  details. 
This  rest-cure  has  already  been  described  in  Chapter  II.,  but  it  is  necessary 
here  to  speak  of  certain  minor  details. 

In  a  large  number  of  cases  traumatic  lumbago  is  a  complication  so  dis- 
tressing as  to  require  special  treatment.  Rest  in  bed  often  becomes  neces- 
sary, the  pain  on  motion  being  so  great,  but  absolute  rest  by  a  spinal  brace  is 
not  to  be  recommended  ;  it  will  often  give  temporary  relief,  but  it  is  merely 
a  palliation,  and  the  progress  is  apt  to  be  slow  under  it.  As  in  sj)rains  else- 
where, it  is  better  to  treat  the  muscles  and  ligaments  by  j^ermitting  and 
encouraging  a  certain  amount  of  motion.  This  motion  can  be  best  obtained 
by  gentle  massage  of  the  injured  muscles.  This  should  be  begun  early,  and 
it  will  usuallv  be  well  borne.  After  a  short  time  it  will  be  found  that  the 
patient  can  bear  more  energetic,  deep  massage,  and  that  he  will  improve 
under  it.  In  addition  to  the  massage  much  relief  may  be  obtained  by  gal- 
vanizing the  tender  region,  applying  a  large  electrode  with  the  positive  coil, 
with  a  current  of  five  to  ten  milliampdres,  over  the  spinal  muscles.  By  mas- 
sage and  electricity  considerable  relief  can  usually  be  obtained,  and  many 
cases  will  be  greatly  benefited.  Certain  other  remedies  are  also  of  advantage. 
Ironing  the  muscles  with  a  flatiron,  as  hot  as  can  be  borne — a  combination  of 
warmth  and  massage — will  give  relief  in  cases  where  massage  itself  cannot  be 
applied.  Cupping,  blistering,  and  counter-irritation  by  iodine  give  temporary 
relief,  but  they  are  apt  to  render  the  skin  sensitive,  so  that  massage  cannot  be 
'used.  The  same  may  be  said  of  the  actual  cautery,  which,  in  more  chronic 
cases,  often  gives  very  distinct  temporary  relief.  As  the  patient's  condition 
improves  and  his  ability  to  move  becomes  greater,  light  gymnastics  for  the 
spinal  muscles  will  often  be  of  distinct  benefit,  but  they  should  not  be  under- 
taken if  they  cause  any  increase  of  the  pain  which  persists  after  exercise. 

In  hysteria  and  neurasthenia  the  rest-cure  of  Weir  Mitchell  is  the  only 
proper  treatment,  and,  in  all  severe  cases,  it  should  be  carried  out  in  all  its 
utmost  details.  Dercum  has  shown  the  benefit  of  this  treatment  when  thor- 
oughly employed  from  the  beginning  of  the  trouble,  and,  as  was  said  above, 
many  patients  may  recover  under  it  who  otherwise  would  remain  chronic 
invalids.  In  the  cases  where  this  is  not  feasible,  from  the  causes  already 
mentioned,  the  physician  is  compelled  to  adopt  a  very  much  more  unsatis- 
factory course,  which  often  means  more  protracted  suffering  and  greater 
expense  for  the  patient,  and  also  a  poorer  chance  of  complete  recovery. 
When  the  complete  rest  cure  cannot  be  instituted  the  patient  should  take  as 
much  rest  as  possible ;  he  should  lie  down  during  the  day,  and  avoid  every- 
thing but  the  most  necessary  duties ;  he  should  be  kept  from  all  excitement 
and  worry ;  forced  feeding  should  be  employed,  milk,  eggs,  soup,  prepared 
foods,  etc.,  should  be  given  in  small  quantities  at  frequent  intervals.  Gal- 
vanism and  massage  are  of  great  benefit.  In  other  respects  treatment  must 
be  symptomatic.  The  bowels  should  be  kept  open,  stimulants,  analgesics, 
and  hypnotics  should  be  avoided  as  much  as  possible,  and  tonics  freely 
given  ;  iron  and  arsenic  seem  more  beneficial  than  strychnine.  Where  there 
are  pronounced  cardiac  symptoms  digitalis  and  similar  remedies  may  be 
necessary. 

Page'  has  claimed  that  the  symptoms  in  many  cases  were  due  not  to  the 
injury,  but  to  the  abuse  of  bromide  of  potassium.  That  the  excessive  use  of 
the  ])romide  is  injurious  no  one  will  deny ;  but  the  symptoms  from  the  abuse 
of  bromide  do  not  resemble  the  symptoms  we  see  in  these  cases.  The  symp- 
toms occur  in  cases  that  have  never  taken  bromide,  and  many  cases  are 

1  Med.  Times  and  Gaz.,  April,  1885. 


182  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

benefited  by  a  moderate  use  of  the  bromide.  I  have  seen  distinct  improve- 
ment occur  after  taking  ten  to  fifteen-grain  doses  of  bromide  three  times  a 
day.  'The  bromides  must  be  used  with  care,  but  they  often  relieve  much  of 
the  nervousness  and  anxiety  from  wlaich  these  patients  sufier.  They  are  best 
given  combined  with  gentian  and  the  tincture  of  chloride  of  iron. 

The  treatment  of  the  traumatic  scleroses  does  not  differ  from  the  treatment 
of  other  forms  of  sclerosis.  Rest,  seclusion,  forced  feeding,  and  tonics  are  the 
essentials.     In  other  respects  the  treatment  must  be  largely  symj)tomatic. 

In  all  medico-legal  cases  the  physician  should  urge  a  settlement  of  the 
case  rather  than  expose  the  patient  to  the  anxiety  and  risks  of  a  trial.  An 
early  settlement  is  of  the  utmost  importance  in  affording  the  patient  a  chance 
for  recovery,  and  it  is  better  to  settle  for  a  moderate  sum  rather  than  to  ex- 
pose the  patient  to  such  risks  in  the  hope  of  getting  a  little  more  money.  If 
any  system  of  procedure  could  be  adopted  in  medico-legal  cases  whereby  one 
competent  expert  could  have  the  opportunity  of  seeing  the  patient  as  often 
as  he  might  see  fit,  and  could  give  an  opinion  which  would  be  accepted  as  a 
judicial  ruling,  it  would  be  much  better  for  the  patient  than  it  is  to  be  sub- 
jected to  frequent  examinations  by  incompetent  men  ;  his  chances  for  recovery 
would  be  greater,  and  the  ends  of  justice  would  be  better  served. 


CHAPTER   Y. 

DIATHETIC  AND  TOXIC  AFFECTIONS  OF  THE  NERVOUS 

SYSTEM. 

By  E.  D.  fisher,  M.D. 

Diathesis  is  a  tendency  to  disease,  and  therefore  chronic  by  its  very  nature. 
We  understand  by  it  a  condition,  inherited  or  acquired,  which  under  certain 
conditions,  as  errors  of  diet,  exposure,  etc.,  may  manifest  a  definite  class  of 
symptoms.  Rheumatism  and  gout  represent  such  diatheses.  The  acute  ex- 
acerbations in  each  of  these  diseases  represent  the  overwhelming  of  the  system 
by  the  distinct  poison  peculiar  to  each. 

The  relation  of  diathesis  to  nervous  affections  is  of  great  importance  in  its 
bearing  on  a  class  of  diseases  which  are  often  not  the  direct  or  immediate 
effect  of  the  poison  on  the  economy,  but  rather  the  accompanying  or  conse- 
quent injury  to  the  nervous  system. 

We  may  define  diathesis,  according  to  Hutchinson,  as  "  any  condition  of 
prolonged  peculiarity  of  health  giving  proclivity  to  definite  forms  of  disease." 
Diatheses  represent  morbid  conditions  of  the  blood.  We  have  to  consider 
them  in  their  relation  to  the  nervous  system  in  two  aspects :  first,  as  to  their 
primary  effect  as  j)oisons  |jer  se  within  the  economy,  producing  characteristic 
symptoms,  and  secondly,  as  to  their  secondary  effect  on  the  nervous  system. 
It  is,  as  a  result  of  this  secondary  effect,  that  we  find  the  more  permanent  and 
chronic  changes  induced. 

RHEUMATISM. 

Rheumatism  may  be  regarded  as  a  morbid  blood  state  affecting  the  chemi- 
cal processes  of  the  body  (Gowers.)  It  affects  almost  all  the  structures  of 
the  nervous  system.  The  somatic  signs  of  the  disease  are  inflammatory 
states  of  the  articular  and  muscular  structures,  accompanied  by  pain  and 
high  temperature. 

Etiology.  In  the  light  of  the  fact  that  the  rheumatic  diathesis  is  peculiar 
to  certain  families,  and  that  therefore  heredity  is  an  important  etiological 
factor  in  the  disease,  it  would  seem  that  the  theory  of  the  disease,  as  due  to 
some  chemical  change  of  nervous  origin,  causing  malnutrition  and  nutritive 
changes,  is  the  correct  one. 

Symptoms.  The  following  symptoms  occur  as  a  direct  or  indirect  result  of 
the  involvement  of  the  nervous  system. 

Insanity,  as  a  direct  result  of  rheumatism,  is  rare.  Clouston  and  Wigles- 
worth  have  reported  several  cases.  The  characteristic  symptoms  are  delirium, 
hallucinations  of  sight  and  hearing,  associated  in  some  cases  with  choreiform 
movements.  The  direct  relationship  between  the  rheumatic  poison  and  the 
appearance  of  the  cerebral  symptoms  seems  positive.  It  cannot,  however,  be 
considered  as  a  metastasis,  but  rather  the  direct  influence  of  the  poison  on  the 
cerebrum. 


184  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Meningitis.  There  is  usually  present  a  marked  delirium,  which  may  be 
low  and  muttering  or  very  active,  and  the  patient  may  pass  into  a  partial 
coma  interrupted  by  delirium.  Convulsions  are  not  common,  although  they 
may  be  present.  The  temperature  may  rise  to  106-7.°  Post-mortem,  in- 
flammation of  the  meninges  is  found,  generally  simple  in  character,  without 
pus  formation.  Hemorrhages  have  been  observed  in  the  cortex  of  the  brain, 
and  general  congestion,  giving  a  rosy  appearance  to  the  surface. 

Hemiplegia.  Cerebral  embolism  is  a  very  frequent  though  late  complica- 
tion of  rheumatism,  due  to  the  endocarditis  which  so  often  accompanies  rheu- 
matic fever.  While  we  cannot  consider  it  as  directly  due  to  the  rheumatic 
diathesis,  yet  this  disease  is  the  most  frequent  cause  of  the  cardiac  complication. 
It  is  essentially  a  disease  of  youth,  so  much  so  that  probably  most  cases  of 
cerebral  hemiplegia  in  the  young  are  due  to  embolism. 

Chorea.  A  considerable  percentage  of  cases  of  chorea  give  a  rheumatic 
history,  with  or  without  cardiac  lesions.  A  large  proportion,  however,  present 
no  such  connection.  The  covirse  and  symptoms  are  similar  in  both  cases,  the 
element  of  rheumatic  disease  not  altering  its  characteristics.  An  anaemic 
condition  is  to  be  observed  in  most  cases.  Sir  Dyce  Duckworth  goes  so  far 
in  his  statement  as  to  say  that  both  chorea  and  rheumatism  are  simply  the 
result  of  the  same  specific  agent,  manifesting  itself  at  one  time  in  one  form 
as  chorea,  and  at  another  time  as  articular  inflammation.  Writers  in  this 
country  do  not  find  rheumatism  so  frequent  an  etiological  factor  in  chorea  as 
the  French  and  English  statistics  would  seem  to  indicate. 

Associated  with  the  chorea  we  may  have  a  neuritis,  general  in  distribution, 
or  again,  apparently,  secondary  to  spinal  cord  disease.  The  paralysis,  even 
when  hemiplegic,  is  usually  flaccid,  the  muscles  are  not  rigid,  and  therefore 
the  indication  is  that  it  is  due  either  to  involvement  of  the  peripheral  nerves 
or  to  the  spinal  cord  in  the  region  of  the  anterior  horns. 

Spinal  Cord  Diseases.  Lesions  of  an  acute  nature,  as  poliomyelitis,  are 
rare.  In  many  rheumatic  cases,  however,  exposure  to  cold  appears  to  affect 
the  nervous  system  so  as  to  cause  the  production  within  it  of  a  toxic  agent 
capable  of  producing  an  inflammatory  condition  within  the  cord  itself.  It  is 
not  improbable  that  both  poliomyelitis  and  general  myelitis  may  be  produced 
in  this  way.  The  relation  of  such  a  cause  to  chronic  and  systemic  disease  of 
the  cord  does  not,  however,  seem  equally  clear.  Meningeal  inflammation, 
•however,  undoubtedly  occurs,  and  when  acute,  is  generally  associated  with 
the  cerebral  condition.  It  may  not,  therefore,  be  recognized.  The  symptoms 
are  those  common  to  meningitis — pain  in  the  spine  on  movement,  with  exten- 
sion into  the  extremities,  giving  evidence  of  irritation  of  the  meninges  and 
the  spinal  nerves  at  their  exit  from  the  canal.  There  is  nothing  diagnostic  in 
the  symptoms  of  their  rheumatic  origin,  except  their  occurrence  in  the  course 
of  acute  rheumatism.  The  prognosis  is  dependent  upon  the  general  course 
of  the  disease. 

Neuritis.  Multiple  neuritis  may  be  present,  but  is  rare.  A  number  of 
cases,  however,  have  been  reported.  It  is  more  commonly  observed  as  affect- 
ing individual  nerves.  It  is  not  uncommon  to  find  the  spinal  accessory,  the 
facial,  the  fifth,  the  ulnar,  and  sciatic  nerves  involved  ;  more  rarely,  the  vagus, 
the  optic,  and  the  oculomotor.  No  nerve  is  perhaps  free  from  the  affection. 
We  must  make  a  distinction  in  these  cases,  however,  from  those  occurring 
around  the  joints  in  the  course  of  articular  rheumatism,  as  here  the  direct 
influence  of  the  joint  inflammation  is  probably  the  cause  of  the  neuritis.  It 
may  also  occur  secondarily  through  the  spinal  cord  (Charcot). 

Neuralgia.  Neuralgia  is  frequently  associated  with  rheumatism,  especially 
on  exposure.  The  sciatic  nerve  is  perhaps  the  most  frequently  involved.  In 
these  cases  there  is  usually  present  some  neuritis. 


DIATHETIC  AND  TOXIC  AFFECTIONS.  185 

Pathology.  In  meningeal  cases  we  find  in  the  brain  the  pial  vessels  usually 
congested.  The  subarachnoid  space  and  ventricles  are  filled  with  fluid,  and 
perhaps  discolored  by  blood.  The  cortex  is  congested  and  of  a  reddish  color. 
Actual  pus  formation  is  rarely,  if  ever,  present.  The  dura  is  not  involved. 
The  spinal  meninges  may  show  a  like  inflammation,  and  changes  of  an  in- 
flammatory nature  in  the  anterior  horns,  with  softening,  have  been  observed. 
The  change  in  the  peripheral  nerves  is  usually  an  interstitial  neuritis,  and 
the  axis  cylinder  in  most  instances  escapes.  Parenchymatous  degeneration, 
however,  with  destruction  of  the  axis  cylinder,  may  occur. 

Diagnosis.  The  diagnosis  is  not  difficult  where  a  previous  history  of  rheu- 
matism is  present ;  otherwise  the  symptoms  are  not  diagnostic. 

Prognosis.  The  prognosis  is  bad  in  cerebral  cases  if  the  temperature  is 
high  and  delirium  and  coma  are  present.  In  neuritis  it  is  generally  favor- 
able. 

Treatment.  In  meningeal  cases,  with  high  temperature,  the  cold  bath  or 
douche  is  advisable,  with  the  salicylates  or  salol.  Acetanilide,  antipyrine,  and 
phenacetine  may  be  prescribed  to  relieve  the  pain.  In  neuritis,  associated 
with  paralysis  or  Avasting,  strychnine,  massage,  and  electricity  are  indicated. 
Remedies  applicable  to  rheumatism  in  general,  such  as  the  alkalies  or  pipera- 
zin,  are  also  of  use  here. 

GOUT. 

Gout  is  an  acute  or  chronic  diathetic  disease  manifested  by  local  inflam- 
mation, with  intense  pain  when  acute,  and  often  without  either  of  these 
symptoms  when  chronic.  It  may  be  inherited  or  acquired.  The  attacks  are 
associated  with  excess  of  uric  acid  in  the  organism,  and  deposits  of  urate  of 
sodium  in  the  articular  cartilages  and  fibrous  structures  (Foster).  It  is,  how- 
ever, as  a  diathesis  that  we  have  to  consider  its  relation  to  the  nervous  system. 
The  predisposition  to  disease  which  this  morbid  blood  state  manifests,  when 
once  acquired,  is  permanent,  and  the  more  conspicuous  outbreaks  are  to  be 
considered  as  a  temporary  exaggeration  of  the  peculiar  morbid  constitutional 
condition  (H.  T.  Lyman).  As  in  rheumatism  many  of  the  effects  have  to 
be  considered  from  the  standpoint  of  their  indirect  action  rather  than  their 
direct  influence  upon  the  system.  It  is  not  only  the  effect  of  the  uric  acid 
itself,  but  its  influence  in  causing  other  nutritional  changes. 

Etiology.  Heredity  is  perhaps  the  most  important  factor  in  the  list  of 
causes.  Malt  liquors  have  a  special  influence,  and  also  excess  in  eating  when 
the  habits  are  sedentary.  Lead  poisoning,  esioecially  in  chronic  cases,  and 
when  associated  with  the  free  use  of  alcohol,  is  also  a  provocative  agent. 

Pathology.  The  morbid  conditions  which  have  an  especial  bearing  on  the 
nervous  system  are  not  well  defined.  Uric  acid  and  urate  of  sodium  have 
been  found  deposited  in  the  meninges  of  the  brain  and  cord,  and  also  in  the 
neurilemma  of  the  nerves  ;  but  the  most  common  cause  of  the  changes  found 
in  these  organs  is  the  sclerosis  which  affects  both  arteries  and  veins.  We 
find  especially  the  vessels  of  the  base  of  the  brain  atheromatous,  and  an  in- 
creased quantity  of  fluid  in  the  ventricles  and  in  the  subarachnoid  space. 
The  vessels  are  at  times  partially  obliterated,  and  it  is  possible  that  when  the 
circulation  is  thus  impaired  that  the  direct  action  of  the  uric  acid  is  mani- 
fested. The  eflTect  of  gout  on  the  vessels  may  be  perhaps  best  studied  in  the 
eye.  Dr.  C.  S.  Bull^  in  an  article  entitled  "Gouty  Retinitis,  Chorio-,  and 
Neuro-retinitis,"  described  the  effects  of  gout  on  the  vascular  system  as  fol- 
lows: (1)  A  high  blood  pressure  in  the  arteries;  (2)  hypertrophy  of  the  left 
ventricle ;  (3)  hard,  incompressible  arteries  undergoing  atheromatous  change. 
From  these  may  result  apoplexy,  by  rupture  of  the  liloodvessel,  aneurism, 


186  j^EBVOUS  DISEASES  AND  THEIR  TREATMENT. 

by  dilatation  of  the  vessel,  or  angina  pectoris,  with  fatty  degeneration  of  the 
heart.  The  first  recognized  departure  from  the  normal  condition  of  the  vessel 
consists  in  stretching  of  the  tunica  media  or  elastic  layer,  and  this  process  is 
the  cause  of  a  diffused  primary  arterio-sclerosis,  characterized  by  dilatation 
and  tortuosity  of  the  arteries,  iDy  eccentric  hypertrophy  of  the  media,  and 
by  diffused  compensatory  fibrous  thickening  of  the  intima.  Cerebral  hemor- 
rhage and  thrombosis  are  common  attendants  on  these  vascular  changes.  In 
the  spinal  cord  we  find  no  special  lesions  other  than  those  dependent  upon 
the  interference  with  the  vascular  supply.  In  some  cases,  as  we  have  said, 
the  uric  acid  deposit  may  give  rise  to  direct  irritation  from  the  meninges,  as 
is  shown  by  shooting  pains  and  spasms,  or  contractures  of  muscles. 
Symptoms.  The  following  nervous  affections  are  met  with  : 
Mental  Disease.  Mental  disease  as  a  consequence  of  the  gouty  diathesis 
is  not  uncommon,  while  at  the  same  time  no  definite  form  of  insanity  can 
be  ascribed  to  it.  Melancholia  is  perhaps  the  most  common  form,  although 
mania  is  not  rare.  Depression  and  loss  of  energy  are  almost  always  asso- 
ciated with  gout,  but  this  may  increase  to  actual  insanity,  pursuing  a  course 
extending  over  months  or  years.  It  is  most  often  seen  in  "suppressed 
gout"  (Garrod),  in  wdiich  gouty  attacks  alternate  with  mental  disturb- 
ances, and  in  which  hallucinations,  delirium,  and  convulsions  are  present. 
The  poison  of  gout  is  especially  observed  in  those  hereditarily  affected  and 
in  those  of  a  neurotic  disposition.  Patients  are  more  liable  to  present 
mental  phenomena  at  the  special  periods  of  life,  such  as  the  climacteric, 
puberty,  and  old  age.  In  women  after  the  climacteric,  we  find  melan- 
cholia with  suicidal  tendencies.  The  arterio-sclerosis  with  its  accompanying 
vasomotor  disturbances  is  the  direct  result  of  the  action  of  the  toxic  material 
in  the  blood.  No  doubt  such  important  factors  as  the  cerebral  anaemia,  occa- 
sioned by  the  arterio-sclerosis,  have  their  influence,  or  there  may  be  special 
exciting  causes,  such  as  financial  or  domestic  worry,  or  excesses  of  various 
kinds.  Little  can  be  added  to  that  already  stated  concerning  the  morbid 
changes.  Arterial  disease  with  signs  of  congestion  and  serous  effusion  is 
found  in  the  brain.  The  cerebral  state  is  one  of  impaired  mental  activity, 
a  tendency  to  apathy  and  loss  of  energy  being  marked ;  or  again,  there 
may  be  the  almost  opposite  state  of  irritability  and  insomnia.  There  is  often 
an  inability  to  concentrate  the  attention  on  any  subject,  and  a  feeling,  as  one 
patient  expressed  it,  as  if  he  were  only  an  on-looker  on  what  was  occurring. 
Vascular  distui'bances,  often  sudden  in  their  onset,  occasion  vei'tigo,  tinnitus 
aurium,  and  sensory  impressions  throughout  the  body,  such  as  heat,  tingling, 
and  numbness,  or  neuralgic  pains,  which  may  secondarily  occasion  hallucina- 
tions of  sight  and  hearing.  Great  depression,  perhaps  alternating  with  ex- 
citement and  restlessness,  is  present,  and  a  fear  of  impending  evil — of  the 
loss  of  money  or  the  fear  of  committing  some  act  to  which  the  patient  is  im- 
pelled. Cephalagia  is  usually  diffused  in  character,  though  at  times  it  is 
unilateral,  and  then  is  probably  dependent  upon  a  neuritis.  This  condition 
may  continue  for  a  long  period  of  time,  changing  as  the  blood  state  varies. 
The  most  common  form  of  mental  disease  associated  with  suppressed  gout, 
however,  is  melancholia,  either  simple,  with  stupor,  or  delusional.  The  close 
relation  of  the  gouty  poison  to  the  cerebral  state  is  clearly  seen  when  an 
acute  "  external "  attack,  e.  g.,  acute  involvement  of  a  joint,  entirely  relieves 
the  mental  condition.  Permanent  dementia  may  result,  dependent  probably 
on  the  malnutrition  and  the  consequent  cerebral  atrophy  accompanying  the 
arterial  degeneration. 

In  the  meotal  affections  of  gout  the  cause  can  only  be  determined  or  made 
probable  by  the  history  of  previous  attacks  of  gout  or  by  a  marked  history 
of  heredity.     Many  of  the  hereditary  cases  occur  in  the  young  and  where 


DIATHETIC  AND  TOXIC  AFFECTIONS.  187 

no  local  manifestations  exist.  Such  conditions  most  probably  fall  under  the 
head  of  cerebral  neurasthenia.  It  is  not  infrequent,  however,  to  find  fixed 
delusions,  especially  of  doubt  and  fear,  with  suicidal  impulses.  Strict  anti- 
gout  treatment  is  always  indicated. 

Cerebral  Neurasthenia.  Lithsemia,  affecting  especially  the  cerebrum,  and 
giving  rise  to  a  large  class  of  indefinite  symptoms,  such  as  hypochondria, 
headache,  depression,  cardialgia  and  palpitation,  various  neuralgias,  etc., 
seems  to  be  a  disease  which  has  to-day  been  especially  called  to  the  atten- 
tion of  the  neurologists  and  the  profession  in  general.  Many  of  the  symp- 
toms already  detailed  in  considering  mental  disease  due  to  gout  can  be  ap- 
plied here.  Hereditary  predisposition  to  nervous  disease  is  perhaps  the 
main  factor  in  its  evolution.  Another  important  factor  is  malnutrition  de- 
pendent upon  poor  assimilation,  leading  to  non-oxidation  of  the  nitrogenous 
elements  of  the  food.  These  patients  rarely  have  gout  in  the  true  sense,  that 
is,  it  rarely  shows  itself  externally  excej)t  perhaps  in  the  irregular  form  of 
some  skin  affection.  They  are  the  victims  of  ill-health ;  they  suffer  from 
a  long  continued  impairment  of  nervous  nutrition.  On  arising  in  the 
morning  the  depression  is  generally  most  marked.  Their  sleej),  which  may 
have  been  profound,  has  not  given  a  sense  of  rest ;  headache,  usually  of  a 
general  character,  and  a  feeling  of  constriction,  are  common,  and  may  alter- 
nate with  severe  hemicrania,  cardialgia,  paroxysmal  dyspnoea,  pleurodynia, 
cramps  in  the  muscles,  tremor,  etc.  Indigestion,  flatulence,  gastralgia,  and 
constipation  are  easily  induced  by  slight  errors  of  diet.  Indisposition  to 
exertion  is  marked.  There  is  frequently  a  fear  of  doing  anything  or  going 
anywhere. 

The  prognosis  in  these  cases  is  unfavorable  as  to  complete  recovery,  though 
marked  improvement  may  be  obtained  by  attention  to  the  diet  and  living  in 
the  open  air.  General  stimulation  by  massage  and  electricity  is  also  indi- 
cated.    (See  also  Chapter  II. ) 

The  morbid  changes  are  usually  not  destructive  in  these  cases.  Rarely, 
it  has  been  said,  urate  of  sodium  has  been  found  in  the  meninges  or  on  the 
surface  of  the  cord.  In  chronic  cases,  degenerative  changes  are  found  in 
the  nerves,  and  are  the  result  of  the  general  arterio-sclerosis,  rather  than 
of  the  gout  per  se.  The  symptoms  do  not  differ  from  those  of  neuritis  in 
general,  and  will  not  be  detailed  here. 

Spinal  Diseases.  Gout  may  be  considered  as  an  etiological  factor  in 
both  acute  and  chronic  myelitis,  more  often  in  the  disseminated  than  in 
the  transverse  form.  It  probably  acts  rather  as  a  predisposing  cause  in 
most  cases  where  exposure  and  overexertion  or  traumatism  have  been 
the  immediate  or  exciting  agents.  Sudden  hemiplegia  or  paraplegia, 
which  not  infrequently  occur  in  the  gouty,  is  the  result  of  an  acute  over- 
whelming of  the  functional  activity  of  the  cord  by  the  toxic  agent.  Spinal 
meningitis  is  rare  as  a  complication ;  not  infrequently,  however,  pain  menin- 
geal in  character,  due  to  gouty  deposit  in  the  meninges,  is  present  and  disap- 
pears upon  treatment.  The  symptoms  are  fixed  pain  in  the  back,  increased  on 
movement  and  on  pressure,  and  shooting  into  the  extremities  along  the  course 
of  the  nerves  involved.  There  is  little  that  is  diagnostic  except  the  history 
of  the  presence  of  the  gouty  diathesis,  and  its  disappearance  on  the  exhibi- 
tion of  the  appropriate  drugs. 

Neuritis.  Various  nerves  may  be  involved,  but  rarely  do  we  find  multiple 
neuritis.  Paralysis  of  individual  muscles  or  groups  of  muscles  may  occur. 
The  cranial  nerves  are  often  involved.  Optic  neuritis  has  been  observed 
by  Hutchinson,  Gowers,  and  others,  and,  as  already  referred  to,  by  Dr. 
Bull.  This  writer  says  the  most  marked  feature  in  the  fundus  is  the  de- 
velopment of  the  arterio-sclerosis  and  phlebo-sclerosis.     The  changes  in  the 


188  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

optic  nerve  seem  to  be  almost  entirely  intra-ocular,  and  cannot  be  traced  for 
any  great  distance  back  of  the  eyeball. 

Neuralgia.  Neuralgia  is  very  frequent  in  gout,  especially  involving  the 
fifth  nerve,  the  sciatic,  and  the  intercostaLs.  The  superficial  distribution  of 
the  nerves  of  the  skin  are  very  often  the  seat  of  pain  of  an  acute  character, 
especially  called  out  by  sudden  changes  in  temperature.  Even  the  removal 
of  the  clothing,  or  entering  a  bath  of  too  low  or  too  high  temperature,  may 
induce  this.  Several  such  cases  have  come  under  my  observation  in  which 
the  pain  has  been  associated  with  cramps  in  the  muscles.  Visceral  neuralgias 
are  very  common.  I  believe  most  of  these  diseases  are  dependent  upon  a 
deficient  blood  supply  to  the  nerves,  owing  to  the  arterio-sclerosis  or  to  the  vaso- 
motor disturbances.  In  the  chronic  cases,  which  are  indeed  the  most  com- 
mon, as  Gowers  says,  there  is  probably  a  neuritis  present.  A  patient  at  present 
under  observation  with  trigeminal  neuralgia  gave  well-defined  anesthesia  over 
the  distribution  of  the  superior  branch  of  the  nerve,  which  disappeared  only 
upon  treatment  for  the  gouty  diathesis.  A  second  case  with  a  similar  afiec- 
tion  showed  a  reflex  spasm  of  the  muscles  of  the  ear,  resembling  a  con\a.ilsive 
tic.     Here  a  long  history  of  gout  revealed  the  basis  of  the  disease. 

General  Prognosis.  The  general  prognosis,  other  things  equal,  is  favorable 
where  strict  attention  is  paid  to  the  diet  indicated  for  gout  in  general.  In 
chronic  cases  with  arterial  changes  there  always  exists  the  danger  of 
cerebral  hemorrhage.  Chronic  renal  changes,  it  is  almost  needless  to  say, 
also  influence  the  prognosis  unfavorably. 

Treatment.  The  treatment  does  not  diflfer  from  that  laid  down  for  the 
ordinary  management  of  gout. 

UREMIA. 

Urgemia  is  a  condition  due  to  the  absorption  or  retention  in  the  blood  of 
materials  which  have  not  been  eliminated  by  the  kidneys.  The  symptoms 
are  as  definite  as  those  due  to  other  toxic  agents,  e.  g.  opium.  They  are 
also  as  temporary,  and  cease  when  the  poison  is  removed;  and,  as  with 
opium,  the  system  can  learn  to  tolerate  moderate  doses  with  but  slight  re- 
action. 

Etiology.  Ursemia  is  commonly  due  to  acute  or  chronic  nephritis  ;  perhaps 
it  is  more  often  associated  with  interstitial  nephritis.  There  is  frequently  a 
history  of  a  chronic  lead  or  alcohol  poisoning.  Bouchard  thinks  it  due  to 
faulty  elimination  of  the  kidneys.  Brown-Sequard  also  believes  that  there  is  a 
defective  kidney  secretion,  causing  a  chemical  modification  of  the  blood.  Ex- 
perimentally kidney  extract  has  relieved  the  ursemic  symptoms  where  both 
kidnevs  have  been  removed. 

Pathology.  The  changes  most  frequently  observed  in  the  brain  are  those 
associated  with  arterio-sclerosis  of  the  cerebral  vessels,  with  increase  of  fluid 
in  the  subarachnoid  space  and  in  the  ventricles,  with  not  infrequently  a  local- 
ized cedema  over  one  hemisphere. 

Symptoms.  Insanity.  Clouston  ascribes  mental  diseases  to  affections  of 
the  kidneys,  especially  those  of  the  maniacal  type ;  while  Griesinger  considers 
Bright's  disease  rare  as  a  causative  agent.  In  the  Alienist  and  Neurologist, 
1890,  Dr.  Alice  Bennett  refers  to  a  number  of  cases  of  insanity  with  Bright's 
disease  as  a  causative  agent.  While  kidney  complications  are  not  uncommon 
among  the  insane,  and  may  modify  the  course  of  the  disease,  it  is  difficult  to 
ascribe  anv  well-defined  form  of  mental  disease  to  them.  I  would  speak, 
therefore,  of  insanity  with  Bright's  disease  rather  than  of  a  special  form  due 
to  uremic  states.    A  case  of  profound  melancholia  with  delusions  of  persecu- 


DIATHETIC  AND  TOXIC  AFFECTIONS.  189 

tion  and  suicidal  attempt  came  under  my  observation,  in  which  there  Avas 
extensive  disease  of  the  kidneys,  as  revealed  by  autopsy.  No  lesion  of  the 
brain  was  present  with  the  exception  of  atheromatous  degeneration  of  the 
vessels  at  the  base,  and  an  increase  of  the  fluids  in  the  subarachnoid  space 
and  in  the  ventricles.  It  is  impossible  to  differentiate  these  symptoms  from 
those  observed  in  any  case  of  melancholia  without  affection  of  the  kidneys. 

The  acute  cerebral  symptoms  consist  of  stupor,  headache,  insomnia,  dysp- 
noea, restlessness,  muscular  twitchings,  general  convulsions,  and  hemiplegia 
with  coma.     In  the  chronic  cases  we  find  alternate  delirium  and  stupor. 

Hemiiolegia.  Hemiplegia,  or,  more  rarely,  monoplegia  of  ursemic  origin, 
has  often  been  observed,  and  several  of  these  cases  have  been  reported  with 
the  usual  symptoms — hemiplegia,  aphasia,  and  exaggerated  reflexes.  Two 
such  cases  came  recently  under  my  observation,  one  of  six  months'  dura- 
tion, the  other  proving  fatal  within  twenty-four  hours.  Careful  post-mortem 
examination  revealed  no  explanatory  cause  for  the  condition.  It  is  possible, 
as  has  been  stated  by  some  Avriters,  that  Ave  have  to  do  Avith  a  serous  effiision 
involving  a  limited  area  of  the  brain,  consequent  upon  disease  of  the  vessels 
insufficient  to  produce  a  hemorrhage  or  actual  softening.  There  may  be, 
hoAA'ever,  more  or  less  complete  obstruction  of  the  circulation,  Avhich,  Avith 
the  diseased  coats  of  the  vessels,  allows  an  exudation  through  their  AA^alls  of 
the  fluid  elements  of  the  blood  into  the  surrounding  tissues.  It  is  cer- 
tainly difficult  to  believe  that  the  poison  in  ureemia  should  select  a  definite 
area  of  the  brain,  except  in  association  Avith  disease  of  the  A^essels  at  that 
point.  There  may  be  all  the  usual  signs  observed  in  cerebi'al  hemorrhage. 
The  onset  is,  ordinarily,  sudden,  and  there  is  marked  coma.  A  diagnostic 
point  is  that  the  paralysis  may  entirely  disappear  in  a  fcAV  hours  or  days.  It 
is  commonly  an  accompaniment  of  chronic  nephritis,  Avhere  the  arteries  are 
the  seat  of  sclerosis.  If  recovery  from  the  hemiplegia  is  only  partial,  that  is, 
if  AA'e  find  traces  of  paresis  with  exaggerated  reflexes,  Ave  must  ascribe  it  to 
softening  rather  than  to  uraemia.  I  think  the  majority  of  cases  reported  will 
fall  under  the  latter  head. 

Convulsions.  Convulsions  are  of  frequent  occurrence,  and  may  be  contin- 
uous or  paroxysmal.  There  is  usually  coma  between  the  attacks,  from  Avhich 
the  patient  may  be  at  times  aroused.  These  seizures  may  be  localized  or 
Jacksonian  in  character,  though  rarely,  being  usually  clonic  and  general  in 
distribution,  resembling  those  observed  in  general  paresis.  The  onset  of  the 
copAailsions  or  of  the  delirium  may  be  sudden  or  gradual.  In  the  former 
the  jDulse  is  of  high  tension.  These  attacks  may  continue  for  days  or  Aveeks, 
the  pulse  changing  in  character  Avith  the  onset  of  the  acute  symptoms.  In 
the  fatal  cases  it  becomes  feeble  and  rapid.  In  chronic  cases  the  high-tension 
pulse  may  not  be  present,  but  instead  of  this  the  pulse  is  rapid  and  compres- 
sible. It  Avould  seem,  therefore,  that  this  condition  is  not  dependent  on  the 
ursemia — that  is,  the  filling  of  the  blood  with  poisonous  materials — but  rather 
due  to  the  contraction  of  the  vessels,  as  relief  of  this  contraction  by  the 
administration  of  nitroglycerin,  or  by  other  means,  causes  these  symptoms  to 
subside.  Again,  this  condition  may  occur  even  Avhere  the  quantity  of  urea 
is  not  diminished  and  the  specific  gravity  of  the  urine  is  normal. 

Diagnosis  It  is  frequently  difficult  to  make  a  differential  diagnosis  from 
cases  of  cerebral  hemorrhage,  either  involving  the  cortex  or  the  A'^entricles, 
especially  Avhere  hemiplegia  is  a  complication  in  ursemia ;  or,  again,  from 
pachymeningitis  hemorrhagica,  especially  as  in  these  conditions  the  urine 
frequently  contains  albumin.  In  ursemic  hemiplegia,  hoAvever,  Avhen  the 
onset  is  sudden,  there  is  usually  a  rise  of  temperature,  although  this  is  absent 
in  chronic  cases,  and  may  even  be  subnormal.  The  sudden  clearing  up  of 
the  paralysis  is,  however,  in  its  favor. 


190  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Prognosis.  The  prognosis  is  entirely  dependent  upon  the  condition  of  the 
kidneys  and  the  degree  of  associated  cardiac  and  arterial  disease.  The 
attacks  may  be  frequently  repeated,  and  the  patient  is  usually  left  weaker, 
and  there  is  less  reaction  after  each  one. 

Treatment  The  general  treatment  for  nephritis  must  be  followed.  The 
kidneys  should  be  stimulated  by  the  administration  of  copious  draughts  of 
water,  infusion  of  digitalis,  etc.  In  coma  and  other  exacerbations  of  the  ursemic 
state,  elaterium,  gr.  i,  may  be  given  to  secure  profuse  watery  stools.  By  these 
means  the  elimination  of  the  toxic  substances  in  the  blood  is  much  favored. 
However,  the  most  efficient  remedy  is  pilocarpine  hydrochlorate,  which  should 
be  given  hypodermatically  in  doses  of  gr.  i  to  gr.  i.  The  immediate  cerebral 
symptoms  are  to  be  relieved  by  attention  to  the  heart  and  arteries.  In  acute 
conditions  with  high-tension  pulse  and  convulsions,  nitroglycerin,  morphine, 
and  chloral  are  indicated.  When  the  pulse  is  feeble  and  of  low  tension,  mor- 
phine seems  to  increase  the  coma,  and  nitroglycerin  is  contraindicated.  We 
then  use  digitalis  and  strophanthus,  Avhich  act  u.nfavorably  when  the  pulse  is 
of  high  tension.  This  was  admirably  shown  in  a  case  where  alternate  condi- 
tions of  high-tension  pulse  and  a  pulse  without  tension  were  present.  Digitalis 
and  sti'ophanthus  increased  the  cerebral  symptoms  when  administered  while 
the  pulse  was  of  high  tension,  but  diminished  them  Avhen  the  pulse  was  of 
low  tension. 

ALCOHOLISM. 

Alcoholism  is  a  term  first  used  in  1848  by  Huss,  and  comprises  the  phe- 
nomena traceable  to  the  taking  into  the  system  of  alcoholic  liquors  (Foster). 
It  is  a  pathological  state  induced  by  the  excessive  use  of  alcohol,  and  is  char- 
acterized by  special  symptoms  due  to  disease  of  the  brain,  spinal  cord,  and 
peripheral  nerves. 

Etiology.  The  eflfect  of  alcohol  on  the  nervous  system  varies  with  the 
manner  in  which  it  is  taken.  Those  addicted  to  periodic  excesses  are  not  as 
liable  to  acute  inflammatory  lesions  as  those  who  habitually  use  alcohol. 
This  may  explain  the  fact  of  the  greater  frequency  of  multiple  neuritis  in 
women  than  in  men,  for  women,  if  addicted  to  the  use  of  alcohol,  are  apt  to 
take  it  continuously  in  small  doses  and  confine  themselves  to  spirits  rather 
than  to  malt  liquors.  The  predilection  of  certain  persons  to  be  afiected  by 
alcohol  is  dependent  upon  some  constitutional  condition  which  it  is  difficult 
to  explain.  This  is  also  observed  in  the  part  of  the  nervous  system  which 
may  be  selected  as  the  site  of  the  disease.  Rheumatism,  gout,  lead,  and 
heredity  have  an  important  influence  in  this  respect.  Not  sufficient  impor- 
tance is  placed  on  the  degenerative  influence  of  alcohol  on  the  children  of 
those  addicted  to  its  use.  Conjoined  with  hereditary  syphilis,  it  is  productive 
of  many  lesions  affecting  the  cranial  nerves.  Cerebral  hemiplegia,  otherwise 
rare  in  childhood,  idiopathic  epilepsy,  and  imbecility,  with  acute  and  systemic 
diseases  of  the  cord,  are  not  infrequently  traceable  to  the  same  cause. 

Pathology.  While  the  peripheral  nerves,  and  especially  the  nerve  endings, 
are  peculiarly  susceptible  to  the  poison  of  alcohol,  the  lorain  and  cord  are 
also  involved.  In  acute  alcoholism  little  pathological  change  is  observed. 
In  chronic  conditions  we  find  pachymeningitis.  The  pia  is  also  frequently 
clouded  or  thickened,  and  there  is  oedema  of  the  convex  surface  of  the  brain 
with  effiision  of  fluid  into  the  subarachnoid  space,  and  into  the  ventricles, 
causing  flattening  of  the  convolution.  Pachymeningitis  hemorrhagica  is  not 
uncommon. .  The  vessels  also  are  the  seat  of  atheromatous  changes.  The 
cells  in  the  cortex  show  degeneration,  their  processes  being  lost.  The  associa- 
tion fibres  also  are  degenerated.     This  is  found  in  manv  of  the  older  cases 


DIATHETIC  AND  TOXIC  AFFECTIONS.  191 

Avlien  dementia  is  present,  and  also  in  those  with  which  multiple  neuritis  is 
associated.  The  cranial  nerves,  especially  the  pneumogastric  and  phrenic, 
give  evidence  of  an  interstitial  neuritis.  Sharkey  refers  to  a  case  of  paralysis 
of  the  phrenic  and  pneumogastric  nerve,  in  which  the  whole  trunk  of  the 
nerve  was  involved,  and  also  the  spinal  cord!  The  spinal  cord  lesions  are 
rare,  and  may  be  of  inflammatory  type,  showing  marked  hypersemia  with 
capillary  hemorrhages  and  softening.  Dr.  David  Finlay  has  reported  a  case 
with  autopsy  in  which  the  anterior  horns  were  involved,  the  cells  being- 
shrunken  and  their  processes  lost.  Chronic  myelitic  conditions  are  not  infre- 
quent, but  are  j^robably  dependent  upon  the  arterial  degeneration,  rather 
than  upon  the  direct  influence  of  the  alcohol.  In  the  nerve  tracts  of  the 
cord  we  find  interstitial,  or,  more  rarely,  parenchymatous  disease  of  the  nerve 
fibres.  Gowers  states  that  acute  alcoholism  more  often  causes  parenchyma- 
tous inflammation,  but  we  may  have  associated  with  it  the  interstitial  form. 
The  peripheral  nerves  are  especially  affected,  and  usually  primarily.  Both 
parenchymatous  and  interstitial  changes  are  usually  present.  The  lesions,  as 
a  rule,  are  symmetrical.  The  axis  cylinder  more  rarely  escapes  than  in  lead, 
gouty,  and  rheumatic  conditions.  The  cranial  nerves  are  the  seat  of  like 
changes,  and  the  optic  nerve  may  show  granular  degeneration  and  congestion 
with  oedema.     These  changes  are  not  observed  in  acute  cases. 

Symptoms.  Insanity  may  occur  in  both  acute  and  chronic  alcoholism. 
Acute  alcoholic  mania  often  results  from  periodical  excesses  or  from  the 
sudden  withdrawal  of  alcohol.  The  system  is  overwhelmed  with  the  poison. 
Associated  with  this  as  a  direct  cause  is  exhaustion  from  malnutrition.  The 
symptoms  of  mania  a  potu  are  too  familiar  to  require  a  description  in  detail. 
Tremor  is  a  marked  feature,  involving  the  extremities,  and  also  the  muscles 
of  the  face  and  tongue.  There  is  excitement  or  delirium,  accompanied  by 
hallucinations  of  sight  and  hearing.  The  patient  is  constantly  talking  with 
imaginary  persons.  Sensory  disturbance  due  to  peripheral  nerve  irritation, 
not  sufficient  to  cause  loss  of  sensation,  produces  parsesthesise  which  frequently 
give  rise  to  illusions  of  animals  moving  over  the  skin.  It  would  seem  also 
that  many  of  the  hallucinations  of  sight  may  owe  their  origin  to  the  same 
cause. 

Inco-ordination  of  voluntary  movement  is  one  of  the  earliest  results  of 
the  abuse  of  alcohol,  as  shown  in  ataxia  of  the  ujDper  and  lower  extrem- 
ities. It  may  affect  the  muscles  of  the  eyes,  causing  vertigo.  In  one  patient 
with  marked  vertigo  the  furniture  in  the  room,  sucli  as  the  tables  and  chairs 
and  pictures,  all  seemed  to  be  rising  from  their  places,  so  that  he  constantly 
requested  that  they  be  held  down.  Coma  is  at  times  complete,  the  breathing- 
stertorous,  and  the  reflexes  lost.  The  patients  can  usually  be  aroused,  but 
pass  quickly  back  into  unconsciousness.  In  the  subacute  or  chronic  state  the 
condition  may  resemble  general  paralysis  of  the  insane,  with  marked  tremor, 
excitement,  and  delusions  of  grandeur. 

Chronic  Alcoholic  Insanity.  This  is  probably  due  to  the  secondary  eflfect 
of  alcohol  on  the  vessels,  leading  to  arterial  degeneration  and  consequent 
organic  changes  in  the  brain  structure,  already  alluded  to.  It  tends  toward 
dementia.  There  are  most  commonly  present  delusions,  esi^ecially  of  suspicion 
of  infidelity  of  wife  or  husband,  delusions  of  persecution,  with  fear  of  poison- 
ing and  dread  of  impending  evil.     The  jDrognosis  is  necessarily  unfavorable. 

Pachymeningitis.  This  is  a  common  condition  in  chronic  alcoholism.  The 
dura  and  pia  are  involved,  and  the  vessels  diseased.  The  symptoms  are 
those  of  irritation,  stupidity,  loss  of  memory,  and  frequently  convulsions. 
There  may  be  meningeal  hemorrhage,  usually  subdural,  accompanied  by  con- 
vulsions, hemiplegia,  and  coma.  The  diffei'ential  diagnosis  from  intra-cerebral 
hemorrhage  is  difficult.     A  previous  history  of  alcoholism  and  convulsions. 


192  NEEVO US  DISEASES  AND  THEIR  TREATMENT. 

especially  if  limited  to  one  side,  perhaps  with  a  history  of  a  slight  injury  to 
the  head,  will  aid  us.  These  symptoms  may  result  long  after  the  use  of 
alcohol  has  been  given  up.  An  early  diagnosis  becomes  important  where  an 
operation  for  the  relief  of  the  meningeal  hemorrhage  is  contemplated.  In  a 
patient  recently  under  obseryation,  with  an  alcohoHc  history,  and  paralysis 
and  conyulsions  affecting  one  side,  the  symptoms  were  entirely  removed  by 
trephining,  a  large  subdural  hemorrhage  being  found.    See  also  Chapter  XIII. 

Epilepsy.  Epilepsy  is  frequently  the  result  of  the  meningeal  complication. 
Epileptic  seizures  may  occur  during  the  excessive  use  of  alcohol,  and  the  epi- 
leptic condition  become  established,  although  alcohol  be  afterward  abstained 
from.  Children  of  alcoholic  parents  are  especially  subject  to  idiopathic 
epilepsy. 

Spinal  Diseases.  Alcohol  is  rarely  the  direct  cause  of  inflammatory  affec- 
tions of  the  cord ;  however,  disease  of  the  anterior  horns  and  degeneration  of 
the  white  tracts  of  the  cord  may  occur.  It  is  probable  that  some  of  the  cases 
of  alcoholic  neuritis  with  symptoms  resembling  locomotor  ataxia  are  also 
associated  with  disease  of  the  posterior  columns.  Pal  refers  to  a  case  with 
degeneration  of  Lissaur's  tract  in  the  lumbar  region  and  of  GoU's  tract  in  the 
cervical  region.  Capillary  hemorrhages  may  occur.  A  case  resembling  Lan- 
dry's paralysis  gave  the  following  post-mortem  lesions  :  h}^erffimia  of  the  cere- 
bellum, medulla,  and  cord,  with  capillary  hemorrhages  in  the  posterior  horns 
in  the  lumbar  region,  and  in  the  anterior  horns  of  the  cervical  region,  third 
to  sixth  segment,  with  degeneration  in  the  vagus,  both  phrenics,  and  the  right 
sciatic  nerve. 

Chi'onic  diseases  of  the  cord,  meningitis  and  myelitis,  are  more  common. 
Without  doubt  alcohol  acts  as  a  predisposing  cause  to  various  lesions, 
especially  if  associated  with  lead  or  sj^Dhilis.  As  already  seen,  the  degene- 
rative influence  of  alcohol  is  not  confined  to  the  peripheral  system.  Buzzard 
indeed  holds  that  the  changes  in  the  nerves  are  secondary  to  lesions  produced 
by  alcohol  in  the  vasomotor  centres  of  the  bulb  and  cord,  leading  thus  to 
anaemia  and  hyperemia,  and  then  to  degeneration  or  inflammation. 

jSfeuritis.  Multiple  neuritis  is  the  form  most  usually  found  in  connection 
with  alcohol.  The  lower  extremities  are  first  involved,  and  later  the  upper. 
There  is  usually  marked  foot  and  wrist  drop  with  atrophy.  Pain  is  present, 
especially  called  forth  on  pressure  over  the  muscles  and  along  the  nerves. 
Electrical  reaction  to  faradism  is  lost,  and  partial  or  complete  reaction  of 
degeneration  to  galvanism  is  present.  The  reflexes  are  absent.  The  course 
of  the  disease  may  be  very  rapid,  suggesting,  as  in  one  case  referred  to, 
Landry's  paralysis ;  or,  again,  it  may  be  very  slow,  resembling  tabes.  In 
severe  and  fatal  cases  the  vagus  and  phrenic  are  involved.  Contractures 
are  common  from  overaction  of  the  muscles  not  involved.  The  legs  are 
usually  flexed  at  the  knee,  and  the  hands  present  the  claw-shaped  appearance. 
There"^may  be  marked  trophic  changes  present,  as  perforating  ulcer,  cedema, 
erythema,  falling  off  of  the  nails,  bullous  eruptions,  bed-sores,  etc.  Rarely 
do  we  find  the  bladder  or  rectum  involved.  The  cranial  nerves  are  fre- 
quently affected,  although  these  lesions  are  comparatively  rare,  considering 
the  large  number  of  cases  of  neuritis.  Ophthalmoplegia  externa,  in  which 
the  third,  fourth,  and  sixth  nerves  are  involved,  has  been  observed.  Thomsen 
refers  to  a  case  with  degeneration  of  the  neuclei  of  the  sixth,  fourth,  third, 
and  hypoglossal  nerves.  Mental  symptoms  are  usually  present,  manifesting 
themselves  frequently  by  loss  of  all  idea  of  time  and  place.  In  such  cases 
there  is  probably  degeneration  of  the  cells  in  the  cortex  of  the  brain  and  the 
association  fibres.  The  pathological  changes,  as  already  stated,  are  those  of 
parenchymatous  and  interstitial  inflammation  of  the  nerves.  See  also 
Chapter  XXV. 


DIATHETIC  AND  TOXIC  AFFECTIONS.  193 

Prognosis.  For  the  prognosis  of  the  diseases  caused  by  alcohol  the  reader 
is  referred  to  the  various  chapters  in  which  they  are  considered  in  detail. 
The  prognosis  in  neuritis  is  generally  favorable,  complete  recoveries  occurring 
where  paralysis  has  existed  for  six  months  or  a  year.  Naturally,  however,  if 
the  vagus  or  phrenic  is  involved,  cardiac  failure  or  respiratory  disease  may 
cause  a  fatal  termination. 

Treatment.  The  general  treatment  of  alcoholism  consists  first  in  the 
withdrawal  of  the  poison.  Acute  conditions  require  sedatives  to  produce 
sleep.  The  usual  exhibition  of  the  bromides  with  chloral  and  digitalis  is 
often  the  most  effective.  Somnal,  trional,  and  sulphonal  are  to  be  used  for 
the  insomnia  in  preference  to  morphine.  However,  in  very  many  cases  they 
prove  inefficient,  and  then  sleep  and  cessation  from  delirium  are  best  obtained 
by  hypodermic  injections  of  morphine,  or  of  morphine  with  hyoscyamia,  or 
hyoscine  hydrobromate.  Strychnine  in  large  closes  has  been  used  with  good 
results ;  however,  in  my  experience  the  moderate  exhibition  of  the  drug — 
one-fiftieth  of  a  grain — with  digitalin,  is  to  be  recommended.  Nourishment 
must  be  given  as  soon  as  jDOSsible.  In  neuritis,  absolute  rest,  relief  of  pain — 
by  antipyrine  and  phenacetine,  and  the  exhibition  of  strychnine,  with  the 
use  of  massage  and  electricity  as  early  as  possible,  and  attention  to  the  relief 
of  deformities,  constitute  the  appropriate  treatment.  Hypodermic  injections 
of  strychnine  do  not  seem  to  offer  greater  advantages  than  the  administration 
of  the  drvig  by  the  mouth,  and  there  is  some  danger  of  suppuration  following 
from  the  lowered  trophic  condition  which  exists. 


MORPHINISM. 

Morphinism  may  be  defined  as  the  morbid  craving  for  morphine  as  a  stimu- 
lant. 

Etiology.  The  habit  is  usually  acquired,  at  least  in  the  Western  Hemis- 
phere, from  the  use  of  morphine  to  relieve  pain,  insomnia,  etc.  The  predis- 
position varies  with  the  inclividual.  Hereditary  influence  is  of  great  impor- 
tance. Especially  predisposing  are  the  various  neuroses,  such  as  neurasthenia 
and  dipsomania.  This  is  also  true  of  phthisis  and  other  acquired  and  in- 
herited degenerative  conditions.  "  The  offspring  of  the  victim  to  the  mor- 
phine habit  has  a  condition  of  the  nervous  system  such  as  once  subjected  to  the 
exciting. cause  develops  the  tendency  rapidly"  (Hoppel).  The  employment 
of  morphine  in  intense  pain,  which  occurs  periodically,  does  not  in  my  experi- 
ence predispose  to  the  habit ;  nor  in  these  patients  is  the  usual  physiological 
cerebral  exaltation  present.  A  not  infrequent  cause  of  the  habit  is  dysentery 
or  other  intestinal  disturbances  of  a  chronic  nature.  Here  the  drug  may  be 
taken  by  the  rectum,  and  will  often  be  continued  by  that  method.  Its  abuse 
is  often  associated  with  that  of  other  drugs,  especially  alcohol,  and  of  late 
years  with  cocaine. 

Pathology.  The  pathological  changes  are  not  definite.  In  no  case  can  we 
ascribe  them  directly  to  the  drug.  Russell,  however,  holds  that  after  a  few 
years  organic  visceral  changes  are  set  up. 

Symptoms.  The  habitual  use  of  the  drug  seems  to  establish  an  unstable 
condition  of  the  nervous  system.  Mentally,  we  observe  vacillation  and 
lack  of  energy,  apathy  and  procrastination  unless  the  stimulant  is  taken. 
The  will  power  is  lost,  and  the  patients  become  forgetfiil  and  unreliable.  The 
moral  nature  is  changed,  and  to  procure  the  desired  drug  patients  will  lie  and 
steal.  They  are  always  to  be  distrusted.  This  is  not  peculiar  to  morphine, 
but  is  found  in  all  victims  of  drug  habits.  There  is  rarely  a  pleasurable  sen- 
sation accompanying  the  taking  of  morphine  in  these  cases ;  that  is,  lively  im- 

13 


194  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

agination  and  pleasant  memories  are  not  present,  nor  does  sleep  result.  Any 
.great  excesses  occurring  in  the  course  of  chronic  morphinism  may  give  rise 
to  acute  maniacal  symptoms,  hallucinations,  and  delusions  of  persecution. 
This  was  the  case  with  an  habitual  morphine-taker,  who,  on  what  he  called  his 
"  morphine  drunks,"  claimed  to  have  taken  sixty  grains  in  twenty-four  hours. 
The  most  marked  nervous  symptoms  are  observed  on  the  withdrawal  of  the 
drug.  There  is  intense  anxiety,  a  dread  of  some  impending  evil ;  the  person 
may  even  become  maniacal.  There  is  marked  insomnia  and  restlessness,  with 
depression,  and  frequently  suicidal  intent.  The  mind  is  ultimately  affected 
with  a  form  of  dementia,  with  chronic  delusions  of  persecution.  We  can 
hardly  say,  however,  that  we  have  a  distinct  form  of  insanity  due  to 
morphinism.  Certain  it  is  that  in  many  cases  excessive  habitual  use  of  mor- 
phine is  carried  on  for  years  with  no  mental  deterioration. 

Motor  Symptoms.  The  physical  signs  of  the  disease  are  tremor  and  more 
or  less  paresis,  which,  indeed,  in  the  more  chronic  cases  is  constant,  but  appears 
only  in  those  of  more  recent  date  on  the  withdrawal  or  decrease  of  the  amount 
of  the  drug.  There  is  at  times  ataxia.  The  latter  symptom  was  specially 
marked  in  a  patient  in  whom  the  amount  of  morphine  had  been  reduced  from 
six  grains  a  day  to  one-eighth  of  a  grain.    The  reflexes  are  not  usually  affected. 

Sensory  Symptoms.  Neuralgia  of  any  special  nerve  is  rare,  but  pains,  dif- 
fuse and  neuralgic  in  character,  are  common.  This  is  frequently  observed 
where  the  drug  has  been  given  a  long  time  for  some  special  pain,  as  in  loco- 
motor ataxia  or  neuralgia,  making  it  difficult  in  such  cases  to  differentiate 
the  real  pain  from  those  of  the  drug.  Possibly  a  neuritis  is  at  the  basis  of 
this  condition.  Vesical  and  rectal  paresis  are  common.  Constipation  or 
diarrhoea  may  be  present.  The  jDupils  are  usually  contracted ;  this  symptom 
is  more  decided  when  the  patient  is  under  full  physiological  effect  of  the 
drug.  Vasomotor  disturbances  manifest  themselves  by  a  tendency  to  profuse 
sweating.  This  symptom  also  is  chiefly  noticeable  on  decreasing  the  drug. 
The  pulse  is  rapid  and  compressible.  General  nutrition  fails,  so  that  emacia- 
tion is  common.  Trophic  changes  are  present,  as  shown  by  a  tendency  to  the 
formation  of  abscesses  at  the  site  of  hypodermic  injections. 

Diagnosis.  The  diagnosis  is  not  difficult.  The  tremor,  the  mental  condi- 
tion, the  pupils,  and  the  sweating  are  characteristic,  especially  when  consid- 
ered along  with  the  knowledge  of  the  habits  of  the  patients. 

Prognosis.  The  prognosis  is  almost  always  unfavorable  as  regards  a  cure 
of  the  habit,  although  its  regulation  and  moderation  can  often  be  established. 

Treatment.  The  various  modes  of  treatment  are  :  1.  Instant  withdrawal ; 
2,  gradual  withdrawal  by  daily  decreasing  the  dose ;  and,  3,  the  rapid  with- 
drawal within  a  few  days.  I  have  seen  all  these  methods  successful.  There 
is  always  great  danger  in  asthenic  cases  from  cardiac  failure  when  sudden 
withdrawal  is  practised.  In  a  patient  addicted  to  the  habit  for  many  years 
several  weeks  after  total  withdrawal  death  suddenly  occurred  from  heart 
failure.  The  autopsy  revealed  a  fatty  heart  and  a  contracted  kidney.  The 
heart  must  be  constantly  watched,  and,  on  evidence  of  failure,  strychnine, 
digitalin,  or  nitroglycerin  administered.  The  substitution  of  other  drugs, 
such  as  chloral,  codein,  or  cocaine,  is  not  to  be  recommended.  I  believe  in 
the  gradual  withdrawal,  and  that  this  is  best  carried  out  in  some  institution 
away  from  home.  An  important  point  to  secure  permanent  recovery  is  to 
have  the  patient  report  regularly  to  the  physician,  as  the  tendency  to  relapse 
is  common.  It  is  not  as  difficult  to  entirely  cut  off"  the  morphine  as  to  pre- 
vent its  being  again  used  when  the  patient  is  exposed  to  the  worry  and  cares 
of  life.     . 


DIATHETIC  AND  TOXIC  AFFECTIONS.  195 


CHLORALISM. 

The  habit  is  often  acquired  from  the  employment  of  the  drug  to  produce 
sleep. 

The  symptoms  of  acute  chloral  poisoning  indicate  paralysis  of  the  vaso- 
motor centres.  In  severe  cases  death  occurs  from  heart  failure,  with  prelimi- 
nary symptoms  in  the  early  stage  of  excitement  and  delirium,  but  later 
dyspnoea,  vertigo,  paralysis  of  the  lower  extremities,  and  parsesthesias.  In 
chronic  cases  of  prolonged  use  of  the  drug  there  may  be  marked  nervousness, 
insomnia,  mental  weakness,  depression  to  the  extent  of  melancholia,  tremor, 
general  weakness,  and  palpitation.  The  sudden  withdrawal  of  the  drug 
causes  an  increase  of  these  symptoms.  Excessive  nervousness  and  dyspnoea, 
with  cardiac  palpitation,  may  come  on,  and  this  may  even  pass  into  mania 
or  melancholia  with  great  agitation.  The  cerebral  anaemia  induced  in- 
chronic  conditions  results  in  dementia. 

The  somatic  signs  are  those  pointing  to  vasomotor  disturbance,  as  shown 
in  the  lividity  of  the  face  and  neck,  and  the  appearance  of  urticarial  ery- 
thema in  the  skin.  There  may  be  excessive  diarrhoea  from  the  same  cause. 
The  prognosis  is  largely  dependent  on  the  association  of  the  habit  Avith  the 
use  of  other  drugs.  It  also  depends  on  the  predisposition  or  hereditary 
tendency,  as  shown  by  the  presence  of  acquired  or  inherited  neuroses.  Treat- 
ment consists  in  stimulation  with  coffee  and  strychnine,  the  use  of  tonics,  and 
supporting  measures  generally. 

For  habitual  users  of  the  drug  its  gradual  withdrawal  is  preferable — with 
constant  cardiac  stimulation,  and  combatting  insomnia  by  less  harmfiil  drugs, 
as  sulphonal,  etc.,  with  massage  and  electricity. 


COCAINISM. 

Etiology.  The  habit  has  been  largely  caused  by  the  frequent  use  of  cocaine 
in  nose  and  throat  diseases. 

It  is,  however,  rarely  acquired  unless  there  is  a  strong  neuropathic  ten- 
dency. The  use  of  cocaine  is  common  among  those  addicted  to  other  drugs, 
as  morphine,  alcohol,  chloral,  etc.  It  is  either  taken  as  a  substitute  in  the 
attetnpt  to  break  up  a  former  drug  habit,  or  more  often  in  the  desire  to  find 
some  new  stimulant.  The  cocaine  habit  rarely  exists  alone.  Medical  men 
are  said  to  be  especially  prone  to  it. 

The  production  of  toxic  effects  depends  somewhat  on  the  manner  of  ad- 
ministration. The  hydrochlorate  of  cocaine  has  greater  toxic  effect  than  the 
phenate.  Also  when  it  is  applied  over  a  large  area  of  the  mucous  membrane 
the  results  are  more  dangerous. 

Certain  persons  have  an  idiosyncrasy  toward  cocaine — small  doses  produc- 
ing almost  immediate  toxic  effects.  Again,  on  the  other  hand,  excessive 
amounts  may  be  taken  before  a  result  is  produced. 

Pathology.  It  is  difficult  to  define  the  changes  solely  due  to  its  chronic 
use,  as  many  other  causes  are  usually  present  capable  of  producing  moi'bid 
conditions. 

Degeneration  in  the  ganglion  cells  of  the  medulla  and  spinal  cord  have 
been  noted,  and  the  coats  of  the  arteries  have  been  found  diseased. 

Few  cases  come  under  observation  for  autopsy,  and  as  the  symptoms  are 
largely  of  a  functional  character  we  would  hardly  expect  much  organic 
change,  especially  when  complications,  such  as  the  habitual  use  of  other 
toxic  agents,  are  absent. 


196  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Symptoms.  Locally,  paralysis  both  of  the  motor  and  sensory  nerves  is 
produced.  The  cerebral  symptoms  seem  to  depend  on  the  vascular  disturb- 
ance. There  is  usually  excitation,  the  person  becoming  brilliant  and  lively. 
This  may  be  observed  especially  in  those  Avho  have  become  addicted  to  its 
use  for  nasal  or  throat  complications,  and  is  probably  explainable  on  the 
ground  of  the  relief  of  the  arterial  congestion  present  and  the  primary  car- 
diac stimulation.     The  pupils  are  dilated. 

Its  persistent  use  causes  early  loss  of  mental  and  moral  control.  Fre- 
quently hallucinations  of  the  special  senses — hearing,  sight  and  smell — may 
be  present.  There  may  also  be  delusions  of  persecution  and  delirium.  The 
pulse  becomes  rapid  and  feeble,  and  vasomotor  disturbances,  showing  them- 
selves by  sweating,  are  common. 

In  one  case  under  my  observation  tinnitus  aurium  was  constant.  It  was 
subject  to  a  paroxysmal  increase,  ending  in  slight  epileptic  seizures  in  which 
partial  loss  of  consciousness  was  present.  The  convulsive  seizures  were  strictly 
limited  to  the  muscles  of  the  eyes,  there  being  bilateral  oscillation  of  the 
eyeballs  with  dilatation  of  the  pupils. 

There  is  evidence  of  gradual  mental  deterioration  and  loss  of  self-control. 
Zanchewski  regards  sexual  depravity  and  loss  of  the  sense  of  the  passage  of 
time  as  important  symptoms.  He  further  says  that  cocainism  may  eventuate 
in  chronic  paranoia. 

It  is  difficult  to  separate  the  various  symptoms  due  to  the  use  of  other 
drugs,  especially  alcohol  and  opium,  as  in  them  we  also  find  delusion,  of  sus- 
picion and  persecution,  and  the  same  tendency  to  deceit  and  lying  to  obtain 
the  needed  stimulant. 

Prognosis.  The  prognosis  is  favorable  when  we  have  not  to  deal  with 
other  habits. 

Treatment.  When  the  drug  is  stopped,  the  symptoms,  under  stimulating 
and  sustaining  treatment,  strychnine,  sparteine,  digitalis,  disappear.  Massage, 
electricity,  and  exercise  are  indicated.  Again,  treatment  at  a  sanitarium 
away  from  home  is  advisable.  I  see  no  advantage  in  sudden  withdrawal, 
believing,  as  in  morphine,  that  the  gradual  decrease  of  the  amount  taken 
causes  less  constitutional  disturbance,  and  is  more  lasting  in  its  effect.  This 
only  applies  when  the  patient  can  be  treated  away  from  home,  or  is  under 
special  observation.  If  he  continues  at  his  ordinary  occupation  it  is  best  to 
cut  off  the  drug  as  rapidly  as  possible,  and  in  these  cases  strychnine  is  most 
useful,  producing  a  feeling  of  rest  and  strengthening  the  pulse.  Large  doses 
can  be  taken — ^  of  a  grain,  in  divided  doses,  daily. 


LEAD  POISONING-. 

There  is  a  marked  tendency  to  the  selection  of  nerve  tissue  by  lead.  Espe- 
cially is  this  seen  in  the  peripheral  nerves.  The  brain  and  spinal  cord  are, 
however,  also  affected.  We  have  two  conditions  to  consider :  First,  a  direct 
intoxication  or  overwhelming  of  the  nervous  system  by  lead  present  in  the 
blood,  a  condition  which  can  be  compared  to  acute  alcoholism  ;  and,  secondly, 
a  chronic  absorption  of  the  poison,  which  jDroduces  a  class  of  symptoms  de- 
pendent to  a  large  extent  on  degenerative  changes  indviced  in  the  arterial 
system,  and  secondarily  on  the  central  and  peripheral  nervous  system. 

Etiology.  The  usual  cause  of  lead  poisoning  is  exposure  in  the  various 
occupations  in  which  the  metal  is  employed.  It  is  inhaled  as  dust  and 
absorbed-  through  the  skin  and  intestinal  tract  by  those  occupied  in  the 
manufacture  of  white  lead,  by  compositors,  painters,  etc.  Lead  poisoning  is 
also  produced  by  the  use  of  certain  cosmetics  and  hair  dyes,  though  this 


DIATHETIC  AND  TOXIC  AFFECTIONS.  197 

does  not  occur  as  frequently  at  present  as  formerly.  Another  source  of 
poisoning  is  the  drinking  of  water  which  has  been  allowed  to  stand  in  tanks 
lined  by  lead  or  in  lead  pipes. 

Symptoms.  Insanity.  Mental  disease  may  present  itself  in  the  following 
forms,  according  to  Dr.  Raynor,  viz. :  (1)  that  of  coarse-lead  poisoning,  jDro- 
ducing  attacks  of  acute  mania  and  conditions  resembling  general  paresis, 
such  as  Tanquerel  described  under  the  term  "  lead  encephalopathy ;"  (2) 
cases  of  minute  and  protracted  lead  intoxication,  producing  slowly-develop- 
ing sensory  hallucinations,  noticeable  by  the  absence  of  delusions  of  persecu- 
tion, and  by  the  persistence  of  hallucinations  of  vision ;  and  (3)  cases  in 
which  there  is  some  coarse  toxaemia.  In  the  first  form  the  gait  and  symptoms 
may  closely  resemble  general  paresis.  It  is  not  infrequent  to  find  the  alcohol 
habit  associated  with  lead  poisoning,  so  that  the  symptoms  are  frequently  a 
combination  of  those  belonging  to  both  states.  Probably  the  alcohol  favors 
the  more  ready  absorption  of  the  lead.  Certainly,  in  countries  where  malt 
liquors  are  largely  used  such  symptoms  are  more  frequent.  While  the  symp- 
toms in  these  cases  often  resemble  general  paresis,  they  difier  in  many  respects 
from  genuine  cases  of  this  disease.  As  a  rule,  we  do  not  find  the  marked  ex- 
altation with  delusions  of  grandeur.  Delasauve,  as  far  back  as  1851,  speaks  of 
pseudo-paralysie  generale  saturnine.  True  general  paralysis  may,  however,  be 
caused  by  lead.  Dr.  Savage  refers  to  a  case  of  acute  mania  with  hallucina- 
tions of  sight  and  hearing,  and  finds  three  forms  due  to  lead:  (1)  acute 
mania ;  (2)  conditions  of  hallucinations  ;  and  (3)  a  condition  resembling 
general  paresis. 

General  Cerebral  Affections.  These  manifest  themselves  in  acute  and 
chronic  forms.  In  the  former  we  observe  cephalalgia,  vertigo,  epileptic 
convulsions,  delirium,  tinnitus  aurium,  diplopia,  hallucinations  of  sight  and 
hearing,  and  delusions  of  persecution  with  mania.  Severe  cases  pass  into 
coma.  Chronic  conditions  are  more  liable  to  take  the  form  of  melancholia, 
with  delusions  of  persecution,  and  a  tendency  to  suicide. 

Tanquerel  divided  saturnine  encepalopathy  into  four  forms :  (1)  the  delir- 
ious ;  (2)  the  comatose  ;  (3)  the  convulsive  ;  and  (4)  the  mixed.  He  found 
cerebral  atrophy  and  an  increase  of  the  fluids  in  the  brain  usually  present. 

O'CarroU  reports  several  cases,  in  one  of  which  there  was  right  hemiplegia 
with  a  tremor  and  aphasia.  Urine  normal ;  death  with  convulsions.  Au- 
topsy showed  cedema  of  the  brain,  increase  of  fluids,  with  flattening  of  the 
convolutions.    The  cells  of  the  cortex  were  not  atrophied,  but  were  pigmented. 

Two  theories  for  the  production  of  the  symptoms  have  been  advanced : 
first,  the  direct  influence  of  the  lead  in  the  small  arteries  and  capillaries  of 
the  brain,  causing  ansemia,  or  secondly,  oedema  of  the  brain,  causing  compres- 
sion of  the  capillaries.     Probably  both  causes  are  active. 

Hemiplegia.  Hemiplegia  following  cerebral  hemorrhage  or  softening  may 
occur,  due  to  endarteritis  of  the  cerebral  vessels.  Not  infrequently  nephritis 
is  a  complication,  and  may  give  rise  to  accompanying  ursemic  symptoms. 
Convulsions  of  a  hystero-epileptic  type  with  hemiansesthesia  and  functional 
hemiplegia  may  be  present.  These  transient  conditions  may  also  involve  the 
optic  nerves,  causing  amaurosis  or  even  hemianopsia,  and  seem  to  point  to  a 
direct  action  of  the  poison.  Permanent  anatomical  changes  may  occur  in 
the  optic  and  other  cranial  nerves. 

Acute  cerebral  conditions  may  supervene  in  the  course  of  chronic  infection, 
and  this  has  also  been  observed  when  the  iodide  of  potassium  has  been  given. 
Dr.  McDonald  reports  that  among  those  employed  in  the  New  Castle  Lead 
Works,  where  previously  no  symptoms  had  manifested  themselves,  the  exhibi- 
tion of  iodide  of  potassium  induced  marked  symptoms  of  lead  poisoning — 
convulsions,  coma,  etc.     While  epileptiform  seizures  are  not  infrequent,  it  is 


198  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

not  probable  that  essential  epilepsy  is  caused  by  lead.  Hysteria  is  frequently 
present,  but  can  hardly  be  considered  as  being  due  to  the  poison.  In  such 
cases  it  is  j^robably  latent,  and  only  called  out  by  the  poison  acting  as  an 
exciting  agent. 

Spinal  Diseases.  Poliomyelitis,  chronic  or  subacute,  is  not  uncommon. 
The  disease  is  subsequent,  as  a  rule,  to  the  peripheral  nerve  affection,  but  may 
be  primary.  We  find  also  diffuse  scleroses  of  the  nerve  tracts  of  the  cord. 
These  degenerations  are  probably  due  to  the  changes  in  the  bloodvessels,  and 
the  resulting  malnutrition.  Ascher  holds  that  it  may  be  through  the  cord 
that  the  nerves  are  affected.  He  reports  a  case  of  a  typical  character,  in 
which  there  was  paralysis  and  wasting  of  the  forearm  of  the  right  side  and 
j)aralysis  and  wasting  of  the  shoulder  on  the  left  side.  {Berliner  klinische 
Wochenschrift,  1893.)  He  apparently  considers  the  case  as  one  of  polio- 
myelitis. 

Periioheral  Palsies.  The  peripheral  nerves  are,  as  a  rule,  the  first  part  of 
the  nervous  system  to  be  affected  by  lead,  and  this  is  especially  true  of  those 
supplying  the  extensor  muscles  of  the  hand  and  fingers.  The  selection  may 
depend  upon  the  more  extensive  use  of  these  members.  The  disease  is 
generally  symmetrical,  commencing  first  in  one  hand,  usually  the  right,  caus- 
ing wrist-droiD,  and  then  extending  to  the  left  hand.  Double  wrist-drop 
therefore  results.  The  paralysis  may  involve  the  shoulder.  Considerable 
atrophy  is  observed.  While  not  infrequently  the  patients  state  that  the  onset 
is  sudden,  this  is  not  the  rule.  The  hand  and  fingers  are  usually  flexed,  and 
very  little  power  of  flexion  can  be  called  out  unless  support  be  given  to  the 
paralyzed  extensors,  when  the  flexors  are  found  to  be  normal.  The  supinator 
longus  and  triceps  usually  escape.  Cases  occur,  however,  in  which  the  supi- 
nators and  shoulder  muscles  are  involved,  including  the  deltoid  and  biceps. 
AVe  may  have  the  median  and  ulnar  nerves  affected,  resulting  in  a  wasting  of 
the  hand  muscles.  This  is  particularly  seen  in  the  ball  of  the  thumb  and  the 
interossei.  The  lower  extremities  are  only  exceptionally  affected.  At  times 
in  acute  cases,  paralysis  may  be  general,  involving  the  muscles  of  the  trunk 
also.  Tremor  is  present  where  paralysis  is  marked,  but  it  is  rather  one  of 
weakness  than  an  intention  tremor.  Fibrillary  twitching  is  observed  in  the 
muscles  as  they  atrophy.  Sensibility  is  not  much  affected.  Deep  pressure 
over  the  nerve  may  elicit  pain.  Associated  with  the  wasting  there  is  fre- 
quently some  swelling  over  the  wrist  and  metacarpal  bones.  Electrical  reac- 
tions show  complete  loss  of  faradism,  and  generally  a  partial  reaction  of 
degeneration,  although,  in  some  cases,  there  is  simply  a  reduction  of  the 
response  to  both  currents. 

Diagnosis.  Lead  j)aralysis  distinguishes  itself  from  alcoholic  neuritis  in 
the  absence  of  the  extreme  tenderness  of  the  muscles  and  nerves  observed  in 
the  latter,  and  also  in  the  manner  of  its  onset,  the  upj)er  extremities  being 
the  first  and  usually  the  only  parts  affected.  In  arsenical  paralysis  the  parts 
effected  are  first  the  legs,  and  often  the  loss  of  power  is  limited  to  them.  In 
lead  poisoning  there  is  at  times  a  close  resemblance  to  poliomyelitis  and  pro- 
gressive muscular  atrophy.  However,  the  distribution  and  manner  of  onset 
of  the  paralysis  differ.  In  the  latter  affections  both  the  extensor  and  flexor 
groups  of  muscles  suffer.  The  history  of  exposure  to  lead  and  the  appearance 
of  the  characteristic  blue  line  along  the  gums  aid  in  establishing  the  diagnosis. 
In  atypical  cases,  however,  especially,  in  affections  of  the  anterior  horns,  it  is 
necessary  to  remember  that  disease  of  the  cord  may  be  present,  and,  indeed, 
in  a  few  cases  the  primary  disease  is  in  the  cord  itself. 

As  we  have  seen,  there  is  often  great  resemblance  at  times  to  general 
paresis,  and  lead  may  be  the  direct  cause  of  that  disease ;  there  is  rarely, 
however,  the  same  exaggeration  of  ideas  and  delusions  of  grandeur  and  gen- 


DIATHETIC  AND  TOXIC  AFFECTIONS.  199 

eral  feeling  of  well-beiug,  and  the  tremors  do  not,  as  a  rule,  affect  the  muscles 
of  the  face  and  tongue.  The  diagnosis  in  cases  where  the  cause  is  obscure, 
as  when  water  has  been  used  from  a  lead-lined  tank  unknown  to  the  physician, 
or  cosmetics  have  been  used,  is  often  difficult.  Urgemia  may  be  mistaken  for 
it,  especially  as  the  kidneys  are  often  involved.  Flint  and  Lauder  Brunton, 
indeed,  ascribe  many  of  the  symptoms  of  lead  to  ureemia.  Epilepsy  cannot 
be  distinguished  from  the  essential  form,  except  through  the  history  of  lead. 
Sufficient  has  been  said  to  call  attention  to  the  difficulty  of  diagnosis  in  cases 
Avhen  the  anterior  horns  of  the  spinal  cord  are  involved.  It  resembles  at  times 
very  closely  progressive  muscular  atrophy.  It  is  in  the  irregular  or  atypical 
cases,  naturally,  where  the  difficulty  is  greatest.  In  all  cases  of  toxic  poisoning 
by  arsenic,  mercury,  and  alcohol,  it  is  now  established  that  Avhile  the  perij^heral 
nerves  are  most  frequently  involved,  the  whole  nervous  system  may  be  affected 
primarily,  so  that  brain  and  spinal  diseases  may  occur.  These  paralyses  were, 
not  long  ago,  always  considered  spinal,  and  now  the  pendulum  is  again  swing- 
ing back  to  that  view. 

In  all  suspected  but  doubtful  cases  of  lead  poisoning  the  urine  should  be 
chemically  examined  for  lead.  The  administration  of  iodide  of  potassium 
for  a  few  days  favors  the  success  of  the  test. 

Prognosis.  The  prognosis  is  usually  favorable  when  the  individual  can  be 
removed  from  the  continued  influence  of  the  lead ;  but  where  degenerative 
changes  have  occurred  in  the  bloodvessels,  or  nephritis  complicates  the  case, 
the  result  must  be  unfavorable.  Again,  second  attacks  are  longer  in  recover- 
ing. Over-exercise  without  renewed  exposure  may  cause  a  relapse  of  the 
symptoms,  especially  of  the  paralysis.  However,  even  when  the  reaction  of 
degeneration  has  been  demonstrated,  there  may  be  complete  recovery. 

Pathology.  We  find  evidence  of  lead  in  the  brain  tissue.  This  has  been 
clearly  shown  by  Blythe.  Chronic  meningeal  changes,  such  as  pachymenin- 
gitis, clouding  of  the  pia  with  serous  effiision  in  the  subarachnoid  space  and 
ventricles,  with  cerebral  atrophy,  are  fr-equently  present.  Atrophy  of  the  optic 
ner\^e  with  evidence  of  interstitial  neuritis  is  not  uncommon,  as  well  as 
affections  of  the  fifth  and  seventh  cranial  nerves.  The  cord  shows  degenera- 
tive changes  involving  the  anterior  horns,  in  which  we  find  atrophy  of  the 
nerve  cells,  with  loss  of  their  processes,  and  an  increase  in  the  neuroglia 
tissue.  The  vessel  Avails  are  thickened.  The  peripheral  nei-A^es  are  the  seat 
of  a  parenchymatous  and  interstitial  nei^hritis,  the  latter  being  the  most 
frequent  condition.  The  axis  cylinder  is  usually  not  affected.  Stieglitz  found, 
in  experiments  on  rabbits  Avith  lead,  atrophic  changes  in  the  anterior  horns, 
vacuolation  of  the  ganglion  cells,  and  corresponding  degeneration  in  the 
nerve  roots  and  peripheral  nerves.  In  a  case  reported  by  me,  atrophy  of  the 
cells  in  the  anterior  horns  in  the  dorsal  region  and  degeneration  in  Lissauer's 
tract  and  in  the  column  of  Goll  Avere  observed.  The  meninges  are  also 
thickened  and  the  vessels  are  the  seat  of  endarteritis.  Buzzard's  case, 
referred  to  by  me,  shoAved  atrophy  of  the  cells  of  the  anterior  horns  in  the 
cervical  and  dorsal  regions.  The  author  considers  the  case  as  one  of  pro- 
gressive muscular  atrophy,  as  the  supinators  had  not  escaped.  HoAVCA^er,  the 
etiological  factor  in  the  case  seemed  to  be  lead,  the  patient  being  a  sign 
painter. 

In  acute  saturnism  transient  amblyopia  AA'ithout  change  in  the  optic  nerve 
has  been  obserA^ed.  HoAvever.  neuritis  going  on  to  atrophy  is  not  uncommon. 
The  diagnosis  of  optic  atrophy  due  to  lead  can  only  be  made  from  the  history 
of  exposure  to  the  poison,  there  being  nothing  diagnostic  in  the  atrophy  itself. 

Treatment.  This  consists  in  the  elimination  of  the  lead  by  potassium 
iodide  as  rapidly  as  pos.sible  ;  if,  hoAVCA^er,  acute  symptoms  suj)ervene  on  the 
administration  of  the  iodide  it  must  be  discontinued  for  a  time.     Opium 


200  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

relieves  pain  and  also  aids  in  the  action  of  the  iodide.  Lead  is  passed  out  of 
the  system  through  the  kidney  and  the  intestinal  tract.  Hot  baths  are  also  to 
be  employed.  For  the  paralysis,  strychnine  and  electricity,  with  massage,  are 
indicated.  Constipation,  if  present,  should  be  treated  by  the  administration 
of  the  sulphate  of  magnesia  or  sulphate  of  sodium,  as  they  render  such  of  the 
poison  as  may  still  be  present  in  the  intestinal  tract  insoluble.  Alum  may 
also  be  administered  with  the  same  end  in  view. 


ARSENICAL    POISONING. 

Arsenical  poisoning  results  from  the  absorption  by  the  system  of  arsenic  in 
toxic  doses. 

Etiology.  Arsenic  is  frequently  introduced  into  the  system  in  cases  of  in- 
tentional poisoning.  Sometimes  a  toxic  action  follows  its  medicinal  use.  A 
number  of  cases  of  chorea  have  been  reported  in  which  arsenic  has  been  used 
in  such  large  dosas  as  to  give  rise  to  symptoms  of  poisoning.  The  same  may 
be  said  of  cases  in  "which  various  medicinal  pastes  containing  arsenic  have 
been  used  too  freely.  Arsenical  poisoning  also  arises  from  the  use  of  arsenic 
as  a  coloring  matter  in  various  arts  and  trades.  It  may  occur  from  the 
atmosphere  through  absorption  from  wall-papers  or  tapestries.  Much  stress 
has  been  laid  on  these  methods  of  slow  poisoning  by  arsenic.  Neuritis  with 
consequent  paralysis  is,  how^ever,  rare  in  these  cases,  most  of  the  symptoms 
pointing  to  affections  of  the  general  nutrition.  Arsenic  has  been  found  in 
the  urine,  however,  thus  proving  the  possibiKty  of  its  absorption  in  this 
manner. 

Pathology.  The  usual  changes  are  similar  to  those  found  in  multiple 
neuritis.  Parenchymatous  and  interstitial  neuritis  may  be  present.  In 
arsenical  poisoning,  as  in  poisoning  by  lead,  the  axis  cylinder  usually  escapes, 
especially  w^hen  the  poison  has  found  an  entrance  by  gradual  absorption. 
Popoff  found,  in  the  case  of  a  man  dead  of  acute  arsenical  poisoning,  dis- 
ease of  the  spinal  cord  in  which  the  cells  in  the  anterior  horns  had  lost 
their  processes,  and  in  which  capillary  hemorrhages  "were  present.  These 
lesions  are  rare,  and  are  usually  the  result  of  acute  poisoning.  However, 
these  results  correspond  with  the  changes  found  experimentally  in  the  guinea- 
pig,  in  which  a  few  hours  after  the  exhibition  of  arsenic  there  was  evidence 
of  myelitis  with  hemorrhage. 

Symptoms.  Cerebral Symptoim.  The  brain,  as  a  rule,  escapes  any  deleteri- 
ous effects,  and  few  symptoms  can  be  ascribed  to  it.  In  acute  cases,  how- 
ever, loss  of  memory  and  mental  confusion  with  delirium  may  be  present. 

Spinal  Affectiom.  The  spinal  cord  is  subject  to  degenerative  changes, 
as  in  poisoning  by  lead  and  alcohol.  Myelitis  may  occur  in  the  more  acute 
forms  of  arsenical  poisoning. 

Peripheral  Affections.  The  peripheral  nerves  are  the  chief  seat  of  the 
disease.  The  symptoms  present  themselves  in  the  form  of  multiple  neu- 
ritis. A  feeling  of  numbness  or  tingling  is  first  noticed  in  the  lower  ex- 
tremities, and  this  is  soon  followed  by  more  or  less  weakness,  developing 
into  actual  paraplegia.  The  disease  extends  toward  the  uj^per  extremities, 
involving  the  extensors  of  the  forearm  and  hand — a  similar  distribution  to 
that  seen  in  alcoholic  neuritis,  although  more  apt  to  remain  limited  to  the 
lower  extremities.  There  is  considerable  atrophy  of  the  muscles  with  dimin- 
ished response  to  faradism  and  galvanism,  but  there  is  rarely  the  reaction 
of  degeneration.  In  marked  cases  there  is  loss  of  the  reflexes,  and  some 
tremor,  though  usually  slight,  is  present,  and  is  dependent  upon  the   mus- 


DIATHETIC  AND  TOXIC  AFFECTIONS.  201 

cular  weakness.  Contractions  causing  deformities,  as  talipes,  or  the  claw- 
shaped  hand,  may  occur,  due  to  the  contraction  of  unopposed  muscles. 

Sensory  Disturbances.  The  sensory  disturbances  are  of  the  character  of 
diminished  appreciation  of  pain  and  touch,  with  areas  of  hyperesthesia 
and  anaesthesia.  On  deep  pressure  over  the  nerves  pain  may  be  elicited, 
though  it  is  rarely  extreme.  As  a  rule,  there  is  no  marked  cutaneous  hyper- 
sesthesia.  Ataxia  is  commonly  present,  and  trophic  changes  following  the 
course  of  the  nerves,  as  herpes,  have  been  observed.  In  the  variety  of  cases 
where  there  is  a  slow  and  gradual  infection,  as  from  absorption  through  the 
atmosphere  fi"om  tapestries  and  wall  paper,  there  are  associated  symptoms, 
in  which  depression,  general  nervousness,  prostration  and  cardiac  weak- 
ness are  marked,  and  where  there  are  few  signs  of  neuritis.  There  is  loss  of 
appetite,  and,  in  fact,  many  symptoms  of  gastric  irritation.  These  frequently 
disappear  on  change  of  surroundings,  only  to  be  renewed  on  return  of  the 
patient,  to  the  place  of  original  infection.  Their  insidious  character  renders 
the  diagnosis  at  the  time  very  difficult. 

Diagnosis.  When  the  motor  symptoms  are  not  well  defined  the  disease 
may  be  confounded  with  tabes,  pseudo-tabes  arsenicosa.  In  obscure  cases, 
when  a  possible  history  of  absorption  from  wall-paper  and  tapestries  only  is 
present,  the  general  character  of  the  symptoms  indicating  cerebral  neuras- 
thenia renders,  with  the  absence  of  neuritis,  the  diagnosis  very  difficult,  and 
the  latter  can  only  be  made  positive  by  the  detection  of  the  arsenic  in  the 
urine.  Neuritis  can  be  distinguished  by  the  usual  distribution  of  the  paralysis, 
sensory  disturbance,  and  by  the  condition  of  the  reflexes  from  myelitis  clironica 
or  poliomyelitis.  The  vesical  paralysis  in  the  former  and  absence  of  sensory 
disturbances  in  the  latter  serve  as  additional  points  of  differentiation. 

Prognosis.  The  prognosis  is  favorable,  other  things  equal,  when  the  cause 
can  be  removed. 

Treatment.  The  treatment  consists  in  the  exhibition  of  strychnine,  the  use 
of  massage  and  electricity,  and  the  removal  of  the  cause  of  the  disease.  For 
the  elimination  of  the  poison  iodide  of  potassium  should  be  exhibited. 


CHRONIC    MERCURIAL    POISONING. 

Chronic  mercurial  poisoning  results  from  the  absorption  of  mercury  in 
toxic  doses. 

Etiology.  The  usual  cause  is  the  absorption  of  the  poison  in  connection 
with  the  various  occupations  in  which  mercury  is  employed,  and  especially 
where  workmen  are  exposed  to  its  fumes,  as  among  those  engaged  in  the 
manufacture  of  rubber.  Among  workmen  in  the  mirror  factories  and 
among  gilders  and  miners  mercury  is  sometimes  absorbed  through  the  skin. 
Mercurial  poisoning  may  follow  the  use  of  the  metal  as  a  medicine,  as  in  the 
application  of  various  ointments,  in  its  internal  administration,  hypoder- 
raically,  or  by  the  mouth. 

Pathology.  The  pathological  changes  are  of  the  degenerative  type,  and 
are  non-inflammatory.  The  peripheral  nerves  show  segmental  atrophy. 
The  myelin  is  disintegrated,  but  the  axis  cylinder  is  rarely  involved.  There 
may  be  optic  atrophy  (Wising).  Arterio-sclerosis  is  present,  and  in  chronic 
cases  we  find,  as  in  other  chronic  metallic  poisonings,  cerebral  oedema,  and 
increa.sed  fluid  in  the  subarachnoid  space  and  in  the  ventricles. 

Symptoms.  General  Symptoms.  Among  the  employes  in  factories  who  are 
subject  to  slow  infection,  a  series  of  symptoms  pointing  to  exhaustion  of  the 
nervous  system  are  common.  A  loss  of  self-control  is  observed,  and  an  in- 
creased emotional  state,  with  a  tendency  to  cerebral  excitement,  irritability. 


202  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

or  marked  depression.     There  is  also  more  or  less  impairment  of  the  memory, 
approaching  in  extreme  cases  dementia. 

Motor  Symptoms.  Tremor  is  observed,  especially  in  the  hands  and  arms, 
but  later  on  it  involves  the  muscles  of  the  face,  tongue,  and  lower  extremi- 
ties. This  may  continue  for  years  without  increasing  appreciably.  The 
tremor  is  at  times  convulsive  in  character,  especially  if  the  patient  is  emo- 
tionally excited.  In  extreme  cases  any  act,  such  as  eating,  may  bring  on 
these  spasmodic  attacks.  This  variety  rarely  comes  under  the  physician's 
observation  except  in  the  mining  districts. 

There  is  also  muscular  weakness,  which  may  be  general,  or  may  affect 
chiefly  the  extensors.  Again  it  may  be  localized,  affecting  the  upper  ex- 
tremities on  one  or  both  sides,  or  it  may  take  the  form  of  hemiplegia.  Gom- 
bault  reports  a  case  of  hemiplegia  with  hemiansesthesia.  The  tremor  may 
be  limited  to  the  paralyzed  part.  Atrophy  is  rarely  marked.  The  muscles 
are  usually  flaccid,  and  the  electrical  reaction,  although  reduced,  shows  no 
qualitative  changes  to  the  galvanic  current.  The  reflexes  are  generally  nor- 
mal, but  may  be  exaggerated  at  times,  and  at  others  diminished  or  lost. 
The  vasomotor  changes  are  present,  as  indicated  by  extreme  sweating.  In 
many  cases  there  are  functional  disturbances  alone,  resembling  hysteria. 
This  is  especially  observed  in  the  emotional  states  and  in  cases  where  hemi- 
plegia and  hemiansesthesia  are  transient. 

Sensory  Disturbances.  The  sensory  disturbances  consist  in  the  general 
lowering  of  the  sensibility  to  heat,  touch,  and  temperature.  They  follow  the 
course  of  the  paralysis,  which  would  seem  to  indicate  that  the  afiection  is  due 
to  the  peripheral  nerves. 

Special  Senses.  The  special  senses  are  often  involved.  Sometimes  there 
is  amblyopia.  In  some  few  cases  there  is  atrophy  of  the  optic  nerve.  Audi- 
tory hypersesthesia  is  sometimes  present. 

Diagnosis.  In  lead  and  alcoholic  poisoning  the  distribution  of  the 
paralysis  is  different,  the  tremor  is  never  as  well  marked.  Multiple  sclerosis 
may  be  mistaken  for  it,  but  in  mercurial  poisoning  we  rarely  find  nystagmus 
present,  or  the  exaggeration  of  the  reflexes,  and  the  spastic  states.  In  paralysis 
agitaus  the  tremor  is  controlled  rather  than  increased  by  voluntary  acts. 

Prognosis.  The  prognosis  is  good,  other  things  equal,  when  the  patient 
can  be  removed  from  the  source  of  infection.  The  longer  a  patient  has  been 
exposed,  the  less  favorable  are  the  results. 

Treatment.  The  treatment  consists  in  the  exhibition  of  the  iodide  of 
potassium  and  the  use  of  baths,  massage,  and  electricity.  Sulphur  baths  are 
no  longer  recommended. 


CHAPTER  YI. 

DISEASES  THE  DIRECT  OR  INDIRECT  RESULT  OF 

INFECTION.     ^ 

By  WILLIAM  OSLER,  M.D. 

CERBBRO-SPINAL.    MENINGITIS. 

Definition.  A  specific  infectious  disease,  occurring  sporadically  and  in 
epidemics,  characterized  anatomically  by  inflammation  of  the  brain  and 
spinal  cord,  and  clinically  by  an  exceedingly  irregular  course,  the  chief 
symptoms  being  fever,  pain  in  the  head  and  back,  muscular  spasms,  and,  in 
severe  forms,  delirium  and  coma. 

Etiology.  The  history  of  the  disease  during  the  present  century,  from  the 
date  of  the  first  recognized  epidemic  in  Geneva,  in  1805,  is  fully  given  in 
the  works  of  Hirsch,  of  Stille,  and  of  Joseph  Jones. 

Children  and  young  adults  are  most  susceptible  to  the  disease,  but  in  some 
epidemics  adults  have  been  chiefly  attacked.  Males  and  females  appear  to 
be  equally  liable.  The  most  severe  epidemics  have  been  in  country  districts. 
In  1873  the  disease  was  very  prevalent  in  the  valley  of  the  Ottawa  River, 
and  the  villages  and  country  districts  sufiered  much  more  severely  than  did 
the  cities  of  Ottawa  and  Montreal. 

The  affection  has  broken  out  simultaneously  in  regions  far  distant  from 
each  other.  The  concentration  of  population,  as  in  large  barracks  and  work- 
houses, favors  the  development  of  the  disease ;  and  in  France  during  the 
fourth  decade  the  numerous  epidemics  were  almost  confined  to  military  hos- 
pitals. The  outbreaks  have  occurred  most  frequently  in  the  winter  and 
spring,  and  have  developed  in  exceptionally  severe  weather.  Some  writers 
have  laid  great  stress  on  excessive  moisture  as  a  factor.  The  most  serious 
outbreaks  have  been  in  towns  and  villages  with  very  defective  sanitary  con- 
ditions. Poverty  and  overcrowding,  with  the  coincident  misery  and  squalor 
of  large  families  dwelling  together  in  small,  imperfectly  ventilated  houses  or 
in  tenements,  favor  the  development  of  the  disease.  Overexertion,  as  in 
prolonged  marches,  has  been  found  by  military  surgeons  to  have  an  impor- 
tant influence. 

The  disease  does  not  appear  to  be  directly  contagious.  It  is  exceptional, 
indeed,  to  have  two  cases  in  the  one  house,  and  physicians  and  nurses  are 
rarely  attacked.  On  the  other  hand,  there  is  very  strong  evidence  in  favor 
of  the  view  that  the  poison  may  be  transmitted  by  individuals  from  one 
place  to  another.     Several  striking  instances  of  this  are  reported  by  Hirsch. 

Evidence  is  accumulating  in  favor  of  the  view  that  the  micrococcus  lan- 
ceolatus  bears  an  etiological  relation  to  the  disease.  Its  presence  has  been 
demonstrated  in  the  exudate  of  the  meninges  in  man}'-  epidemics.  It  is  also 
present  in  the  meningitis  secondary  to  pneumonia,  and  it  has  been  found  now 
in  many  instances  of  sporadic  cerebro-spinal  meningitis.  The  same  organ- 
ism has  also  been  demonstrated  in  the  meningitis  developing  in  the  course  of 


204  NERVOUS  DISEASES  AND  THE  IB  TREATMENT. 

diseases  other  tlian  pneumonia  and  in  that  following  injury.  Altogether, 
the  bacteriological  observations  of  the  past  ten  years  point  to  the  association 
of  the  micrococcus  lanceolatus  with  both  the  sporadic  and  the  epidemic  forms 
of  the  disease.  Other  organisms  have  been  met  with  in  purulent  meningitis, 
the  staph}dococcus  pyogenes  aureus,  the  t^-phoid  bacillus,  the  colon  bacillus, 
and  other  less  definite  forms. 

There  are  insuperable  difficulties  in  the  way  of  a  rational  explanation  of 
the  conditions  favoring  the  growth  and  development  of  the  organism  in  the 
meninges.  The  micrococcus  lanceolatus  Ls  a  normal  occupant  of  the  body  in 
a  very  considerable  proportion  of  all  individuaLs,  at  least  20  per  cent.,  accord- 
ing to  some  authors. 

The  possibility  of  the  disease  being  due  to  an  auto-infection  has  been  sug- 
gested through  the  nasal  fossa  by  Striimpell  and  through  the  intestine  by 
Flexner  and  Barker.  There  are  serious  difficulties,  however,  in  the  way  of 
accepting  such  views  which  offer  no  explanation  whatever  of  the  epidemic 
prevalence,  or  of  the  remarkable  facts  quoted  by  Hu'sch  in  favor  of  its 
transmission  from  one  locality  to  another  by  a  third  person. 

Mortid  Anatomy.  The  patient  may  die  before  any  inflammatory  exudate 
occurs  in  the  meninges,  and  then  the  condition  is  one  of  an  extreme  grade 
of  hypersemia  and  of  a  slight  serous  effusion.  In  well-developed  cases  on 
external  inspection  the  petechise,  sometimes  herpes,  may  be  noticed  on  the 
skin.  On  removing  the  skull-cap  the  dura  is  tense,  and  its  inner  surface 
hyperffimic ;  the  sinuses  full  of  firm  clots.  On  exposing  the  cerebral  cortex 
in  severe  cases  the  convolutions  may  be  covered  completely  with  a  creamy 
exudate.  Often  this  is  patchy,  most  marked,  perhaps,  on  either  side  of  the 
longitudinal  fissure  and  in  the  chief  sulci.  The  cortical  veins  may  be  dis- 
tended and  prominent,  and  the  smaller  vessels  of  the  pia  are  deeply  engorged. 
Occasionally  superficial  hemorrhages  are  seen ;  the  exudate  is  upon  the  pia 
mater ;  the  arachnoid  itself  may  be  opaque.  The  effiision  is  usually  abundant 
at  the  base  of  the  brain  about  the  chiasma  and  in  the  Sylvian  fissures,  and 
may  cover  completely  the  pons  and  medulla.  The  lesions  are  not  confined 
to  the  meninges,  but" the  cerebral  substance  is  also  involved,  and  the  process 
is  in  reality  a  meningo-encephalitis.  The  gray  matter  Ls  hypersemic,  juicy,  and 
foci  of  infiltration  and  of  hemorrhage  may  be  seen.  Abscesses  of  some  size 
are  occasionally  found.  The  inflammation  may  involve  the  nerves  at  the 
base,  which  are  surrounded  with  the  fibrinous  exudate.  The  ventricles  may 
contain  only  an  increased  amount  of  serum,  but  in  some  instances  the  inflam- 
mation is  most  intense  on  the  velum  and  choroidal  plexuses.  The  ependyma 
is  softened,  ecchymosed,  infiltrated  with  and  covered  by  pus,  and  the  ven- 
tricular contents" may  be  of  the  same  nature.  In  cases  which  have  lasted  for 
a  long  time  there  may  be  no  longer  any  fibrinous  exudates,  but  there  are 
areas  of  meningeal  thickening,  adhesions,  and  most  constant  of  all  great  in- 
crease in  the  serous  effusion,  which  may  cause  great  dilatation  of  the  ventricles 
(hydrocephalus).  Even  in  cases  in  which  death  has  taken  place  so  soon  as 
the  fifth  week  the  ventricular  efR.ision  has  amounted  to  three  pints.  The 
spinal  meninges  show  the  same  lesions.  Small  hemorrhages  are  not  uncom- 
mon. The  exudate  may  be,  in  very  acute  cases,  only  a  turbid  serum,  but 
more  commonly  a  creamy,  thick  material,  chiefly  on  the  posterior  part  of  the 
cord.  Frequently  it  collects  more  particularly  in  certain  regions,  producing 
irregular  bulging's  on  the  araclnioid.  The  greater  grade  of  exudation  on  the 
posterior  surface  is  due  entirely  to  the  effect  of  gravity.  In  some  instances 
the  entu-e  cord  is  imbedded  in  a  thick,  grayish-yellow  lympho-purulent  exu- 
date. The  substances  of  the  cord  may  show  the  same  changes  as  in  the 
brain,  namely,  hemorrhages  and  infiltration  with  leucocytes,  sometimes  foci 
of  such  extent  as  to  form  small  miliary  abscesses.     Microscopically  the  exu- 


INFECTIVE  DISEASES.  205 

date  consists  of  polyiiuclear  leucocytes,  lymphoid  cells,  larger  cells  with 
vacuolar  nuclei,  and  even  cells  larger  still,  which  in  some  places  are  very 
numerous,  and  even  these  contain  other  leucocytes  and  red  blood  cells 
within  them,  (Flexner  and  Barker.)  The  micrococcus  lanceolatus  may 
usually  be  demonstrated  in  the  exudate.  The  changes  in  the  other  organs 
are  those  usually  associated  with  fever.  In  very  severe  cases  there  may  be 
hemorrhages  on  the  serous  membranes.  The  lungs  often  show  changes,  bron- 
chitis, intense  hyperemia  and  oedema,  and  sometimes  lobular,  less  frequently 
lobar  pneumonia.  Acute  inflammation  of  the  pleura  and  of  the  pericardium 
has  also  been  found ;  endocarditis  is  rare ;  colitis  may  be  present.  The 
spleen  usually  varies  in  size  according  to  the  period  at  which  death  has 
occurred.     It  may  sometimes  be  greatly  enlarged. 

Symptomatology.  A  stage  of  incubation  with  prodromal  symptoms  is  rare. 
Loss  of  appetite,  malaise,  headache,  pain  in  the  limbs  occur  in  a  few  cases. 
The  onset,  as  a  rule,  as  in  pneumonia,  is  abrupt,  and  the  patient,  without 
preliminary  symptoms  of  any  moment,  is  seized  with  a  chill  or  with  violent 
headache,  vomiting,  and  fever.  Few  disorders  present  so  varied  a  sympto- 
matology, and  the  cases  are  perhaps  best  described  in  groups  characterized 
by  special  features. 

1.  Fulminant  form.  No  acute  disease — cholera  scarcely  excepted — may 
kill  with  such  rapidity  as  cerebro-spinal  meningitis.  Cases  are  on  record  in 
which  death  occurred  after  an  illness  of  ten  hours,  or  even  of  five  hours. 
This  type  is  seen  with  variable  frequency  in  different  epidemics.  In  the 
recent  one  studied  by  Flexner  and  Barker  ten  patients  died  within  forty- 
eight  hours  after  the  appearance  of  the  symptoms.  The  onset  is  abrupt,  with 
a  violent  chiU,  and  without  the  slighest  premonition  the  patient  may  be  seized 
with  agonizing  headache,  vomiting,  high  fever,  active  delirium,  succeeded  by 
great  depression  of  the  vital  functions,  gradual  somnolence,  sometimes  spasms 
or  rigidity  of  the  muscles,  or  even  general  convulsions.  Death  may  occur 
before  the  development  of  petechise  on  the  skin,  but  in  cases  which  last  for 
more  than  twenty-four  hours  herpes  and  ecchymoses  are  almost  invariably 
present.  The  fever  in  this  so-called  apoplectic  type  is  not  necessarily  high. 
In  many  of  the  cases  it  has  been  quite  moderate,  102°  and  103°  ;  the  pulse 
may  be  rapid  and  feeble,  but  instances  are  on  record  in  which  it  has  been 
slow,  falling  to  50  or  60  in  the  minute. 

2,  Ordinary  form.  Commonly  without  any  prodomal  symptoms  the  dis- 
ease sets  in  with  severe  chill,  headache,  and  vomiting.  The  headache,  usually 
severe  and  accompanied  with  great  sensitiveness  to  light  and  to  noises,  may 
be  diffuse  over  the  entire  head,  or  localized  chiefly  to  the  occiput  or  the 
forehead.  It  is  one  of  the  most  constant  features  of  the  disease.  The  tem- 
perature rises  rapidly  and  may  reach  103°  or  104°,  sometimes  higher,  but 
occasionally  even  in  severe  cases  the  pyrexia  is  not  at  the  outset  or  during 
the  course  of  a  high  grade.  The  pulse  is  full  and  strong ;  later  irregular, 
and  when  symptoms  of  depression  occur  feeble  and  rapid.  The  pyrexia, 
which  has  no  fixed  type,  does  not  really  bear  any  relation  to  the  severity  of  the 
other  symptoms.  Vomiting,  which  occurs  early,  may  cease  within  twenty- 
four  hours,  or  in  exceptional  cases  recurs  throughout  the  course  of  the  dis- 
ease. An  early  and  important  symptom  is  a  painful  stiflTness  in  the  muscles  of 
the  neck  and  of  the  back,  accompanied  with  aching,  which  often  extends 
into  the  limbs.  As  the  disease  progresses,  usually  from  the  second  to  the 
fifth  day,  this  stiffness  becomes  more  marked,  and  there  may  be  rigidity  of 
the  muscles  of  the  back  and  neck,  the  latter  causing  marked  retraction  of  the 
head.  Opisthotonos  is  not  common,  but  orthotonos,  in  which  the  trunk  is 
rigid  and  firm,  is  not  infrequent.  Cases  have  been  described  in  which  the 
general  rigidity  and  stiffiiess  was  such  that  the  body  could  be  moved  like  a 


206  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

statue.  Unilateral  spasm  of  the  back  muscles,  leading  to  pleurosthotonos,  is 
rare.  Except  in  early  childhood  and  a  short  time  before  death  general  con- 
vulsions are  not  common.  Tremor  or  clonic  spasms  may  be  present.  Spasm 
of  the  muscles  of  the  face  may  also  occur.  Lesions  of  the  nerves  at  the  base 
may  cause  paralysis  of  the  muscles  supplied  by  the  third,  inequality  of  the 
pupils,  nystagmus,  deafness,  and  disturbances  of  the  sense  of  smell.  Sighing, 
respirations,  and  Cheyne-Stokes  breathing  are  met  with  in  some  instances. 
Intra-ocular  changes  are  common,  particularly  passive  congestion  of  the 
retinal  veins  and  optic  neuritis.  Disturbance  of  sensation  is  common,  par- 
ticularly hypereesthesia  of  the  skin,  and  the  patient  may  cry  out  when 
attempting  to  move  the  trunk  or  limbs.  In  part  this  may  be  due  to  hyper- 
sesthesia,  and  sometimes  to  the  tension  spasm  in  the  muscles.  It  may  be  very 
marked  in  the  legs,  and  the  slightest  movement  may  be  sufficient,  even  in  a 
patient  in  a  profound  stupor,  to  cause  reflex  spasms. 

The  cutaneous  features  of  the  disease  are  important.  The  petechial  rash, 
which  has  given  the  name  "  spotted  fever  "  to  the  affection,  is  very  variable. 
Stille  states  that  they  were  present  in  only  37  of  98  cases  in  the  Philadelphia 
Hospital.  With  the  ecchymoses  there  may  be  roseola  and  erythema,  or 
these  latter  may  occur  alone.  The  distribution  of  the  petechise  may  be  sym- 
metrical. In  the  epidemic  at  Lonaconing,  studied  by  Flexner  and  Barker, 
the  petechial  eruj^tion  was  comparatively  rare,  but  an  indistinct  purplish 
mottling  over  the  surface  of  the  body  was  more  common.  Herpes  is  perhaps 
more  frequent  in  this  than  in  any  other  disease.  It  is  seen  first  upon  the 
face,  either  on  the  nose  or  lips,  but  often  extends,  and  is  symmetrical  in  its 
distribution.  Urticarial  forms  of  erythema,  pemphigus,  and  in  a  few  in- 
stances gangrene  of  the  skin  have  been  described. 

As  already  mentioned,  vomiting  is  an  early  and  a  prominent  symptom. 
The  tongue  in  protracted  cases  is  dry  and  covered  with  sordes.  Lacunar 
tonsillitis  sometimes  occurs.  Difficulty  in  swallowing  may  be  due  either  to 
the  extreme  reti'action  of  the  neck  or  to  disturbed  innervation.  Diarrhoea 
is  not  common,  but  in  four  of  the  Lonaconing  cases  already  referred  to  there 
was  well-marked  dysentery.  The  abdomen  is  somewhat  retracted.  Jaundice 
has  been  met  with  in  a  few  instances.  The  spleen  is  sometimes  enlarged,  but, 
from  the  varying  statements  made  with  reference  to  it,  it  evidently  is  not  a 
common  feature.  Of  respiratory  symptoms  disturbed  rhythm  in  breathing 
is  common,  particularly  toward  the  close,  and  the  respirations  may  be  of  the 
Cheyne-Stokes  type.  Epistaxis  is  a  very  fi-equent  feature  in  some  epidemics. 
Bronchitis,  broncho-pneumonia,  and  pneumonia  occasionally  occur,  and  in 
the  protracted  cases  there  is  much  hypostatic  congestion  at  the  bases. 

In  the  severer  cases  the  urine  is  albuminous  and  may  show  the  presence  of 
hyaline  and  granular  casts.  Phosphates  are  often  in  excess,  and  blood  may 
be  present  in  the  severer  cases.  Marked  polyuria  has  been  noted,  and  it  has 
sometimes  persisted  for  years.  Glycosuria  may  also  occur.  The  blood  con- 
dition was  carefully  studied  by  Flexner  and  Barker,  who  found  marked  leu- 
cocytosis  in  all  the  cases.  Neither  the  red  corpuscles  nor  the  haemoglobin 
showed  any  special  changes. 

The  course  of  the  disease  is  extremely  variable.  More  than  one-half  of  the 
deaths  occur  within  the  first  five  days.  Improvement  is  indicated  by  a  faU 
in  the  fever,  lessening  of  the  spasm,  and  a  return  of  consciousness.  Conva- 
lescence may  be  extremely  tedious,  and  after  the  acute  symptoms  have  sub- 
sided may  be  interrupted  by  the  complications  and  sequelae  to  be  mentioned 
shortly. 

3.  Anomalous  form,  (a)  Abortive  tyx>e.  The  attack  may  set  in  acutely 
with  high "  fever,  severe  headache,  photophobia,  but  in  a  few  days  all  these 
symptoms  subside  and  rapid  convalescence  is  established.     Striimpell  distin- 


INFECTIVE  DISEASES.  207 

guishes  between  the  abortive  form,  setting  in  with  great  intensity,  and  the 
mild,  ambulant  cases,  which  have  been  described,  in  Avhich  the  patients 
complain  of  headache,  nausea,  unpleasant  sensations  in  the  back  and  limbs, 
and  stiffness  in  the  neck.  There  may  be  no  initial  vomiting  and  very  slight 
fever.  Such  cases  could  only,  in  reality,  be  recognized  as  due  to  the  poison 
of  the  disease  during  the  prevalence  of  an  epidemic. 

(h)  Intermittent  tyj^e-  In  this  form  the  fever  is  of  an  intermittent  type, 
assuming  sometimes  a  quotidian,  sometimes  a  tertian  character,  and  in  the 
intervals  of  the  fever  there  may  be  almost  complete  freedom  from  the  other 
symptoms  of  the  disease.  This  is  a  form  upon  which  we  require  further  in- 
formation. 

(c)  Chronic  ty2)e.  The  attack  may  be  protracted  for  two  or  three  months, 
or  even  extend  to  six  months,  and  may  lead  to  the  most  intense  marasmus. 
There  are  recurrences  of  the  fever  ;  thus  Heubner  gives  an  instance  of  a  lad, 
aged  seven  years,  who  had  rejDeated  recurrences  from  the  end  of  February 
until  the  end  of  June,  and,  though  worn  to  a  skeleton,  he  made  a  complete 
recovery. 

Complications  and  Sequels.  Endocarditis  and  pericarditis  are  rare. 
Pneumonia,  lobar  or  lobular,  is  a  frequent  complication  in  some  epidemics. 
The  percentage  of  cases  is,  however,  very  variable  in  different  epidemics  ;  in 
sonje  a  majority  of  the  cases  have  presented  this  complication.  It  may  be 
present  only  toward  the  close  of  an  epidemic.  Parotitis  has  been  described, 
and  occurred  in  a  number  of  cases  in  the  Lonaconing  epidemic. 

A  remarkable  compKcation  is  the  arthritis  first  described  by  James  Jack- 
son, Sr.,  the  number  of  cases  varying  considerably  in  different  epidemics.  In 
the  Lonaconing  epidemic  twenty  per  cent,  of  the  severer  cases  had  joint 
affections,  the  knees,  elbows,  wrists,  and  ankles  being  involved.  There  were 
some  cases  in  which,  had  it  not  been  for  the  initial  symptoms  indicating  a 
meningitis,  the  disease  would  have  been  diagnosed  acute  rheumatism.  "  Ker- 
nig  has  described  a  symptom  which  he  thinks  is  pathognomonic  of  meningitis. 
In  thirteen  cases  he  observed  a  peculiar  flexion-contracture  (beuge-kontrak- 
tur)  of  the  knee-joints,  which  could  not  be  reduced  when  the  patient  was  in 
the  sitting  position.  In  attempting  to  extend  the  knee,  the  leg  could  not  be 
straightened  further  than  a  point  where  it  made  an  angle  of  about  135° 
with  the  thigh,  although  when  lying  or  standing  this  contracture  was  com- 
pletely absent.  If  the  patient  lay  on  his  side  with  the  thighs  drawn  up  the 
symptom  was  still  present.  It  has  been  claimed  that  the  same  phenomena 
may  be  seen  in  many  other  conditions  (old  age,  chronic  alcoholism,  etc.),  but 
Kernig  asserts  that  he  has  examined  thousands  of  individuals  with  particular 
reference  to  this  point,  and  has  never  found  this  contracture  except  in  cases 
of  meningitis." 

The  most  important  sequelae  are  those  affecting  the  special  senses.  Kera- 
titis may  develop  with  ulceration  ;  less  often  iritis.  The  double  optic  neuri- 
tis may  be  followed  by  atrophy  and  blindness.  Serious  auditory  lesions  are 
still  more  common.  Deafness  may  follow  inflammation  of  the  labyrinth,  and 
in  children  this  not  infrequently  leads  to  the  condition  of  deaf-mutism.  It  is 
interesting  to  note  that  in  the  deaf-mute  institution  at  Bamberg,  of  forty-two 
pupils  in  1874,  all  had  become  deaf  mutes  from  epidemic  meningitis  (von 
Ziemssen). 

Mental  feebleness  and  aphasia  have  occasionally  followed  the  disorder. 
Headache  may  persist  for  months  or  years  after  an  attack.  Von  Ziemssen 
regards  chronic  hydrocephalus  as  a  frequent  sequelae,  the  symptoms  being 
"  paroxysms  of  severe  headache,  pains  in  the  neck  and  extremities,  vomiting, 
loss  of  consciousness,  convulsions,  and  involuntary  discharges  of  feces  and 
urine."     Paralysis  of  some  of  the  cranial  nerves  may  persist.     Occasionally 


208  XERVO US  DISEASES  AND  THEIR  TREATMENT. 

there  is  jDaralvsis  and  wastino'  of  the  extremities  due  to  multiple  neuritis 
(MiUsj. 

Diagnosis.  During  an  epidemic  the  recognition  of  the  disease  is  easy,  and 
the  descrij)tion  of  the  anomalous  t}-pes  is  now  so  clear  that  they,  too,  are  not 
often  overlooked.  On  the  other  hand,  mistakes  frequently  arise  in  the  spora- 
dic form,  but  cases  of  other  acute  infectious  disorders  are  more  often  diagnosed 
cerebro-spinal  meningitis  than  are  cases  of  this  disease  overlooked.  The  dis- 
ease must  be  recognized  from 

1.  CeHain  of  the  Acute,  Infection-^  Disease-?.  These  are  very  likely  to  present 
cerebro-spinal  manifestations  which  simulate  those  of  the  true  cerebro-spinal 
fever.  Typhoid  fever,  beginning  with  marked  cerebral  manifestations,  delir- 
ium, tremor,  and  subsequently  develo]3ing  more  or  less  rigidity  of  the  muscles 
and  retraction  of  the  neck,  may  present  a  very  deceptive  picture.  I  have 
known  at  least  three  instances  in  which  the  diagnosis  was  made  of  cerebro- 
spinal fever,  but  post-mortem  the  lesions  were  those  of  tv|Dhoid  fever,  and  the 
meninges  presented  only  extreme  congestion.  The  presence  of  rose  spots,  the 
development  of  tympanites  and  other  intestinal  features,  and  the  gradual 
subsidence  of  the  meningeal  symptoms  may  lead  to  a  revision  of  diagnosis. 
Many  of  these  cases,  unless  an  autopsy  is  secured,  go  into  the  mortahty  bills 
as  cerebro-spinal  fever.  So  also  in  typhus  fever,  the  headache,  backache, 
vomiting,  h^^pereesthesia,  and  the  presence  of  roseola  and  petechise  may  for  a 
time  leave  the  practitioner  in  doubt.  In  certain  of  the  severer  types  of 
smallpox  the  agonizing  headache  and  the  petechial  rash  may  lead  to  the 
diagnosis  of  cerebro-spinal  meningitLs.  A  four-year-old  child  became  ill 
suddenly  with  fever,  pains  in  the  back  and  head,  and  on  the  second  or 
third  day  petechise  appeared  on  the  skin.  There  were  retraction  of  the 
head  and  marked  rigidity  of  the  limbs.  Cerebro-spinal  meningitis  existed 
in  Montreal  at  the  time,  and  both  the  physician  under  whose  care  the  child 
was,  and  Dr.  E.  P.  Howard,  who  saw  it  in  consultation,  agreed  that  the  symp- 
toms were  highly  suggestive  of  this  disease.  The  cutaneous  hemorrhages 
became  more  abundant,  the  spasm  and  rigidity  were  extreme,  heematemesis 
occurred,  and  the  child  died  on  the  sixth  day.  At  the  j)ost -mortem  there 
were  no  lesions  of  meningitis,  and  in  the  deeply  hemorrhagic  skin  papules 
could  be  readily  felt.  The  post-mortem  diagnosis  of  smallpox  was  unhap- 
pily confirmed  by  the  mother  taking  the  disease  and  dying  of  it. 

Other  Forms  of  Meningitis.  It  is  to  be  remembered  that  poliomyelitis  may 
occur  in  epidemic  form.  In  the  remarkable  outbreak  which  occurred  in  1894 
about  Rutland,  Vermont,  and  which  is  described  by  Caverly,  of  that  town, 
many  of  the  cases  were  thought  at  first  to  be  cerebro-spinal  fever. 

(a)  Tuberculous.  Here  the  insidious  onset  and  more  protracted  course  are 
important  points,  and,  as  the  meninges  of  the  cord  are  not  often  aifected, 
backache  and  rigidity  and  retraction  of  the  head  are  seldom  seen.  The  skin 
eruptions  are  also  rare  in  tuberculous  meningitis,  and  the  presence  of  pete- 
chise and  herpes  is  against  the  tuberculous  form.  On  the  other  hand,  local 
palsies  of  the  ocular  muscles,  hemiplegia,  and  ajDhasia  are  more  common,  and, 
important  of  all,  the  determination  of  local  tuberculous  disease  in  other  parts. 

(6)  Pneumonic  Meningitis.  As  the  membranes  of  the  brain  are  chiefly  in- 
volved there  is  commonly  at  first  active  delirium,  frequently  tremor  and  motor 
spasm,  but  not  often  great  retraction  of  the  muscles  of  the  neck  or  back.  In 
sporadic  cases  it  may  be  very  difficult  to  determine  Avhether  the  pnuemonia 
has  been  a  complication  of  the  meningitis,  or  the  meningitis  a  sec[uence  of 
the  pneumonia.  There  have  been  ej^idemics  of  cerebro-spinal  meningitis  in 
which  a  large  majority  of  the  cases  were  complicated  by  pneumonia. 

3.  CeHain  toxic  conditions,  particularly  uraemia,  may  be  associated  with  con- 
vulsions, rigidity  and  coma,  and  simulate  in  some  degree  cerebro-spinal  menin- 


INFECTIVE  DISEASES.  209 

gitis.  The  absence  of  fever  and  the  conditions  under  which  the  symptoms 
arise,  and  in  ur?emia,  the  presence  of  albumin  and  tube-casts  in  the  urine 
should  make  the  diagnosis  clear. 

Prognosis.  The  mortality  has  ranged  in  various  ej^idemics  from  20  to  75 
per  cent.  Hirsch  states  that  of  15,632  cases  37  per  cent.  died.  In  children 
the  death-rate  is  higher  than  in  adults.  Cases  with  deep  coma,  repeated  con- 
vulsions, and  high  fever  rarely  recover.  In  the  chronic  form,  even  after  the 
symptoms  have  persisted  for  months  and  there  is  extreme  wasting  with  con- 
tractures, perfect  recovery  may  occur. 

Treatment.  Considering  the  frequent  association  of  the  disease  with  filthy 
surroundings,  an  important  prophylactic  measure  is  the  thorough  cleansing  of 
towns  and  villages  in  localities  liable  to  the  disorder. 

As  in  other  specific  fevers  careflil  nursing  and  feeding  are  the  most  impor- 
tant elements  in  the  treatment.  The  room  should  be  kept  dark  and  thor- 
oughly ventilated.  The  diet  should  consist  of  milk  and  strong  broths.  Many 
cases  are  very  difficult  to  feed,  and  it  may  be  necessary  to  use  the  stomach 
tube,  or  to  resort  to  rectal  injections.  In  the  more  chronic  cases  stimulants 
should  be  freely  given. 

In  strong,  robust  patients  with  high  fever  and  much  mental  excitement, 
abstraction  of  blood  by  wet  cups,  or  even  in  suitable  instances  general  blood- 
letting may  be  employed.  The  application  of  cold  to  the  head  and  spine, 
which  was  recommended  so  strongly  by  the  Xew  England  physicians  in  the 
first  epidemics  in  this  country,  is  of  great  service.  The  ice-cap  to  the  head 
and  the  spinal  ice-bag  may  be  kept  continually  applied.  With  high  fever 
and  active  delirium  or  coma  the  cold  bath  may  be  used,  or  cold  sponging,  or, 
if  necessary,  the  cold  pack.  Counter-irritation  is  of  doubtflil  benefit,  and  if 
applied  at  all  the  good  effects  are  j)robably  obtained  by  the  light  apj)lication 
of  the  Paquelin  cautery. 

Of  the  drug  treatment  of  the  disease  we  have  no  satisfactory  knowledge. 
Opium  has  been  much  used  by  American  physicians.  It  is  particularly  recom- 
mended by  Stille.  H}'podermics  of  morphine  may  be  used  in  reducing  the 
violence  of  the  muscular  spasms.  It  should  be  freely  used  until  the  symp- 
toms are  controlled.  Mercury,  iodide  of  potassium,  quinine,  the  salicylates, 
ergot,  belladonna,  and  calabar  bean  are  a  few  among  the  host  of  di'ugs  which, 
have  been  recommended. 


TETANUS    (Trismus— Lockjaw). 

Definition.  An  acute  infectious  disease  characterized  by  tonic  spasms  of 
the  voluntary  muscles,  with  marked  exacerbations.  As  the  disease  shows  itself 
first  in  the  muscles  of  the  jaw  the  names  trismus  and  lockjaw  have  been  applied 
to  it. 

The  aflTection  was  well  known  to  the  ancients,  and  the  descriptions  given  of 
it  by  Hippocrates  and  Areteus  are  particularly  graphic.  The  disease  com- 
monly follows  trauma  (traumatic  tetanus),  but  may  occur  spontaneously  or 
after  exposure  to  cold  (so-called  idiopathic  or  rheumatic  tetanus),  and,  lastly, 
an  important  variety  develops  in  newborn  children  (trismus  neonatorum). 

Etiology.  The  disease  is  more  frequent  in  hot  climates,  and  has  prevailed 
extensively  in  the  AY  est  Indies  and  in  the  Southern  States  of  America.  The 
mortality  in  some  of  the  West  India  Islands  from  trismus  neonatorum  has 
been  enormous.  The  colored  races  are  more  prone  than  is  the  Caucasian. 
The  incidence  of  the  disease  in  military  campaigns  has  varied  remarkably ; 
thus  in  the  Franco-Prussian  War  and  in  the  Civil  War  in  this  country  very 
few  cases  were  oliserved.     The  disease  may  be  endemic  in  certain  localities. 

14 


210  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Attention  was  early  called  in  this  country  to  its  prevalence  at  the  eastern  end 
of  Long  Island. 

The  disease  occurs  also  in  horses  in  which  veterinarians  have  long  recog- 
nized its  infectious  nature,  as  cases  are  very  apt  to  develop  simultaneously  or 
successively  in  the  one  stable.     Cattle  and  sheep  are  also  affected. 

After  the  first  month  of  life  the  disease  is  rare  in  children.  It  prevails 
most  frequently  in  the  third  and  fourth  decades.  Males  are  somewhat  more 
frequently  affected  than  females. 

In  a  very  large  proportion  of  all  cases  there  is  a  trauma.  Since  the  recog- 
nized specific  character  of  the  malady,  many  now  doubt  if  the  disease  ever 
occurs  without  a  lesion  of  the  surface,  through  which  the  poison  may  be  intro- 
duced. It  may  follow  wounds  of  any  kind,  but  is  more  common  after  con- 
tused or  lacerated  wounds,  particularly  when  the  nerves  are  involved.  Wounds 
of  the  extremities,  particularly  of  the  hand,  are  most  liable  to  become  in- 
fected. The  disease  has  also  followed  frost-bite  and  burns,  the  removal  of  a 
tooth,  and  even  the  most  trifling  injuries,  as  the  sting  of  an  insect,  or  a  small 
splinter  of  wood.  It  is  rare  after  surgical  operations.  Cases  have  occurred 
during  the  progress  of  vaccination.  A  special  form  of  it  is  met  with  in  con- 
nection with  the  open  surface  of  the  uterus  after  parturition — the  puerperal 
tetanus — of  which  mention  will  be  made  later. 

It  is  interesting  to  note  that  in  a  large  proportion  of  all  the  cases  there  has 
been  in  the  injury  a  possibility  of  contamination  by  the  soil.  "  Since  atten- 
tion has  been  given  to  the  point,  it  has  been  observed  that  in  a  considerable 
proportion  of  the  cases  the  injury  involved  contamination  of  the  wound  with 
soil,  as  in  falls  on  the  ground,  a  puncture  by  a  broken  stick  or  stake  which 
had  been  in  the  earth,  or  by  a  splinter  fi'om  a  dirty  floor.  Such  a  splinter 
from  the  floor  of  a  skittle  alley,  penetrating  beneath  the  nail,  has  produced  it ; 
one  fatal  case  was  due  to  a  compound  fracture  of  both  femora,  from  a  fall  in 
which  the  ends  of  the  bones  were  covered  with  earth ;  gardeners  have  suf- 
fered from  punctures  by  sticks.  In  most  of  these  cases  the  tetanus  bacilli 
were  found  in  the  source  of  the  contaminating  material ;  their  presence  ex- 
plains the  influence  of  these  injuries.  They  have  been  found  in  spiders'  webs, 
and  tetanus  has  followed  the  application  of  such  webs  as  a  styptic  (a  popu- 
lar custom  in  some  places),  and  also  the  application  of  earth  to  a  wound." 
(Gowers.) 

The  experience  of  the  Civil  War  is  interesting  in  connection  with  the  in- 
stances of  the  disease  in  military  surgery.  Of  505  cases  of  tetanus  the  fol- 
lowing was  the  distribution  :  upper  limb,  137  ;  distributed  as  follows  :  shoul- 
der, 31 ;  arm,  37  ;  coude,  7  ;  forearm,  24  ;  thumb,  4  ;  hand,  37  ;  lower  limb, 
292  cases :  hanche,  2  ;  thigh,  99  ;  knee,  17  ;  leg,  95  ;  coudepied,  22  ;  and  foot, 
57.  It  is  interesting  to  note  that  these  figures  do  not  confirm  the  usual  state- 
ment that  tetanus  more  usually  follows  wounds  of  the  hand  than  of  the  foot. 
The  relative  frequency  of  the  disease  after  operations  and  wounds  is  as  fol- 
lows: in  29,980  amputations  there  were  116  cases  of  tetanus  ;  in  4656  resec- 
tions there  were  15  cases;  and  in  212,076  wounds  there  were  374  cases. 

The  Tetanus  Bacillm.  The  disease  is  caused  by  a  specific  organism, 
discovered  by  Nicolaier,  and  subsequently  studied  elaborately  by  Kitasato. 
The  organism  may  be  procured  by  inoculating  an  agar  tube  with  pus  from  a 
wound  of  a  human  being  suffering  from  tetanus,  which  in  the  incubator  at 
35°  to  37°  C.  shows  the  characteristic  cbum-stick  liacilli.  "  The  bacilli  grow 
out  into  long  threads  at  ordinary  room  temperature ;  but  form  the  charac- 
teristic spores  at  35°  to  37°  C.  in  the  incubator  in  about  twenty-four  hours. 
They  then  appear  as  short,  fine  rods,  with  a  large  round  knob  on  one  end, 
the  knob  constituting  the  resistant,  glistening  spore.  The  bacilli  have  inde- 
pendent, but  slow  motion."     (Bolton.) 


INFECTIVE  DISEASES.  211 

The  bacilli  aud  its  spores  are  Avidely  spread  in  the  soil  of  inhabited  regions  ; 
of  twenty-three  specimens  of  soil  taken  from  various  parts  of  Copenhagen, 
sixteen  proved  virulent  when  inoculated  into  animals.  The  resistance  of  the 
organism  is  very  great,  and  the  virus  has  proved  virulent  in  pus  which  has 
been  dried  for  many  months.  The  bacillus  has  been  demonstrated  in  the 
dust  from  the  floor  of  the  wards  of  a  military  hospital. 

Produds  of  the  Growth  of  the  Bacilli.  The  filtrate  of  the  culture  three  or 
four  weeks  old,  entirely  free  fr-om  germs,  contains  the  specific  poison  of  tetanus, 
from  which  Brieger  has  separated  two  basic  bodies,  which  are  called  tetanin 
and  tetano-toxine.  Brieger  and  Fraenkel  have  also  separated  a  potent  tox- 
albumen,  but  the  true  chemical  nature  of  the  poison  has  not  been  accurately 
determined. 

With  the  products  of  the  growth  of  the  tetanus  bacillus  the  disease  is  very 
readily  produced  experimentally,  and  comparatively  small  doses  are  required 
to  kill  a  mouse — 0.001  ccm.  of  the  filtrate.  Dogs,  which  are  immune  natur- 
ally, require  a  proportionately  larger  dose.  The  poison  is  not  effective  when 
administered  through  the  stomach.  The  disease  produced  experimentally 
presents  a  picture  similar  to  that  seen  in  man.  It  is  interesting  to  note  that 
the  cramps  develop  first  in  the  muscles  nearest  the  seat  of  inoculation.  The 
effects  are  produced  by  the  poison,  not  by  the  bacilli  at  the  site  of  the  inocu- 
lation. This  is  shown  by  the  fact  that  the  identical  symptoms  are  produced 
by  the  germ-free  filtrate  of  the  pure  culture,  and  also  by  the  interesting 
experiments  of  Kitasato,  who  injected  the  tetanus  bacilli  into  a  mouse,  at  the 
root  of  the  tail,  and  excised  and  burnt  the  seat  of  inoculation  at  various 
times  afterward,  as  half  an  hour,  an  hour,  an  hour  and  a  half,  destroying  in 
this  way  all  the  bacilli  at  the  seat  of  inoculation.  Only  those  animals  in 
which  the  seat  of  inoculation  was  treated  locally  by  incision  and  burning  half 
an  hour  after  injection  recovered  ;  the  others  died  of  the  disease,  showing  that 
within  an  hour  enough  of  the  poison  is  absorbed  to  produce  the  symptoms 
and  cause  fatal  results.  There  are  several  very  interesting  points  still  to  be 
worked  out  about  the  production  of  the  poison ;  thus  it  has  been  shown  that 
when  the  cultures  are  grown  at  20°  to  22°  C.  they  do  not  for  several  days 
produce  any  poison,  and  are  no  longer  virulent.  It  is  interesting,  too,  to  note 
that  these  non-poisonous  bacilli  may  become  toxic  when  grown  with  other 
forms  not  capable  of  producing  the  disease.  In  accidental  infection  the 
local  suppuration  produced  by  other  organisms  inoculated  at  the  same  time 
may  furnish  the  very  condition  favorable  for  the  production  of  the  tetanus 
poison.  There  is  experimental  evidence  to  show  that  the  poison  works  like 
strychnine,  and  has  its  action  upon  the  spinal  cord. 

Morbid  Anatomy.  The  condition  of  the  wound  is  variable.  Very  often 
the  nerves  in  the  locality  have  been  found  reddened  and  swollen,  but  in  a 
majority  of  the  cases  they  have  been  normal.  IS"o  characteristic  lesions  occur 
in  the  brain  or  cord.  Congestion  of  the  bloodvessels,  small  hemorrhages, 
perivascular  exudation,  increased  pigmentation  in  the  ganglion  cells  have 
been  described,  but  these  changes  are  neither  uniform  nor  distinctive.  Minute 
ecchymoses  are  common  on  the  serous  surfaces.  Qildema  and  hypostatic  con- 
gestion of  the  lungs  are  frequently  present.  Rupture  of  muscle  fibres  may 
result  from  the  intensity  of  the  spasms. 

Symptoms.  Following  an  injury  the  first  indications  of  the  disease  are 
usually  manifest  Avithin  ten  days.  In  Yandell's  statistics  in  two-fifths  of  the 
cases,  and  in  Joseph  Jones's  statistics  in  four-fifths  of  the  cases,  the  symptoms 
began  before  the  fifteenth  day.  Slight  stiffiiess  of  the  neck  and  of  the  mus- 
cles of  the  jaw  is  the  earliest  feature,  or  the  patient  complains  of  difficulty 
in  mastication,  or  that  the  movements  of  the  tongue  are  not  so  free  in 
talking. 


212  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

In  a  few  cases  chilly  feelings  or  even  rigors  may  precede  these  symptoms? 
and  for  a  day  or  so  there  may  be  sensitiveness  or  even  pain  in  the  wound- 
Gradually  the  tonic  spasm  of  the  muscles  increases  until  the  condition  of 
trismus  or  lockjaw  becomes  so  marked  that  the  jaws  are  separated  with  the 
greatest  difficulty.  With  the  muscles  of  mastication  those  of  the  face  are 
also  involved,  so  that  the  angles  of  the  mouth  are  drawn  outward  and  up- 
ward, producing  the  sardonic  grin,  rims  sardonicus.  With  increasing  in- 
volvement of  the  muscles  of  the  neck  the  head  is  drawn  backward  and  the 
muscles  of  the  back  become  rigid,  and  the  contraction  may  be  extreme 
enough  to  cause  marked  arching  of  the  vertebral  column.  The  body  may  either 
remain  perfectly  straight,  the  condition  known  as  orthotonos  ;  or  depending 
upon  the  strength  of  the  spasm  of  the  different  groups,  opisthotonos,  in  which 
the  back  is  arched  like  a  boA¥  ;  emprosthotonos,  in  which  the  body  is  bent 
forward ;  or  pleurosthotonos,  in  which  it  is  turned  to  one  side.  The  tonic 
spasm  may  involve  the  muscles  of  the  legs  and  arms,  but  as  a  rule  the  arms 
and  hands  are  not  much  affected.  While  the  rigidity  is  tonic  in  character 
there  are  frequent  clonic  exacerbations,  which  are  apt  to  be  excited  by 
peripheral  irritation,  such  as  a  draught  of  air,  or  a  touch,  or  a  noise.  These 
exacerbations  vary  very  much  in  frequency  and  severity,  and  they  bear  some 
proportion  to  the  intensity  of  the  disease.  At  first  the  rigidity  is  not  very 
painful,  but  subsequently  the  suffering  is  extreme  from  the  violent  contrac- 
tion. In  very  severe  attacks  the  thorax  may  be  rigidly  compressed  by  the 
muscles.  The  respirations  are  rapid,  and  spasm  of  the  glottis  may  occur, 
causing  asphyxia.  In  the  severe  paroxysms  sweating  may  be  profuse.  The 
heart's  action  is  increased  during  the  paroxysm  ;  the  j)ulse  may  be  from  130° 
to  160°.  The  temperature  is  very  variable.  It  may  be  normal  throughout 
or  present  only  a  very  slight  increase.  In  a  few  cases  the  disease  is  associated 
with  hyperpyrexia,  particularly  as  an  ante-mortem  phenomenon,  and  there 
are  instances  in  which  the  body  heat  has  reached  from  110°  to  114°.  The 
urine  is  scanty,  and  according  to  Senator  the  amount  of  nitrogenous  matter 
is  not  increased.  There  may  be  retention  from  spasm.  The  mind  usually 
remains  clear,  except  toward  the  close  in  protracted  cases.  Death  may  occur 
during  a  paroxysm  either  from  asphyxia  or  cardiac  dilatation.  There  is  an 
instance  on  record  in  which  rupture  of  the  walls  of  the  heart  occurred  dur- 
ing the  violence  of  the  spasm.  In  other  cases  the  fatal  result  is  brought  on 
by  exhaustion. 

There  are  certain  varieties  which  are  of  interest.  In  the  head-tetanus  of 
Rose,  which  has  followed  in  a  majority  of  instances  wounds  of  the  face,  tris- 
mus, dysphagia,  respiratory  distress,  and  facial  paralysis  are  the  prominent 
features.  On  account,  too,  of  the  spasm  in  the  deglutition  muscles,  and 
consequent  difficulty  in  deglutition,  this  form  has  been  called  also  tetanus 
hydrophobicus.  The  cause  of  the  facial  paralysis  is  not  known.  There  may 
be  also  paralysis  of  the  eye  muscles  on  the  same  side.  This  modification  is 
not  very  common.  Janin^  has  collected  all  the  cases,  thirty-one  in  number, 
up  to  1892,  and  he  regards  it  as  a  form  in  which  the  toxic  materials  act 
chiefly  in  the  medulla.  The  attacks  recur  at  varying  intervals,  but  they 
may  be  almost  continuous.  In  other  cases  they  are  extremely  slight ;  the 
most  serious  attacks  are  those  caused  by  attempting  to  take  food,  when  there 
may  be  spasm  of  the  muscles  of  deglutition  and  great  interference  with  the 
respiration. 

Tetanus  neonatorum,  a  rare  form  in  temperature  regions,  and  fortunately 
now  rare  in  the  trophies,  was  formerly  very  common  in  certain  countries, 
particularly  in  the  West  Indies,  where  in  some  islands  one-half  of  the  negro 

1  Paris  Thesis.    Du  Tetanos  Bulbaire,  1892. 


INFECTIVE  DISEASES.  213 

children  died  of  the  disease.  Hillary,  in  his  Diseases  Peculiar  to  the  West 
India  Islands,  gives  the  following  graphic  account  of  the  disorder  :  "  For 
when  the  child  lays  in  this  miserable,  rigid,  immovable  condition,  upon  mov- 
ing its  hands  or  feet  in  the  most  gentle  manner,  or  softly  touching  any  part 
of  its  body,  or  giving  it  the  least  motion,  even  feeling  its  pulse  in  the  most 
gentle,  tender  manner,  or  the  least  noise,  or  even  touching  its  clothes,  will 
bring  on  the  convulsive  spasms,  and  cause  it  to  be  strongly  convulsed  back- 
ward, or  drawn  into  a  rigid  straight  line,  strongly  extended  and  immovable 
like  a  statue,  and  will  so  remain  immovable  out  of  either  of  those  postures, 
for  a  considerable  time,  a  minute  or  two."  (Edition  by  Benjamin  Rush, 
1811). 

In  the  Southern  States  of  America  the  disease  was  formerly  very  common. 

Puerperal  tetanus  is  now  fortunately  rare,  but  formerly  in  some  countries 
it  proved  the  most  fatal  of  all  forms  of  the  disease.  The  disease  begins,  as  a 
rule,  within  five  or  ten  days  after  parturition.  In  a  number  of  cases  it  has 
followed  abortion. 

Whether  tetanus  ever  occurs  idiopathically  has  been  doubted,  but  there 
are  cases  on  record,  particularly  in  army  practice,  in  which,  without  any 
apparent  external  injury,  the  disease  has  developed  after  exposure  to  cold. 

Mortality.  The  prognosis  is  always  extremely  grave,  and  two  of  the 
aphorisms  of  HipjDOcrates  may  be  quoted  at  the  present  day,  namely,  "  the 
spasm  supervening  on  a  wound  is  fatal,"  and  "  such  persons  as  are  seized 
with  tetanus  die  within  four  days,  or  if  they  pass  these  they  recover."  In 
the  traumatic  cases  the  death-rate  is  not  less  than  80  per  cent.  In  the  cases 
which  develop  without  any  wound  the  mortality  is  not  nearly  so  high.  From 
the  puerperal  form  recovery  is  excessively  rare,  and  the  form  in  infants  is 
also  very  fatal.  Death  occurs  from  asphyxia,  or  from  heart  strain,  which  in 
one  case  has  resulted  in  rupture  of  the  wall.  Favorable  indications  are  late 
onset,  absence  of  fever,  and  localization  of  the  spasms  to  the  muscles  of  the 
neck  and  jaw. 

Diagnosis.  In  well-developed  cases  following  injury  no  possible  difficulty 
could  arise.  From  strychnine  poisoning,  which  presents  very  similar  mus- 
cular spasms,  it  is  differentiated  by  the  following  points :  The  anamnesis, 
the  rapid  development  of  the  symptoms,  and  the  greater  extension  and  the 
reflex  spasms,  as  well  as  the  fact  that  the  jaw  muscles  in  strychnine  poison- 
ing are  not  involved  early  if  at  all,  and  between  the  paroxysms  there  may  be 
no  muscular  rigidity.  These  points  should  suffice  to  distinguish  it  from 
strychnine  poisoning.  The  question  has  been  raised  by  the  defence  in  murder 
trials,  as  in  the  celebrated  Palmer  case. 

In  hydrophobia,  for  which  the  head  tetanus  may  be  mistaken,  there  is  no 
special  spasm  of  the  jaw,  or  any  rigidity  of  the  muscles,  or  paroxysms  in 
which  the  cervical  and  dorsal  muscles  are  involved.  In  tetany  the  distribu- 
tion of  the  spasm,  chieffy  in  the  hands  and  feet,  the  special  involvement  of 
the  hands,  their  peculiar  position,  and  the  conditions  under  which  it  develops 
should  suffice  usually  to  separate  the  affections.  Hysteria,  which  may  imi- 
tate almost  any  one  of  the  diseases  with  motor  phenomena,  rarely  presents 
the  picture  of  tetanus.  "  But  trismus,  causing  persistent  closure  of  the  jaw, 
occurs  in  hysteria.  It  may  succeed  a  convulsion,  and  last  until  another,  or 
it  may  come  on  without  obvious  cause,  continue  for  a  few  hours  or  days,  and 
then  suddenly  vanish.  It  is  prone  to  recur,  and  this  chai-acter,  the  sudden- 
ness of  onset,  its  complete  degree,  and  the  absence  of  rigidity  in  the  neck, 
and  the  presence  of  other  symptoms  of  hysteria  will  rarely  leave  any  doubt 
as  to  its  nature."     (Gowers). 

The  bacteriological  diagnosis  is  of  some  importance.  Cultures  should  be 
made  from  the  pus  of  the  wound,   from  the  granulation  tissues,   from  the 


214  NER  VOUS  DISEASES  A  ND  THEIR  TREA  TMENT. 

splinter  of  wood,  or  from  the  earth  in  the  part  where  the  wound  was  re- 
ceived, or  portions  may  be  inoculated  into  a  mouse,  which  is  the  animal  most 
susceptible,  and  which  usually  dies  within  a  few  days  of  the  inoculation. 

Treatment.  Immunization.  The  present  status  of  this  question  with  ref- 
erence to  tetanus  may  be  thus  stated  :  Animals  which  are  very  slightly  sus- 
ceptible, such  as  the  dog  and  hen,  can  be  rendered  immune  by  the  injection 
of  gradually  increasing  doses  of  the  tetanus  virus.  The  serum  of  animals  so 
treated  has  the  power  of  conferring  immunity.  For  more  susceptible  ani- 
mals Behring  emj^loyed  the  bouillon  cultures,  diluted  with  the  addition  of 
iodine  trichloride,  beginning  with  a  culture  containing  0.25  per  cent.,  then  a 
percentage  of  0.2,  then  a  percentage  of  0.15,  and  ultimately  the  undiluted 
culture.  The  serum  of  animals  immunized  in  this  way  may  be  preserved 
with  0.6  per  cent,  of  carbolic  acid,  and  may  be  used  for  immunizing  other 
animals  not  previously  treated.  The  material  used  by  Tizzoni  and  Catani  in 
their  observations  upon  man  is  the  serum  of  the  immunized  dog  treated  with 
alcohol,  by  which  they  obtained  a  material  known  as  the  tetanus  antitoxin. 

Animals  inoculated  with  fatal  doses  of  tetanus  poison  treated  with  the 
serum  of  immunized  animals  have  recovered.  Up  to  the  early  part  of  1894 
about  a  dozen  cases  of  tetanus  in  man  had  been  treated  by  the  Tizzoni- 
Catani  antitoxin.  The  general  expression  of  opinion  by  experts  in  the 
question  of  serum-therapy  in  tetanus  is  not  althogether  favorable  ;  thus 
Klemperer  and  Levy  in  their  recent  works  on  clinical  bacteriology,  1894, 
question  whether  a  sure  and  undoubted  result  has  been  obtained  in  any  one 
of  the  cases,  as  the  healed  cases  were  not  so  acute  that  the  prognosis  was  en- 
tirely doubtful.  On  the  other  hand,  Remesoff  and  Fedoroff,'  in  a  recent 
report  of  a  case  supposed  to  be  cured  by  the  serum  of  an  immunized  animal, 
claim  in  a  review  of  the  recorded  cases  that  the  duration  of  the  disorder  is 
decidedly  diminished  by  the  treatment,  that  the  temperature  is  reduced,  the 
attacks  of  spasms  are  less  severe,  sleep  is  promoted,  and  a  very  great  im- 
provement in  the  general  condition.  Recent  reports  by  Gilman  Thompson 
and  others  are  altogether  more  favorable,  and  the  antitoxin  should  be  used 
at  the  earliest  aj)pearance  of  the  symptoms. 

Surgical  measures  are  usually  employed  at  the  site  of  the  lesion,  such  as 
burning  or  excision  of  the  scar.  Unless  done  very  promptly  experimental 
evidence,  as  mentioned  above,  would  indicate  that  they  are  not  of  much  im- 
portance, and  this  is  borne  out  by  experience.  Excision  of  the  nerves  at  the 
part  and  stretching  have  also  been  employed.  Thorough  cleansing  and  dis- 
infecting of  the  wound,  possibly  excision,  are  the  most  justifiable  remedies. 
The  general  management  of  the  case  is  most  important.  The  patient  should 
be  in  a  darkened  room,  attended  by  only  one  person  at  a  time,  and  all  out- 
side communication  should  be  forbidden.  Veterinarians  have  long  appreci- 
ated the  importance  of  complete  seculsion,  and  in  many  of  their  well-equipped 
infirmaries  there  is  seen  a  brick,  padded  chamber,  in  which  these  cases  are 
treated.  The  question  of  feeding  usually  becomes  very  important,  owing  to 
the  presence  of  lockjaw.  The  diet  should  be  restricted  to  nourishing  broths 
and  milk,  which  usually  can  be  taken  through  the  teeth  even  when  there  is 
spasm  of  the  jaws.  If  necessary  food  can  be  introduced  into  the  stomach  by 
a  catheter  passed  through  the  nose.  The  teeth  have  sometimes  been  ex- 
tracted. In  such  cases  we  should  trust  for  a  time  at  least  to  the  nutritive  in- 
jections. 

The  drug  treatment  consists  of  the  administration,  in  first  place,  of  reme- 
dies which  relieve  the  spasm.  For  this  purj^ose  chloroform  is  the  most  satis- 
factory, though  unfortunately  the  attacks  recur  as  the  effects  pass  away. 

1  Centralbl.  f.  Bakt.,  1894. 


INFECTIVE  DISEASES.  21 5 

Nitrite  of  amyl  may  be  tried  for  the  same  j)urpose  in  large  doses,  and  in  the 
severe  paroxysms  the  sudden  inhalation  sometimes  causes  relaxation.  Mor- 
phine may  be  used  for  the  same  purpose,  and  in  some  instances  has  seemed  to 
be  actually  curative.  Chloral  hydrate  has  been  largely  used.  To  be  eflPec- 
tive  it  must  be  given  in  doses  of  from  a  drachm  to  two  drachms  in  the  day, 
and  increasing.  In  the  tetanus  neonatorum  it  should  be  used  in  proportion- 
ately smaller  doses.  It  may  be  sometimes  combined  with  the  bromide  of 
potassium.  The  Calabar  bean  has  been  used  successfully  in  some  cases  ;  also 
curare,  which  must  be  employed  in  large  doses,  as  much  as  a  quarter  or  half 
a  grain  every  hour  or  two.  It  is  not,  however,  without  danger.  Among 
other  means  which  have  been  recommended  are  the  continuous  warm  baths, 
and  the  appHcation  of  ice  to  the  spine,  and  electricity  and  bleeding.  In  the 
severer  spasms,  leading  to  stoppage  of  respiration  and  cyanosis,  artificial  res- 
piration should  be  actively  employed. 


HYDROPHOBIA     (Lyssa— Rabies). 

Definition.  An  acute  infectious  disease  of  animals,  dependent  upon  an 
unknown  specific  poison  communicated  to  man  by  inoculation. 

In  animals  the  disease,  known  as  rabies,  is  met  with  chiefly  in  the  car- 
nivora,  particularly  dogs  and  wolves.  It  is  communicated  from  animal  to 
animal  by  inoculation  ;  hence,  the  extreme  rarity  of  the  disease  in  countries 
such  as  North  Germany,  where  the  muzzling  of  dogs  is  rigidly  enforced.  It 
is  not  infrequently  communicated  by  inoculation  to  cattle,  and  occasionally 
to  horses  and  pigs.  It  is  said  that  in  the  Western  States  the  skunk  is  par- 
ticularly liable,  and  a  number  of  instances  have  been  reported  of  the  disease 
following  the  bite  of  this  animal.  In  the  dog  the  early  symptoms  are  a 
change  in  the  disposition  ;  it  becomes  quiet,  dull  and  heavy,  and  very  irrita- 
ble toward  strangers.  The  bark  may  have  a  peculiar  ringing  character. 
The  animal  does  not  take  its  ordinary  food,  but  eats  all  sorts  of  articles,  such 
as  straw  and  wood,  and  dirt.  In  some  instances,  the  so-called  furious  rabies, 
there  is  very  much  excitement,  but  in  a  majority  of  cases  the  symptoms  are 
rather  those  of  the  dumb,  or  so-called  paralytic,  rabies,  in  which,  after  a 
transient  stage  of  excitement,  there  is  unsteadiness  in  the  legs,  with  increas- 
ing weakness  and  ultimately  paralysis  and  coma.  The  poison  is  present  in 
the  salivary  glands,  in  the  nervous  system,  central  and  peripheral,  and  in  the 
pancreas,  adrenals,  and  mammje.  The  disease  may  be  produced  in  animals 
by  the  inoculation  of  portions  of  these  structures.  In  rabbits,  the  animals 
usually  employed,  inoculation  is  made  beneath  the  dura,  and  death  follows 
in  from  seventeen  to  nineteen  days.  The  virus  prepared  for  the  protective 
inoculation  is  obtained  by  passing  through  a  series  of  rabbits,  when  it  is 
found  after  successive  inoculations  that  the  incubation  period  is  reduced  to 
seven  days  and  becomes  remarkably  uniform. 

Hydrophobia  is  a  rare  disease  in  man  in  the  United  States.  Dulles,  from 
June  1,  1888,  to  January  1,  1894,  collected  seventy-eight  cases,  an  average 
of  fourteen  per  annum.  Sixty-two  per  cent,  of  the  cases  were  in  the  Atlantic 
States.  The  disease  is  much  more  common  in  Europe,  particularly  in  Russia 
and  in  France. 

Incubation.  There  is  an  extraordinary  variability  in  the  time  which 
elapses  between  the  introduction  of  the  virus  and  the  appearance  of  the 
symptoms.  Horsley  states  that  the  variation  depends  upon  the  following 
factors :  "  a.  Age.  The  incubation  is  shorter  in  childi-en  than  in  adults. 
For  obvious  reasons  the  former  are  more  frequently  attacked,  h.  Part  in- 
fected.    The  rapidity  of  onset  of  the  symptoms  is  greatly  determined  by  the 


216  NEB  VO  US  DISEASES  AND  THEIR  TBEA  TMENT. 

part  of  the  body  which  may  happen  to  have  been  bitten.  AVounds  about 
the  face  and  head  are  especially  dangerous ;  next  in  order  of  degrees  of  mor- 
tality come  bites  on  the  hands,  then  injuries  on  the  other  parts  of  the  body. 
This  relative  order  is,  no  doubt,  greatly  dependent  upon  the  fact  that  the 
face,  head,  and  hands  are  usually  naked,  while  the  other  parts  are  clothed, 
e.  The  extent  and  severity  of  the  wound.  Puncture  wounds  are  the  most 
dangerous ;  the  lacerations  are  fatal  in  proportion  to  the  extent  of  the  sur- 
face afforded  for  absorption  of  the  virus,  d.  The  animal  conveying  the 
infection.  In  order  of  decreasing  severity  come:  first,  the  wolf;  second,  the 
cat ;  third,  the  dog ;  fourth,  other  animals."  The  average  period  is  probably 
from  six  weeks  to  two  months.  It  may  be  prolonged  to  more  than  three 
months,  and  there  are  cases  in  which  the  incubation  has  apparently  lasted  for 
a  year  or  eighteen  months.  Of  persons  bitten  by  rabid  dogs  only  a  certain 
percentage  become  infected ;  according  to  Horsley  not  more  than  15  per 
cent.  The  death-rate  of  those  bitten  by  wolves  is  not  less  than  40  per  cent. 
Bites  upon  the  face  are  particularly  dangerous. 

Symptoms.  In  the  premonitory  stage  there  is  usually  some  irritation  about 
the  bites,  such  as  pain,  numbness,  or  parsesthesia.  There  is  loss  of  appetite, 
headache,  and  depression  of  spirits.  The  patient  may  become  very  irritable 
and  sleepless,  and  there  is  a  constant  sense  of  impending  danger.  Slight 
fever  has  been  noted  at  this  stage,  and  the  2Dulse  is  accelerated.  The  general 
sensibility  is  greatly  increased ;  a  bright  light  or  a  loud  noise  isvery  distress- 
ing. Stiffness  about  the  throat  muscles,  and  slight  difficulty  in  swallowing 
may  be  expressed,  and  the  voice  is  a  little  husky.  In  the  second  stage — the 
period  of  excitement — there  is  great  restlessness  and  hyj)er?esthesia.  "Any 
afferent  stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association 
of  a  verbal  suggestion — will  cause  a  violent  reflex  spasm.  In  man  this 
symptom  constitutes  the  most  distressing  feature  of  the  malady.  The  spasms, 
which  affect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceed- 
ingly painful  and  are  accompanied  by  an  intense  sense  of  dyspnoea,  even 
when  the  glottis  is  widely  opened  or  tracheotomy  has  been  performed."  (Hor- 
sley). Any  attempt  to  take  water  is  associated  with  painful  sj)asms  of  the 
muscles  of  the  pharynx  and  larynx,  and  of  the  elevators  of  the  hyoid  bone. 
This  it  is  which  makes  the  patient  dread  the  very  sight  of  water,  and  has 
given  the  name  hydrophobia  to  the  disease.  These  inspiratory  and  degluti- 
tion convulsions,  as  they  may  be  called,  are  sometimes  associated  with  man- 
iacal symptoms.  In  the  intervals  between  the  attacks  the  patient  may  be 
quite  quiet  and  the  mind  unclouded.  Hallucinations  and  delusions  may  be 
present,  not  infrequently  associated  with  the  idea  of  the  presence  of  a  dog- 
in  the  room.  He  very  rarely  makes  any  attempt  to  injure  the  attendant, 
and  indeed  may  be  particularly  anxious  to  avoid  hurting  anyone.  There 
may  be,  however,  occasional  fits  of  furious  mania,  and  in  the  contraction  of 
the  muscles  of  the  larynx  and  pharynx  odd  sounds  are  occasionally  uttered. 
The  saliva  is  usually  abundant  and  tenacious,  and  flows  from  the  mouth, 
owing  to  the  difficulty  the  patient  has  in  swallowing  it.  The  temperature  in 
this  stage  is  usually  elevated,  and  may  reach  from  100°  to  103^.  The  course 
may  be  afebrile  throughout. 

In  addition  to  the  local  spasms  of  the  respiration  and  deglutition  muscles, 
there  may  be  convulsive  seizures  of  a  tetanoid  character.  After  lasting  for 
a  day  and  a  half  to  three  days  this  is  succeeded  by  the  paralytic  stage,  in 
which  the  spasms  no  longer  occur.  The  patient  becomes  quiet,  and  uncon- 
sciousness gradually  supervenes.  The  heart's  action  gets  more  and  more 
feeble,  and,  death  occurs  by  syncope.  In  animals  the  preliminary  and  furious 
stages  are  absent  as  a  rule,  and  the  paralytic  may  be  marked  from  the  first, 
the  so-called  dumb  rabies.     In  man  the  paralytic  form  is  extremely  uncom- 


INFECTIVE  DISEASES.  217 

mou,  though  cases  of  it  have  been  reported,  and  it  may  developed  with  a 
sudden  jjaraplegia,  and  with  symptoms  resembling  acute  ascending  myelitis. 

Morbid  Anatomy.  The  chief  lesions  are  in  the  nervous  system.  Gowers, 
who  has  examined  9  cases,  found  morbid  changes  in  7.  "  These  were  indi- 
cations of  vascular  disturbance ;  dilatation  of  small  vessels,  accumulations  of 
leucocyte-like  corpuscles  around  them  and  in  the  tissues,  clots  in  small  ves- 
sels evidently  formed  during  life,  and  minute  hemorrhages.  These  changes 
are  met  with  in  various  parts,  especially  in  the  cortex  of  the  hemispheres, 
the  medulla  oblongata,  and  the  spinal  cord.  They  are  always  most  intense 
in  the  medulla,  between  the  eminentia  teres  above  and  the  decussation  of  the 
pyramids  below,  and  especially  in  the  neighborhood  of  the  j^neumogastric, 
hypoglossal,  and  spinal  accessory  nuclei.  The  accumulations  of  leucocytes 
about  the  vessels  is  a  very  conspicuous  change.  They  surround  the  outer 
wall  and  may  be  so  numerous  as  to  fill  up  the  whole  space  within  the  lympatic 
sheath ;  they  may  extend  along  the  vessel  for  a  considerable  distance,  and 
even  pass  into  the  adjacent  tissue.  The  nuclei  contain  a  much  larger  number 
of  corpuscles  than  normal,  and  in  places  they  may  be  aggregated  and  form 
dense  masses,  which,  since  the  corpuscles  may  be  regarded  as  identical  with 
pus-cells,  are,  in  fact,  '  miliary  abscesses.'  ....  In  the  spinal  cord 
the  alterations  are  usually  much  slighter,  and  are  confined  to  encrustation  of 
the  vessels  with  leucocytes  and  to  an  increase  in  the  number  within  the  gray 
matter ;  in  this  the  changes  are  usually  greater  than  in  the  white  columns, 
although  they  involve  these  in  severe  forms.  They  may,  indeed,  be  so  in- 
tense as  to  constitute  a  condition  practically  of  acute  myelitis.  Even  when 
a  case  has  run  so  rapid  a  course  as  to  be  fatal  in  three  days  such  myelitic 
changes  may  be  conspicuous.  The  '  miliary  abscesses '  are  very  seldom  seen 
in  the  cord.  On  the  other  hand,  the  central  nervous  system  may  present  no 
other  alterations  than  are  common  after  death  from  asphxia,  and  this  even  in 
an  animal  inoculated  with  rabies,  as  well  as  in  man.  Outside  the  nervous 
system  leucocytal  infiltration  has  been  seen  in  the  salivary  glands  and  in  the 
kidneys."  The  mucous  membrane  of  the  larynx  and  pharynx  is  congested. 
In  the  clog  the  stomach  not  infrequently  contains  straw,  hay,  and  foreign 
matter  which  the  animal  has  eaten.  There  are  no  special  changes  in  the 
abdominal  or  thoracic  viscera. 

Diagnosis.  There  is  rarely  any  difficulty  in  distinguishing  hydrophobia 
from  other  organic  affections  of  the  nervous  system  associated  with  spasms 
and  cramp.  In  tetanus,  spasms  of  the  deglutition  and  inspiratory  muscles 
occur  occasionally,  but  the  character  of  the  wound,  the  short  time  which  has 
elapsed  before  the  symptoms  develoj),  the  presence  of  trismus  and  opisthotonos, 
and  the  absence  of  any  aversion  to  liquid,  render  the  diagnosis  clear. 

The  greatest  liability  to  error  is  in  the  so-called  pseudo-hydrophobia,  or 
lyssophobia,  which  is  a  neurotic  or  hysterical  manifestation,  and  may  closely 
simulate  the  true  disease.  A  nervous  person  bitten  by  a  dog,  either  rabid  or 
supposed  to  be  so,  may  display  within  a  few  months,  or  even  several  years 
after,  symptoms  resembling  hydrophobia.  He  becomes  irritable,  depressed,  and 
moody,  constantly  speaks  of  his  alarming  condition,  and  insists  that  he  is 
certain  to  go  mad.  There  may  be  hysterical  paroxysms,  in  which  he  says 
that  he  is  unable  to  drink,  and  shudders  at  the  sight  of  fluid,  grasps  convul- 
sively at  his  throat,  and  becomes  emotional.  A  few  years  ago,  when  the 
newspapers  were  full  of  the  details  of  Pasteur's  treatment,  a  young  man  con- 
sulted me,  who  had  been  bitten  a  year  or  more  previously  by  a  dog  which  was 
still  alive.  Some  of  his  fellow  clerks  had  joked  him  upon  the  sul)ject,  and 
he  had  gradually  become  very  much  alarmed.  When  I  saw  him  he  was 
greatly  excited,  had  pains  in  the  throat,  difficulty  in  swallowing,  and  in 
attempting  to  take  a  glass  of  water  he  Avould  become  greatly  excited  and 


218  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

alarmed,  and  would  have  a  pseudo-convulsive  attack.  These  symptoms  per- 
sisted for  a  couple  of  weeks,  and  ultimately  yielded  to  treatment  with  static 
electricity.  There  have  been  instances  published  as  lyssophobia  in  which 
these  seizures  have  become  more  frequent,  and  the  patient  has  died  exhausted. 
Gowers  holds  that  the  majority  of  these  cases  are  in  reality  genuine,  and  his 
remarks  on  this  point  are  worth  quoting :  "  There  has  more  often  been  a  ten- 
dency to  regard  the  genuine  disease  as  imaginary  than  to  mistake  the  sj^urious 
for  the  genuine.  This  tendency  is  especially  marked  among  critics  who  have 
not  seen  the  case,  who  do  not  scruple  to  cast  doubts  on  the  nature  of  even  fatal 
cases.  It  is  not  certain  that  death  has  ever  occurred  from  mere  lyssophobia." 
Nowadays  the  test  of  the  nature  of  a  fatal  case  can  be  readily  made,  as  the 
inoculation  experiments  are  quite  conclusive. 

Dulles,  in  particular,  has  called  attention  to  a  number  of  diseases  in  which 
symptoms  of  hydrophobia  may  occur,  and  he  has  rightly  urged  a  more 
thorough  and  systematic  examination  of  patients,  and  greater  caution  in 
pronouncing  upon  the  irregular  symptoms,  which,  in  nervous  people,  are  apt 
to  follow  the  bite  of  a  dog. 

Treatment.  The  local  treatment  of  the  wound  is  important.  If  on  a  limb, 
a  ligature  should  be  placed  above,  and  it  should  then  be  thoroughly  cauter- 
ized. A  bunch  of  lighted  matches  will  serve  the  purpose,  if  nothing  better  is 
at  hand.  Strong  carbolic  acid  or  nitrate  of  silver  may  be  used.  The  wound 
should  be  encouraged  to  bleed,  and  it  should  be  kept  open  for  some  time. 
Excision  of  the  wound  is  also  recommended.  When  the  disease  has  developed 
the  patient  should  be  kept  absolutely  quiet  in  a  darkened  room,  in  charge  of 
a  couple  of  nurses.  There  is  rarely  any  necessity  for  restraint,  and  the  phy- 
sician can  assure  the  attendants  that  there  is  no  risk  in  their  duties.  There 
is  not  a  single  instance  on  record  in  which  the  disease  has  been  transmitted 
from  patient  to  nurse.  As  a  rule,  the  patient  is  readily  controlled,  and  does 
not  require  to  be  forcibly  held  or  restrained.  No  attempts  should  be  made 
to  force  the  patient  to  drink  or  to  eat.  Sometimes  he  can  swallow  readily. 
It  is  stated  that  the  local  application  of  cocaine  allays  the  sensitiveness  of  the 
throat  and  enables  the  patient  to  swallow.  If  necessary,  nutrient  enemata 
may  be  given,  or,  if  the  patient  cannot  take  water  by  the  mouth,  large  injec- 
tions may  be  given  per  rectum. 

There  is  no  medicinal  treatment  of  any  value.  In  the  violent  spasm  the 
inhalation  of  chloroform  may  be  tried.  Morphine,  chloral,  bromide  of  potas- 
sium, and  curare  have  been  recommended.  The  latter  may  be  tried  in  doses 
of  from  a  tenth  to  half  a  grain,  repeated  every  half-hour  until  there  is  mus- 
cular weakness. 

Preventive  Inoculation.  Pasteur  found  that  the  virus  in  the  spinal 
cords  of  inoculated  rabbits,  when  preserved  with  careful  antiseptic  precau- 
tions, gradually  diminished  in  intensity,  so  that  the  fourteen-day-old  cord  was 
no  longer  poisonous.  Dogs  inoculated  with  portions  of  cords  dried  in  this 
way  and  of  increasing  intensity  acquire  immunity,  and  are  in  reality  vacci- 
nated against  the  strongest  virus,  which  would  otherwise  have  proved  fatal. 
Relying  on  these  observations  and  on  the  fact  of  the  long  incubation  period, 
Pasteur  began  the  inoculation  in  human  beings  bitten  by  rabid  animals.  In 
what  is  known  as  the  simple  method  the  individual  receives  an  injection  on 
the  first  day  of  a  portion  of  the  spinal  cord  of  a  rabbit  Avhich  has  been  pre- 
served in  the  dry  air  for  fourteen  days  ;  on  the  second  day  a  bit  of  the  cord  of 
thirteen  days  old,  and  so  on  until  the  coi-d  of  the  fifth  day  is  used.  In  what 
is  called  the  more  intensive  method,  on  the  morning  of  the  first  day  a  portion 
of  the  cord  (rubbed  up  in  sterilized  bouillon)  of  the  fourteenth  and  thirteenth 
day  is  used,"  and  in  the  evening  the  cord  of  the  twelve  and  eleventh  day. 
On  the  second  day  in  the  morning  the  cord  of  the  tenth  and  ninth  day  is  used, 


INFECTIVE  DISEASES.  219 

and  in  the  evening  of  the  eighth  and  seventh.  On  the  third  day  the  morning 
and  evening  injections  are  of  the  cord  of  the  sixth  day,  and  then  one  injec- 
tion is  made  each  day  until  the  cord  of  the  third  day  is  used.  Then  a  new 
series  is  begun,  usually  with  the  cord  of  the  fifth  day,  and  a  third,  or  even  a 
fourth,  series  of  injections  may  be  employed. 

An  enormous  number  (from  1886  to  January  1,  1894,  14,430  persons) 
bitten  by  animals  rabid,  or  supposed  to  be  so,  have  been  treated  at  the  Pasteur 
Institute.  Of  these  only  72  have  died.  A  great  difficulty  has  been  that 
many  persons  bitten  by  animals  not  rabid  have  flocked  to  Paris  for  the  treat- 
ment.    In  the  jDreparation  of  the  statistics  these  are  carefvilly  separated. 

While  the  preventive  inoculation  is  not  invariably  successful,  as,  indeed,  is 
only  natural,  since  many  persons  apply  weeks  or  months  after  they  have  been 
bitten,  it  cannot  be  denied  that  the  percentage  of  mortality  in  persons  bitten 
by  animals  undoubtedly  rabid  is,  after  the  treatment  by  the  inoculation,  very 
greatly  lessened,  and  in  some  years  has  been  nil ;  thus,  in  1891,  of  394  persons 
treated  in  whom  the  nature  of  the  disease  in  the  animal  was  determined  with 
all  possible  certainty,  not  a  single  one  succumbed.  The  possibility  of  com- 
municating rabies  has,  of  course,  been  urged,  but  it  must  be  extremely  slight, 
though  there  is  one  case  in  which  this  seems  really  to  have  occurred. 


TETANY. 

Definition.  A  paroxysmal  affection,  characterized  by  bilateral  tonic  spasms 
affecting  chiefly  the  extremities. 

Etiology.  The  disease  occurs  chiefly  in  young  persons,  and  attacks  males 
rather  more  frequently  than  females.  Of  150  cases  collected  by  Gowers  from 
different  sources,  76  were  in  males  and  6Q  in  females.  The  following  are  the 
most  important  conditions  under  which  the  disease  develops : 

a.  In  children  associated  with  the  debility  of  chronic  exhausting  maladies, 
such  as  diarrhoea.  The  carpopedal  spasm,  so  frequently  seen  in  connection 
with  rickets,  is  regarded  by  some  as  a  variety  of  tetany.  It  occurs  as  a 
sequence  of  the  fevers;  many  cases  have  developed  after  typhoid  fever, 
jjarticularly  in  certain  epidemics.  A  few  typical  instances  have  occurred  in 
connection  with  pregnancy  and  lactation.  Trousseau  called  the  disease  the 
rheumatic  contraction  of  nurses.     It  may  recur  in  successive  pregnancies. 

b,.  A  remarkable  association  exists  between  tetany  and  the  removal  of  the 
thyroid  gland.  Thirteen  cases  followed  78  thyroidectomies  in  Billroth's 
clinic,  six  of  which  proved  fatal.  It  follows  total,  not  partial  extirpation. 
This  is  the  most  serious  form  of  the  disease.  Removal  of  the  thyroid  in 
animals  is  also  followed  by  tetany.  Tetany  and  myxoedema  may  be  associated, 
as  in  a  case  reported  by  James  Stewart.' 

c.  The  disease  occurs  in  epidemic  form,  particularly  on  the  continent  of 
Europe  during  the  winter  months.  Extensive  epidemics  occurred  in  Paris 
in  1855  and  1876,  and  a  recent  epidemic  described  by  von  Jacksch  occurred 
in  young  men  of  the  working  classes,  usually  with  slight  fever.  Fatal  cases 
are  rare  in  this  form. 

And,  lastly,  tetany  has  been  met  with  in  connection  with  dilatation  of  the 
stomach,  particularly  in  the  cases  in  which  lavage  has  been  practised. 
Death  is  very  apt  to  occur  in  coma.  A  full  record  of  the  cases  to  1892  will 
be  found  in  the  Paris  Thesis  by  Vautier.  In  America  true  tetany  is  very 
rare,  and  it  has  not  occurred  in  epidemic  form.  If,  however,  cases  of  carpo- 
pedal spasm  be  included  the  disease  is  not  infrequent,  and  Griffith  has  been 

1  Transactions  of  the  Association  of  American  Physicians,  vol.  iv. 


220  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

able  to  collect  from  the  literature  72  cases,  but  the  aiFection  in  adults,  with 
all  the  cardinal  symptoms,  is  rarely  seen. 

Symptoms.  The  following  brief  statement  of  a  case  which  was  in  my 
wards  in  1894  will  illustrate  some  of  the  remarkable  characters  of  the  form 
of  tetany  which  recurs  with  pregnancy  : 

Mrs.  P.,  aged  thirty-three  years ;  married  at  eighteen ;  first  child  born 
nineteen  months  afterward,  and  a  second  child  two  years  after  the  first. 
While  three  months  pregnant  with  the  second  child  she  noticed  that  her  hands 
ached  and  felt  tired,  and  two  or  three  times  a  day  would  get  quite  stiff.  These 
symptoms  continued  until  a  short  time  before  her  confinement,  when  she  felt 
much  better.  She  remained  free  from  the  cramps  until  the  ninth  day  after 
labor,  when  they  returned  and  were  more  violent.  ISTot  only  were  the  hands 
closed  in  cramp,  but  the  feet  would  also  draw  together.  The  attacks  were  not 
accompanied  by  much  pain.  In  the  intervals  the  hands  and  feet  felt  as 
usual.  The  attacks  recurred  for  five  months  and  then  disappeared  for  two 
months.  In  November,  1882,  after  exposure  in  the  snow,  the  spasms  re- 
appeared with  greater  intensity,  and  early  in  December  she  had  an  unusually 
severe  attack  in  which  the  hands  were  closed,  the  elbows  flexed,  and  the  arms 
held  close  to  the  body.     The  spasms  in  the  hands  did  not  relax  for  a  week. 

In  her  third  pregnancy,  which  followed  in  a  short  time,  during  the  first 
five  months  she  had  no  cramps,  but  in  the  last  four  months  she  had  them 
daily.  They  again  disappeared  just  before  labor.  She  did  not  nurse  this 
baby,  and  the  fourth  pregnancy  followed  in  four  months.  She  had  no 
cramps  for  the  first  four  or  five  months,  but  they  recurred  as  before  during 
the  last  four  months.  While  in  labor  she  had  a  very  severe  attack  lasting 
four  or  five  hours.  She  afterward  remained  free  until  the  ninth  day,  when 
she  had  a  very  severe  attack. 

In  her  fifth  pregnancy,  which  followed  in  five  months,  the  spasms  occurred 
at  intervals  throughout  the  entire  period.  In  her  sixth  pregnancy,  which 
began  eighteen  months  after  the  birth  of  the  fifth  child,  she  was  free  during 
the  first  five  months,  then  the  cramps  returned  worse  than  ever.  The  hands 
and  legs  would  get  stiff  and  painfi.il,  and  she  had  for  the  first  time  spasm  of 
the  larynx.  During  the  last  month  of  this  pregnancy  there  Avere  no  attacks. 
They  recurred  again  on  the  ninth  day  after  labor.  From  this  time  until 
her  seventh  pregnancy,  nearly  tlu'ee  years,  she  was  well,  except  at  about  the 
time  of  the  menstrual  periods,  when  she  always  had  the  spasms. 

In  her  seventh  pregnancy  the  attacks  occurred  as  usual,  but  she  was  better 
for  a  longer  period  before  labor. 

Since  June,  1892,  the  date  of  her  last  confinement,  she  has  had  the  attacks 
at  intervals,  usually  about  the  time  of  the  menstrual  period. 

The  patient  is  a  young-looking  woman,  well  nourished,  a  little  pale.  The 
mechanical  excitability  of  the  motor  nerves  was  very  great,  the  slightest 
tapping  in  the  course  of  the  facial  nerve  was  sufficient  to  produce  contraction 
of  the  muscles  of  the  face  on  that  side,  and  the  electrical  reactions,  to  be 
mentioned  hereafter,  were  present  in  a  typical  manner. 

The  onset  of  the  intermittent  spasms  may  be  sudden  and  unexpected,  but 
as  a  rule  there  are  slight  feelings  of  numbness  or  pain  in  the  extremities,  or 
a  feeling  of  lassitude  and  headache.  The  hands  are  usually  affected  first, 
and  the  spasms  may  be  confined  to  them.  The  contraction  begins  in  the  in- 
terossei  and  the  smaller  muscles  of  the  hands,  which  feel  stiff  and  cramped, 
and  gradually  assume  what  has  been  known  as  the  writing  posture.  The 
fingers  are  closely  pressed  together,  the  thumbs  adducted  and  pressed  firmly 
against  the  index  fingers,  or,  in  children,  not  infi-equently  flexed  tightly  be- 
neath the  fingers.  The  hand  itself  is  generally  flexed,  and  the  elbow  also 
held  in  flexion.     In  children  the  arms  are  not  infrequently  folded  over  the 


INFECTIVE  DISEASES.  221 

chest.  In  the  lower  extremities  the  flexors  of  the  feet  aud  toes  are  in  tonic 
spasm ;  the  toes  strongly  flexed  and  the  feet  in  the  talipes  equino-varus  posi- 
tion. The  thigh  muscles  are  rarely  involved.  The  muscles  of  the  face  and 
neck  are  less  commonly  attacked.  In  severe  cases  there  may  be  trismus,  and 
the  angles  of  the  mouth  are  drawn  out.  The  trunk  muscles  are  very  rarely 
involved,  but  there  is  occasionally  a  slight  degree  of  opisthotonos,  and  dur- 
ing a  severe  spasm  the  thorax  may  be  fixed,  and  there  may  be  slight  difficulty 
in  breathing.  The  skin  of  the  hands  and  feet  is  sometimes  tense  and  oede- 
matous.  The  spasms  are  paroxysmal,  continuing  from  a  few"  minutes  to  an 
hour  or  more,  occasionally  lasting  for  several  days.  The  contracture  is,  as  a 
rule,  painless,  but  when  the  spasms  are  intense  the  pain  may  be  severe  and 
cramp-like.  The  mind  is  clear,  except  in  the  extreme  debility  of  children 
and  in  cases  associated  with  dilated  stomach,  in  which  coma  is  a  not  infre- 
quent accompaniment.  The  temperature  is  sometimes  elevated  during  the  at- 
tack, but  it  may  be  sub-normal.  The  pulse  is  usually  accelerated.  In  the  inter- 
vals between  the  paroxysms  there  may  be  a  sensation  of  stiffiiess  in  the  muscles. 
There  are  several  important  symptoms  on  the  part  of  the  muscles  and  nerves. 

Trousseau  found  that  pressure  on  the  nerve  trunks  or  on  the  vessels  brought 
on  an  attack  of  spasm  in  the  muscles  of  the  limb.  "So  long  as  the  attack 
is  not  over,  the  paroxysms  may  be  reproduced  at  will,  even  though  the 
patient  has  been  free  from  them  for  twenty-four,  thirty-six,  forty-eight,  seventy- 
two  hours  or  more.  This  is  affected  by  simply  compressing  the  affected  parts, 
either  in  the  direction  of  their  principal  nerve-trunks  or  over  their  blood- 
vessels, so  as  to  impede  the  venous  or  arterial  circulation."  (Trousseau.)  In 
characteristic  cases  tight  pressure  round  the  wrist  may  be  sufficient  to  produce 
cramp  of  the  muscles  of  the  hand. 

There  is  a  remarkable  increase  in  the  mechanical  excitability  of  the  motor 
nerves.  A  very  slight  tapping  in  the  course  of  a  nerve  is  sufficient  to  pro- 
duce active  contraction ;  if  with  the  percussion  hammer  the  slightest  tap  be 
made  in  the  course  of  the  facial  nerve  on  the  cheek,  the  muscles  to  which  it 
is  distributed  will  be  instantly  thrown  into  active  contraction.  This  is  known 
as  the  facial  phenomenon,  or  Chvostek's  symptom.  It  is  not  characteristic  of 
tetany,  and  may  occasionally  be  induced  in  tuberculosis.  A  very  important 
sign  is  the  great  increase  in  the  electrical  excitability  of  the  motor  nerves 
(Erb's  symptom).  The  current  from  a  single  cell  may  be  sufficient  to  cause 
contraction  of  the  face  muscles.  "Instead  of  the  normal  reaction  1,  KCIC; 
2,  ACIC,  KOC  ;  3,  AOC,  we  have  1,  ACIC  ;  2,  AOC  ;  3,  KCIC,  or  1,  AOC  ; 
2,  ACIC,  KCIC,  AOTe."     (Cowers.) 

And,  lastly,  the  mechanical  and  electrical  excitability  of  the  sensory  nerves 
is  also  greatly  increased  (Hoffmann's  symptom),  and  the  slightest  j)ressure  on 
the  supra-orbital,  the  auricularis  magnus,  or  the  ulnar  nerves  (which  in  a 
healthy  nerve  would  only  produce  a  slight  local  sensation)  is  sufficient  to 
cause  parsesthesia  in  the  parts  to  which  the  filaments  are  distributed.  Other 
less  constant  symptoms  are  profrise  sweating,  oedematous  sw^elling  of  the  skin, 
herpes,  urticaria,  nutritive  changes  in  the  nails  and  hair,  pigmentation  of  the 
skin,  and  in  rare  instances  local  or  general  atrophy  of  the  muscles.  The 
reflexes  are  usually  normal,  sometimes  exaggerated.  Psychical  disturbances 
are  rare,  but  epileptic  attacks  have  been  described.  Though  the  spasms  as  a 
rule  are  intermittent,  they  are  sometimes  remittent,  or  they  may  be  continu- 
ous, often  in  the  same  case.  It  is  stated,  too,  that  the  sj^asms  may  persist 
sometimes  durhig  sleep.  There  are  cases  in  Avhich  partesthesise  and  stiffness 
may  exist  without  the  spasms.  Gowers  speaks  of  a  variety  met  with  in  adult 
women  in  feeble  health,  who  have  a  feeling  of  stiffness  and  tingling  in  the 
hands  on  awakening,  which  may  last  for  a  few  minutes  or  longer.  He  says 
that  there  are  instances  in  which  this  "sleep  tetany  "  recurs  through  the  day. 


222  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  course  of  the  disease  is  very  variable.  The  patient  may  have  one  or 
two  slight  attacks  and  no  recurrence,  or  it  may  last  for  many  months,  and 
then  again,  as  in  the  case  above  mentioned,  it  may  recur  throughout  a  period 
of  years.  There  are  instances  in  which  it  has  recurred  year  by  year  during 
the"  winter  months.  In  a  few  instances  the  disease  proves  fatal.  Trousseau 
mentions  such  a  case  in  which  with  very  violent  contractions,  particularly  of 
the  muscles  of  the  face  and  neck,  asphyxia  developed  and  caused  death. 
More  serious  are  the  cases  which  follow  extirpation  of  the  thyroid  and  those 
which  devebp  in  connection  with  dilatation  of  the  stomach.  Children  not 
infrequently  die  of  the  disease  causing  the  exhaustion,  rarely  of  the  tetany 
itself. 

The  anatomical  condition  is  unknown,  nor  is  its  pathology  as  yet  clear. 
The  occurrence  in  epidemic  form  has  been  held  to  show  the  infective  charac- 
ter of  the  disease.  The  occurrence  after  thyroid  extirpation  and  in  dilata- 
tion of  the  stomach  suggest  its  dependence  upon  some  toxic  material,  to  the 
nature  of  which,  however,  we  have  no  clew.  Bouveret  and  Devic  in  cases 
of  tetany  in  dilated  stomach  have  extracted  from  the  stomach  contents  a 
material  which  they  state  produces  a  tetany-like  group  of  symptoms  in  ani- 
mals. Recently  Oddo  and  Sarles  have  reported  a  case  of  tetany  in  a  child 
aged  eighteen  months,  associated  with  retention  of  urine  and  anasarca.  There 
was,  however,  no  albumin  in  the  urine,  but  indican  and  an  excessive  quantity 
of  earthy  phosphates. 

Diagnosis.  Typical  forms  of  the  disease  are  very  readily  recognized.  Hys- 
teria may  simulate  it  very  closely,  but  neither  Trousseau's  phenomenon  nor 
the  increased  excitability  of  the  muscles  and  nerves  is  present.  In  rare  in- 
stances the  disease  might  be  mistaken  for  idiopathic  tetanus  when  the  spasms 
are  widespread,  and  in  such  a  case  the  etiological  factor  would  be  most  im- 
portant. Some  writers  include  with  tetany  all  cases  of  carpopedal  spasms 
in  children.  This  has  been  done  by  Griffith  in  his  recent  paper.  It  is  true, 
as  he  says,  that  there  are  numberless  gradations  between  the  condition  of 
well-marked,  widespread,  intermittent  contractions  and  the  continuous  or  in- 
termittent carpopedal  spasms.  While  recognizing  that  there  are  instances 
in  rickety  children  in  which  more  extensive  spasms  occur  than  those  of  the 
ordinary  carpopedal  form  and  with  the  character  of  tetany  (sometimes  with 
laryngismus),  yet  I  think  it  is  better  to  limit  the  name  to  those  cases  which 
with  the  spasm  show  marked  increase  in  the  mechanical  and  electrical  excit- 
ability of  the  muscles  and  nerves. 

Treatment.  When  the  spasms  are  severe  chloroform  inhalations  may  be 
used,  as  recommended  by  Trousseau.  The  entire  range  of  antispasmodics 
may  be  tried,  usually  without  any  benefit.  Such  tonics  as  strychnine,  arsenic, 
and  zinc  are  appropriate.  Gowers  speaks  highly  of  the  valerianate  of  zinc 
with  bromide  of  potassium,  and  for  the  nocturnal  tetany  a  dose  of  digitalis 
at  bedtime.     Ice  to  the  spine  and  electricity  in  its  various  forms  may  be  used. 

Where  possible  the  treatment  should  be  directed  to  the  underlying  condi- 
tions. In  the  stomach  cases,  as  the  contractures  very  often  follow  directly 
upon  the  use  of  the  tube,  this  should  be  restricted  as  much  as  possible.  When 
the  disease  has  followed  extirpation  of  the  thyroid,  the  extract  of  the  gland 
may  be  given,  or  a  portion  of  the  thyroid  may  be  transplanted. 


DIPHTHERITIC    PARALYSIS. 

Nature  of  the  Poison.  Roux  and  Yersin  showed  by  the  inoculation  of 
animals  with  the  cultures  and  .with  the  toxins  of  the  diphtheria  bacilli 
that  a  peripheral  paralysis  could  be  produced  similar  to  that  which  occurs  in 


INFECTIVE  DISEASES.  223 

man.  The  observations  of  Sidney  Mai'tin  on  the  character  and  actions  of 
the  chemical  products  of  the  diphtheria  bacillus  are  most  important.  He 
was  able  to  extract  from  the  spleen  and  blood  of  persons  dead  of  diphtheria 
an  albumose  and  an  organic  acid.  The  albumose  produced  in  animals,  when 
injected  subcutaneously,  pyrexia,  loss  in  weight,  and  paralysis,  which  ana- 
tomically was  shown  to  be  due  to  degeneration  and  atrophy  of  the  axis-cylin- 
der of  the  nerves.  The  loss  of  Aveight  was  a  very  striking  feature  in  the 
animal.  Very  similar  results  followed  the  injection  of  the  organic  acid,  but 
larger  doses  were  necessary.     Martin's  conclusions  are  as  follows : 

1.  "That  the  bacillus  forms  in  the  diphtheria  membrane  and  in  culture 
fluids  products,  viz. :  albumoses  and  an  organic  acid  identical  with  those 
found  in  the  tissues  of  persons  dead  from  diphtheria. 

2.  "That  the  physiological  actions  of  single  or  repeated  doses  of  these 
products,  viz. :  fever,  emaciation,  and  progressive  muscular  paresis  due  to 
degeneration  of  the  peripheral  nerves,  are  the  same  as  those  of  the  corre- 
sponding substances  obtained  from  the  tissues,  and  as  the  phenomena  of  the 
disease  itself. 

3.  "  That  the  bacillus  is  therefore  the  primary  infective  agent  in  diphtheria. 

4.  "  That  it  liberates  in  the  membrane  a  ferment  which  when  absorbed 
digests  the  proteids  of  the  body,  forming  albumoses  and  an  organic  acid. 

5.  "  That  these  are  the  immediate  agents  in  the  production  of  fever,  paraly- 
sis, emaciation,  and  death. 

6.  "That  the  relatively  enormous  quantity  of  these  products  found  in  the 
spleen  (in  diphtheria  as  in  anthrax)  is  explicable  by  the  larger  proportion  of 
proteids  normally  present — stagnating,  so  to  say — in  the  blood  of  the  spleen 
than  in  the  general  circulation." 

Anatomical  Changes.  The  central  nervous  system  is  not,  as  a  rule,  in- 
volved. There  may  be  a  slight  infiltration  of  the  meninges,  hemorrhagic 
foci,  and  the  smaller  vessels  have  been  found  blocked  with  micrococci.  The 
diphtheria  bacilli  are  not  found  in  the  nervous  system.  Many  observers 
have  described  changes  in  the  motor  nerve  cells  of  the  anterior  horns  of  the 
spinal  cord,  but  they  are  not  constant. 

The  nerves  show  important  changes,  which  were  first  described  by  Charcot 
and  Vulpian  in  those  of  the  palate,  by  Ruhl  in  the  spinal  nerve  roots,  and 
in  the  peripheral  nerves  by  Dejerine.  The  toxines  produce  either  parenchy- 
matous or  interstitial  neuritis,  sometimes  both.  The  alterations  found  have 
usually  been  in  some  proportion  to  the  degree  of  the  paralysis.  The  histolo- 
gical changes  present  nothing  peculiar,  being  those  described  under  the  sec- 
tion of  peripheral  neuritis. 

Hochhaus  has  called  attention  to  the  fact  that  the  muscles  are  also  in- 
volved. Granular  and  fatty  degeneration  is,  of  course,  common  in  the 
muscles  of  the  palate,  but  in  the  paralyzed  muscles  in  other  j)arts  of  the  body 
there  may  be  a  very  intense  interstitial  and  parenchymatous  myositis. 

Symptoms.  Paralysis  follows  diphtheria  in  a  very  variable  number  of 
cases,  ranging  from  ten  to  twenty  per  cent.  While  it  may  develop  as  early 
as  the  seventh  or  eighth  day,  it  is  more  strictly  a  sequel,  not  manifest  until 
convalescence  from  the  disease  is  well  established.  It  may  follow  diphtheria 
of  any  part,  and  may  occur  after  very  slight  forms  of  the  disease.  Children 
are  very  much  less  apt  to  suffer  than  adults. 

The  onset  is  usually  slow,  and  not  manifested  by  any  I'ecurrence  or  aggra- 
vation of  the  local  throat  symptoms,  nor  is  there,  as  a  rule,  any  fever.  An 
interesting  point,  to  which  attention  has  been  specially  called  by  Bernhardt, 
Buzzard,  and  R.  L.  MacDonnell,  is  the  loss  of  the  knee-jerk  during  con- 
valescence from  diphtheria.  It  may  be  an  early  feature,  while  the  local 
disease  is  still  present,  but  more  commonly  it  is  found  during  convalescence. 


224  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

It  is  important  to  bear  in  mind  that  it  occurs  in  about  two-thirds  of  all  cases, 
and  that  it  is  not  necessarily  associated  with  or  followed  by  paralysis. 

Local  and  general  forms  of  diphtheritic  paralysis  are  recognized. 

Local  Paralysis,  (a)  Palate,  pharynx,  and  larynx.  By  far  the  most 
common  form  is  the  gradual  loss  of  power  in  the  muscles  of  the  palate,  indi- 
cated by  a  nasal  tone  of  the  voice  and  difficulty  in  swallowing.  The  change 
in  the  voice  is  due  to  the  fact  that  in  the  pronunciation  of  certain  words  the 
cavity  of  the  nose  is  not  shut  off.  In  consequence  also  of  this  inability  the 
patient  cannot  distend  the  cheeks  or  blow  out  a  candle  unless  the  nose  is 
held.  The  difficulty  in  swallowing,  manifest  by  regurgitation  of  liquids 
through  the  nose,  is  variable,  being  much  more  marked  in  some  instances 
than  in  others.  The  palate  is  seen  to  be  relaxed,  hangs  more  vertically,  and 
cannot  be  raised.  When  touched  the  sensation  is  also  much  impaired. 
Atrophy  of  the  muscles  follows  the  paralysis,  and  the  reaction  of  degenera- 
tion has  been  obtained,  though  with  difficulty.  This,  the  slightest  and  most 
transient  form  of  diphtheritic  paralysis,  may  disappear  spontaneously  within 
two  or  three  weeks.     Occasionally  unilateral  facial  paralysis  occurs  with  it. 

When  the  muscles  of  the  pharynx  are  involved,  which  is  fortunately  not 
so  common,  the  act  of  swallowing  is  accomplished  with  difficulty,  or  in  ex- 
treme cases  may  be  impossible,  so  that  the  patient  has  to  be  fed  with  a  tube. 

Involvement  of  the  laryngeal  nerves :  "  Paralysis  of  the  upper  part 
(superior  laryngeal  nerve)  is  more  frequent  than  that  of  the  vocal  cords 
(inferior  laryngeal  nerve).  In  the  former  case  the  epiglottis  stands  erect 
against  the  base  of  the  tongue,  and  does  not  descend  over  the  opening  during 
the  act  of  deglutition,  in  consequence  of  the  weakness  of  the  depressors. 
The  upper  part  of  the  larynx  is  insensitive,  although  Avhen  a  foreign  body 
reaches  the  vocal  cords  pain  is  felt.  Hence,  food  is  ajDt  to  get  into  the  larynx 
and  to  cause  coughing.  The  voice  is  hoarse,  probably  in  consequence  of 
paralysis  of  the  crico-thyroid  muscle,  but  the  vocal  cords  move  as  usual.  In 
other  cases  there  is  paralysis  in  the  region  of  the  inferior  laryngeal  nerve, 
and  phonation  may  be  impossible.  The  laryngoscope  then  shows  immobility 
of  the  cords  and  sometimes  a  preponderant  weakness  of  abduction,  so  that 
the  cords  are  not  separated  during  inspiration.  In  one  fatal  case,  at  the  end 
of  the  first  week,  swallowing  was  impossible,  and  there  was  complete  motor  and 
sensory  paralysis  of  the  larynx."  (Growers.) 

(b.)  Special  senses.  Paralysis  of  the  eye  muscles,  intrinsic  and  extrinsic, 
is  not  uncommon.  Loss  of  the  power  of  accommodation,  due  to  afiection  of 
the  ciliary  muscle,  and  loss  of  the  light  reflex  may  be  present.  Ptosis  and 
external  and  internal  strabismus  are  occasionally  seen,  and  in  rare  instances 
complete  ophthalmoplegia.     There  may  be  contraction  of  the  fields  of  vision. 

It  is  much  rarer  to  have  the  other  special  senses  involved,  but  cases  are  on 
record  of  loss  of  the  sense  of  taste,  of  smell,  and  of  hearing. 

(c)  Cardiac  nerves.  Various  forms  of  arrhythmia  are  not  uncommon.  The 
heart's  action  may  be  slowed  to  twenty  or  thirty  beats  per  minute.  In  other 
cases  there  may  be  tachycardia,  or  the  two  conditions  may  alternate  in  the 
same  patient.  In  other  cases  the  pulse  is  irregular  in  volume  and  in  rhythm. 
Fatal  syncope  may  occur,  either  at  the  height  of  the  disease  or  during  con- 
valescence. Occurring  during  the  fever  the  child  may,  after  an  exaggeration 
of  the  symptoms,  present  unusual  pallor ;  the  pulse  may  either  be  weak  and 
rapid  or  may  be  not  more  than  forty  or  fifty  ;  the  extremities  are  cold,  the 
temperature  sinks,  and  death  takes  place  within  a  few  hours  with  all  the 
features  of  collapse.  More  often  the  fatal  event  occurs  during  convalescence, 
even  as  late  as  the  sixth  or  seventh  week  after  apparent  recovery.  The 
attack  may  occur  abruptly  while  the  child  is  in  bed,  or  may  follow  a  sudden 
exertion ;  more  commonly  there  have  been  symptoms  pointing  to  disturbed 


INFECTIVE  DISEASES.  225 

cardiac  rhythm,  or  there  have  been  fainting  spells.  In  some  cases  vomiting 
has  preceded  the  attack.  There  are  not  often  physical  signs  other  than 
slight  increase  in  the  area  of  dulness  and  the  presence  of  a  gallop  rhythm. 
These  serious  symptoms  are  ascribed  to  a  neuritis  of  the  vagi  or  of  the  in- 
trinsic heart  nerves.  Possibly  in  some  of  the  cases  the  lesion,  as  pointed  out 
by  Hosier  and  by  Leyden,  is  an  infectious  myocarditis. 

"  General  Paralysis.  The  multiple  form  of  diphtheritic  paralysis  is  by 
no  means  uncommon.  It  usually  begins  with  an  affection  of  the  palate,  or 
with  the  loss  of  accommodation  in  the  eye,  and  an  absence  of  tendon  re- 
flexes. It  is,  as  a  rule,  bilateral,  involving  the  legs  first,  and  the  patient 
complains  that  they  are  heavy  and  stiff",  and  that  he  tires  easily.  Gradually 
the  weakness  progresses,  and  the  paraplegia  may  become  complete,  or  it  may 
involve  chiefly  the  extensor  groups  of  muscles.  The  paralysis  may  extend 
and  involve  the  arms  and  face  and  render  the  patient  completely  helpless. 
The  muscles  usually  waste,  and  there  is  a  diminution  or  even  complete  loss 
of  the  faradic  irritability.  The  sphincters  may  be  involved,  though  they  are 
often  spared,  even  when  the  paralysis  is  extensive.  Disturbance  of  sensation 
in  the  form  of  numbness,  tingling,  and  anaesthesia  may  develop.  Anaesthesia 
may  be  present  as  a  very  special  feature  ;  thus  Hallager'  reports  an  instance 
in  which  some  paresis  of  all  four  extremities  occurred  with  anaesthesia  of  the 
distal  parts,  in  the  arms  not  extending  above  the  elbow,  and  in  the  legs  to 
the  middle  of  the  thighs.  The  muscles  of  respiration  are  usually  spared,  but 
the  intercostal  muscles  and  the  diaphragm  muscles  are  occasionally  involved, 
and  the  muscles  of  the  neck  and  back  may  be  so  weak  that  the  patient  can 
neither  turn  over  nor  hold  up  his  head. 

The  outlook,  of  course,  in  these  very  severe  cases  is  serious,  and  yet  is  not 
in  many  cases  so  bad  as  some  of  the  symptoms  indicate.  Of  13  cases  of  the 
severer  forms  of  multiple  diphtheritic  paralysis  collected  by  Cadet  de  Gassi- 
court  only  6  died. 

The  duration  of  these  severer  forms  is  very  variable,  from  several  months 
to  an  entire  year.  I  remember  the  case  of  a  medical  student  in  whom  the 
peripheral  paralysis  did  not  disappear  for  more  than  fifteen  months. 

The  prognosis  in  the  local  palsies  is  good,  except  in  the  instances  in  which 
the  pharynx  and  larynx  are  seriously  involved,  and  in  the  cases  with  affec- 
tion of  the  heart.  The  most  dangerous  are  those  in  which  a  rapid  and  wide- 
spread palsy  supervenes  shortly  after  the  primary  disease. 

Dliagnosis.  The  diagnosis  is  rarely  doubtful  when  the  history  of  an  attack 
of  diphtheria  is  clear.  In  many  instances  the  nature  of  a  throat  or  nose 
trouble  has  been  made  manifest  by  the  onset  of  a  paralysis  having  the  char- 
acters of  that  which  so  often  follows  diphtheria.  Rarely  could  the  absence  of 
knee-jerks  and  the  slight  inco-ordination  lead  to  a  diagnosis  of  locomotor 
ataxia,  nor  is  the  gait,  when  the  extensors  of  the  feet  are  chiefly  involved, 
at  all  like  that  of  true  tabes.  There  are  instances  on  record  in  which  hys- 
teria, complicating  the  diphtheritic  paralysis,  has  caused  anaesthesia,  either 
total  or  hemiplegic. 

Treatment.  As  in  all  forms  of  peripheral  neuritis,  there  is  naturally  a 
strong  tendency  to  recovery,  and  the  main  indications  are  to  supj)ort  the 
patient's  strength  and  to  keep  up,  as  far  as  possible,  the  nutrition  of  the 
muscles  by  electricity  and  massage.  The  special  treatment  is  that  of  the 
ordinary  forms  of  peripheral  neuritis.  We  know  of  no  measures  which  can 
directly  counteract  the  poison  in  the  system.  When  the  palate  is  paralyzed 
there  is  rarely  great  difficulty  in  giving  abundant  nourishment.  It  is  to  be 
remembered  that  in  this  state  solid  and  semi-solid  foods  are  better  swallowed 

1  Neurologisches  Centralblatt,  Bd.  ix. 
15 


226  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

than  liquids.  When  the  pharynx  is  seriously  involved  the  patient  must  be 
fed  per  rectum  or  with  a  soft  stomach-tube,  the  greatest  care  being  exercised 
that  particles  of  food  do  not  get  into  the  larynx. 

It  is  too  soon  to  say  how  far  the  new  antitoxin  treatment  (the  results  of 
which  seem  so  favorable)  will  diminish  the  liability  to  these  most  serious 
sequelae  of  the  disease. 

Disorders  other  than  neuritis  may  follow  diphtheria  ;  thus  multiple  sclero- 
sis may  develop  in  children,  as  noted  particularly  by  Marie. 

Hemiplegia  following  diphtheria  is  not  usually  due  to  neuritis,  but  to  acute 
encephalitis  or  to  cerebral  embolism  from  heart-disease.  Of  160  cases  of  iu- 
fantile  hemiplegia  in  Wollenberg's  statistics,  three  followed  diphtheria.  Not 
one  of  my  series  of  120  cases  followed  this  disease.  Seifert^  has  reported  two 
interesting  cases,  both  in  children  about  the  age  of  ten,  Avho  had  had  the 
ordinary  palsy  of  the  throat  following  diphtheria.  In  one  hemiplegia  devel- 
oped suddenly  ;  in  the  other  more  gradually.  He  has  collected  only  six  cases 
from  the  literature  of  complete  hemiplegia  after  diphtheria,  two  of  which 
were  fatal,  both  from  hemorrhage.  As  in  other  instances,  the  condition  is 
probably  due  to  an  acute  encephalitis,  setting  in  with  convulsions  and  fever. 
Caspar  Sharpies  has  reported  the  case^  of  a  boy,  aged  thirteen  years,  who 
during  an  attack  of  diphtheria  was  seized  with  right  hemiplegia  and  aphasia. 

1  Neurologisches  Centralblatt,  No.  12. 

2  Medical  News,  August  4,  1891. 


CHAPTER    VII. 

CHOREIFORM  AFFECTIONS. 
By  WHARTON  SINKLER,  M.D. 

CHOREA. 

Under  this  head  are  included  a  number  of  different  spasmodic  affections, 
embracing  tlie  ordinary  form  of  cliorea  known  generally  as  Sydenham's 
chorea,  hereditary  or  Huntington's  chorea,  chorea  of  pregnancy,  hysterical 
chorea,  post-hemiplegic  chorea,  senile  chorea,  chorea  major,  and  the  so-called 
electric  chorea. 

SYDENHAM'S    CHOREA. 

Synonyms  :  Chorea  minor,  St.  Vitus's  dance,  and  St.  Anthony's  dance. 
This  is  the  variety  of  chorea  commonly  met  with,  and  is  what  is  usually 
referred  to  when  the  term  St.  Vitus's  dance  is  used. 

Definition.  Chorea  minor  is  an  acute  functional  disease,  occurring  princi- 
pally in  children,  and  is  characterized  by  irregular  and  inco-ordinate  mus- 
cular contractions  and  twitchings,  which  are  ordinarily  beyond  the  control  of 
the  patient's  will,  and  cease  during  sleep.  There  is  present  in  most  cases 
more  or  less  psychical  impairment. 

Sydenham's  original  description  of  chorea  is  so  graphic  and  clear  that 
it  is  worth  repeating.  He  says  (Entire  Works  of  Sydenham,  London, 
1783,  Schedula  Montoria,  etc.,  page  562) :  "This  disorder  is  a  kind  of  con- 
vulsion which  chiefly  attacks  children  from  ten  to  fourteen  years  of  age.  It 
first  shows  itself  by  a  certain  lameness,  or,  rather,  unsteadiness  of  one  leg, 
which  the  patient  draws  after  him  like  an  idiot,  and  afterward  affects  the 
arm  of  the  same  side,  which,  being  brought  to  the  breast  or  to  any  other 
part,  cannot  be  held  in  the  same  posture  a  moment,  but  it  is  distorted  or 
snatched  by  a  kind  of  convulsion  into  a  different  posture  and  place,  notwith- 
standing all  his  eftbrts  to  the  contrary.  If  a  glass  of  liquor  be  put  into  his 
hand  to  drink,  he  uses  a  thousand  odd  gestures  before  he  can  get  it  to  his 
mouth,  for  not  being  able  to  caiuy  it  in  a  straight  line  thereto,  because  his 
hand  is  drawn  different  ways  by  the  convulsion.  As  soon  as  it  has  haj)pily 
reached  his  lips  he  throws  it  suddenly  into  his  mouth,  and  drinks  it  very 
hastily,  as  if  he  meant  only  to  divert  the  spectators." 

Etiology.  In  studying  the  causes  and  conditions  Avhich  influence  the 
development  of  chorea  we  must  remember  that  in  infancy  all  of  the 
attempted  movements  of  the  child  are  irregular  and  inco-ordinate ;  and  even 
when  the  infant  is  not  attempting  to  perform  a  voluntary  act  there  are  more 
or  less  irregular  movements  taking  place  in  the  extremities.  If  a  young- 
infant  attempts  to  grasp  an  object,  its  hand  is  unable  to  reach  it  without  a 
number  of  efforts,  which  are  spasmodic  and  inco-ordinate,  and  like  the  move- 
ments of  a  choreic  child. 


228  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Heredity.  It  is  not  often  that  one  can  trace  chorea  through  a  family, 
but  it  is  fairly  common  that  more  than  one  case  occurs  among  brothers  and 
sisters.  I  have  seen  five  cases  of  chorea  in  a  family  of  six  children,  and 
there  was  no  principle  of  imitation  involved  in  this  instance,  as  all  of  the 
cases  occurred  at  different  times.  In  797  of  the  cases  studied  at  the  Ortho- 
pedic Hospital  and  Infirmary  for  Nervous  Diseases  at  Philadelphia,  no 
heredity  could  be  traced  in  631 ;  in  33,  one  of  the  parents  had  suffered  from 
chorea ;  in  96,  a  brother  or  a  sister ;  in  30,  an  uncle  or  an  aunt ;  in  seven  there 
was  a  history  of  chorea  in  the  grandmother. 

The  parents  of  choreic  children  are  frequently  sufferers  from  some  form  of 
nervous  affection,  such  as  migraine  or  neuralgia,  but  at  times  there  is  no 
neurotic  family  history  to  be  traced. 

Age.  This  plays  an  important  part  in  the  affection.  The  majority  of 
cases  occur  between  the  ages  of  five  and  fifteen  years.  In  the  cases  of 
chorea  in  the  note-books  of  the  Infirmary  for  Nervous  Diseases,  which  I 
have  examined  with  the  assistance  of  Dr.  J.  H.  Rhein,  we  found  in  961 
cases  that  816  were  between  the  ages  of  five  and  fifteen  years,  the  greatest 
number  occurring  at  the  age  of  nine ;  that  is,  113  cases.  Gowers  believes 
that  most  cases  occur  at  the  age  of  thirteen  years.  Age  of  incidence  in 
937  cases:  First  hemidecade,  one  to  five  years,  107.  Second  hemidecade, 
six  to  eleven  years,  453.  Third  hemidecade,  eleven  to  sixteen  years, 
309.  Fourth  hemidecade,  sixteen  to  twenty-one  j^ears,  68.  Total,  937. 
The  disease  may  occur  at  any  period  of  life.  I  have  recorded  two  cases 
which  were  apparently  congenital,  and  have  seen  one  case  at  the  age  of  eighty 
years.  It  is  rare  under  five  years.  In  the  961  cases  above  referred  to,  but 
53  occurred  under  that  age.  In  one  case,  the  choreic  movements  were  observed 
at  one  month ;  in  another  the  child,  a  girl,  was  attacked  at  a  year  and  a  half; 
8  cases  occurred  at  two  years,  17  at  three  years,  and  27  at  four  years. 

Moyer  {Medical  Times  and  Register,  May  13,  1893)  reports  a  case  which 
began  at  ten  months,  but  it  was  evidently  not  Sydenham's  chorea.  The 
patient  was  fifteen  years  of  age  when  examined,  and  the  movements  were  like 
those  which  are  associated  with  infantile  diplegia. 

I  have  seen  a  case  of  chorea  which  had  existed  since  birth,  and  it  was 
attributed  to  a  fright  which  the  mother  of  the  patient  received  during 
pregnancy.     Similar  cases  have  been  reported  by  others. 

Sex.  Growers  gives  the  proportion  of  the  sexes  as  three  girls  to  one 
boy.  This  ratio  was  obtained  from  the  examination  of  a  combination  of 
statistics  amounting  to  1365  cases,  and  is  the  same  which  I  found  in  the  961 
cases  which  were  treated  at  the  Philadelphia  Infirmary.  Of  the  961  cases 
which  I  analyzed,  696  were  females  and  265  were  males,  or  a  ratio  of 
almost  exactly  three  to  one.  In  adults,  if  one  excludes  the  chorea  of  preg- 
nancy, the  influence  of  sex  is  less  marked.  Contrary  to  what  one  would 
expect,  the  approach  of  puberty  in  girls  seems  to  make  no  increase  in  the 
proportion  of  cases  in  that  sex.  Of  309  cases  in  the  series  which  I  have 
examined,  there  were  219  girls  to  90  boys,  a  ratio  of  2.43  to  1,  between 
the  ages  of  eleven  and  fifteen,  inclusive,  the  period  at  which  the  catamenia 
is  likely  to  appear.  Osier  states  that  after  puberty  the  proportion  of  females 
to  males  becomes  greater,  but  this  does  not  agree  with  my  statistics. 

Race.  It  is  exceedingly  rare  in  the  negro  race,  and  Dana  states  that  in 
New  York  it  is  more  common  in  children  of  the  German,  Hebrew,  and 
Portuguese  races.  Ogle  (British  and  Foreign  Med.-CMr.  Rev.,  vol.  xli.) 
says  that  chorea  is  common  among  Jews,  and  quotes  Addison,  Steibel,  and 
others  as  making  the  same  statement.  It  is  difficult  to  estimate  the  influence 
of  race,  unless  one  knows  the  proportion  of  the  different  nationalities  in  a 
given  place,  but,  from  my  OAvn  experience  at  the  Infirmary  for  Nervous 


CHOREIFORM  AFFECTIONS.  229 

Diseases,  I  am  satisfied  that  in  Philadelphia  it  is  more  frequent  in  children 
of  American  parentage  than  in  foreigners.  Mitchell  made  extensive  inquiries 
in  regard  to  the  extent  of  chorea  in  negroes,  and  the  testimony  Avhich  he 
obtained  Avas  "that  chorea  is  seldom  met  with  among  pure-blooded  negroes." 
I  have  met  with  five  cases  of  chorea  in  negroes,  in  two  of  these  only 
were  the  patients  full-blooded  negroes.  In  the  majority  there  was  some 
peculiar  combination  of  influences  brought  to  bear  to  produce  the  attack. 
One  of  the  cases  was  a  mulatto  woman  aged  nineteen  years ;  her  parents 
were  dead — both  of  them  light  colored.  The  patient  had  an  attack  of 
rheumatism  one  year  previously.  She  had  been  married  three  months,  and 
was  in  the  fourth  month  of  pregnancy.  Four  weeks  before  she  had  got 
into  an  altercation,  and  was  struck  on  the  left  hand  with  a  stick,  and  was  hurt 
considerably,  so  that  the  hand  was  swollen  and  sore  at  the  time  she  was  seen 
by  me.  One  week  after  the  injury  choreic  movements  began  in  her  left  hand, 
and  they  soon  extended  to  the  shoulder  and  then  to  the  leg.  The  move- 
ments involved  the  whole  left  side  when  seen,  and  were  increased  when  she 
made  a  voluntary  efibrt.  In  this  patient  there  w^ere  three  predisposing 
causes  for  chorea.  First,  rheumatism,  second,  pregnancy,  and,  third,  the 
injury  associated  with  considerable  mental  excitement  at  the  time  of  its 
receipt.  Another  case  was  that  of  a  mulatto  girl,  aged  twelve.  She  was  one 
of  five  children,  all  of  whom  were  healthy,  except  two,  who  suffered  from 
rickets.  She  was  small  for  her  age,  and  had  never  menstruated.  In  Septem- 
ber, 1893,  she  had  an  attack  of  tonsillitis,  which  was  followed  by  subacute 
rheumatism,  in  which  all  of  the  large  joints  were  involved.  On  December 
10th,  two  months  after  the  attack  of  rheumatism,  she  presented  herself  with 
marked  evidences  of  chorea.  It  began  at  first  with  difficulty  in  articulation, 
then  the  right  side  of  the  body  became  affected,  and  later  the  whole  body. 
The  patient  had  some  soreness  of  the  joints,  and  there  was  a  loud  and  well- 
marked  mitral  systolic  murmur.  The  patient  slept  badly,  was  restless,  and 
frequently  awoke  crying.  She  was  irritable,  cross,  and  peevish.  Under  the 
use  of  the  salicylate  of  sodium  she  made  a  rapid  recovery.  Other  cases  of 
chorea  in  negroes  have  been  reported.  Skinner  (Phila.  Med.  Times,  1875) 
records  a  case  of  a  girl  of  eighteen,  of  pure  African  descent.  Roy  {New 
York  Med.  Record,  May,  1892)  also  reports  a  case  in  a  negro.  Sachs  says 
he  has  seen  several  in  New  York. 

Climate  and  Social  Station.  Chorea  occurs  more  frequently  in  the  city 
than  in  the  country,  although  country  children  by  no  means  possess  an 
immunity  from  it ;  neither  is  it  any  respecter  of  persons  as  regards  social 
station,  although  some  writere  think  that  it  occurs  more  frequently  among 
children  of  the  poorer  classes.  It  is  difficult  to  make  any  accurate  estimate 
in  regard  to  this  point,  for  the  majority  of  cases  which  occur  among  the  bet- 
ter classes  are  treated  by  the  family  physician  and  do  not  come  under  the 
notice  of  a  specialist,  while  among  the  poor  they  are  usually  brought  to  dis- 
pensaries for  treatment,  and  these  fall  under  the  notice  of  a  neurologist. 

Eskridge^  found  that  the  climate  of  Colorado  at  altitudes  varying  from  4400 
feet  to  10,200  did  not  predispose  to  chorea ;  but  he  found  that  at  the  higher 
altitudes  the  disease  was  more  difficult  to  cure,  and  it  was  necessary  to  send 
cases  to  lower  levels  before  they  got  well. 

Season.  Chorea  occurs  most  frequently  in  the  spring.  Gerhard^  in  a 
study  of  80  cases,  most  of  which  were  observed  at  the  Philadelphia  Infirm- 
ary for  iSTervous  Diseases,  found  that  of  68  cases,  39  occurred  in  the  spring, 
10  in  the  summer,  7  in  the  autumn,  and  12  in  the  winter.     Mitchell^  has 

1  The  Climatologist,  August,  1891, 

-  American  Journal  of  the  Medical  Sciences,  July,  1876,  p.  99. 

3  Lectures  on  Diseases  of  the  Nervous  System,  Philadelphia,  1881,  p.  128. 


230 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


also  written  on  the  relation  between  season  and  attacks  of  chorea.  Eecently 
Morris  J.  Lewis  has  written  an  elaborate  paper  on  the  relation  of  season  to 
chorea  and  rheumatism.i  He  has  examined  1383  separate  attacks  of  chorea  in 
regard  to  the  month  of  the  onset  of  the  disease.  Of  these  717  are  from  the 
note-books  of  the  Philadelphia  Infirmary  for  Nervous  Diseases,  and  666  cases 
occurred  in  Boston,  and  were  collected  by  James  J.  Putnam  and  PhiKp 
Coombs  Knapp.  Lewis  found  that  of  these  cases,  there  occurred  in  January 
106,  February  101,  March  172,  April  159,  May  160,  June  150,  July  126,  Au- 
gust 106,  September  76,  October  74,  November  54,  December  99— total,  1383. 
I  have  studied  all  the  cases  of  chorea  in  the  note-books  at  the  Philadel- 
phia Infirmary  for  Nervous  Diseases  up  to  date,  and  find  that  in  812  attacks, 
in  which  the  month  of  onset  is  noted,  there  occurred  in  January  Q%,  Febru- 
ary 59,  March  79,  April  93,  May  74,  June  93,  July  87,  August  74,  Septem- 
ber 52,  October  35,  November  33,  December  67,  as  will  be  seen  by  the  ac- 
companying diagram. 


Jan. 

Feb. 

Mar. 

Apl. 

Fig.  56. 
May  June  July 

Aug.  Sept. 

Oct. 

Nov. 

Dec: 

A 

As^ 

1 

f\ 

1 

/   ^ 

\ 

70 
60 
50 

1 

V 

\ 

\ 

\ 

\ 

I 

\ 

1 

\ 

1 

30 

J 

Diagram  showing  month  of  onset  of  812  cases  of  chorea  which  were  observed  at  the  Philadelphia 
Infirmary  for  Nervous  Diseases. 

Dr.  M.  Allen  Starr^  records  325  cases  of  chorea  which  he  had  observed  in 
New  York,  in  which  he  had  noted  the  month  and  day  of  onset  of  the  disease. 
Of  these  the  largest  number,  49,  occurred  in  the  month  of  April,  and  the 
smallest  number  of  cases  occurred  in  October,  November,  and  December. 

Other  observers  have  differed  somewhat  in  regard  to  the  season  at  wliich 
the  greatest  number  of  cases  occur,  but  I  believe  the  discrepancy  depends 
upon  the  smaller  number  of  cases  which  have  been  studied  by  them. 

Koch,^  in  a  study  of  267  cases,  found  that  it  was  most  prevalent  in  December, 
22  per  cent,  of  his  cases  having  occurred  in  that  month  ;  and  Dana'*  says  that 


1  Transactions  of  Association  of  American  Physicians,  1892,  vol.  vii.,  p.  249. 

2  Ibid.,  p.  262.  3  Archiv  fiir  Klinische  Medicin,  1888. 
*  Text-book  of  Nervous  Diseases,  p.  437. 


CHOREIFORM  AFFECTIONS.  231 

in  New  York  there  is  almost  an  equal  number  of  cases  in  the  autumn  and 
the  spring. 

Lewis/  in  a  study  of  the  relation  of  weather  to  chorea,  thought  that  the 
"weather  influenced  the  production  of  the  attacks,  and  believed  that  the  cases 
are  rather  more  frequent  when  the  mean  relative  humidity  and  barometric 
pressure  are  low.  More  extended  observations,  however,  have  made  him 
regard  the  influence  of  weather  as  less  marked  than  he  formerly  thought. 

JRheumatism.  The  relationship  between  rheumatism  and  chorea  has  been 
recognized  for  many  years,  but  great  difierences  of  opinion  have  prevailed  as 
to  this  point.  The  English  and  French  writers,  with  but  few  exceptions, 
have  upheld  the  view  of  the  relationship,  while  the  German  authorities 
thought  that  the  connection  was  very  small.  I  have  seen  too  many  cases  of 
chorea  which  immediately  followed  an  attack  of  acute  rheumatism  not  to 
believe  that  association  between  the  two  diseases  is  real  and  not  accidental. 

Osler^  has  analyzed  554  cases,  in  which  15.5  per  cent,  had  a  history  of 
rheumatism  in  the  family.  In  88  cases,  or  13.8  per  cent.,  there  was  a  history 
of  articular  swelling,  acute  or  subacute. 

Of  927  cases  w^hich  I  analyzed  at  the  Philadelphia  Infirmary  for  Nervous 
Diseases  there  was  a  history  of  rheumatism,  acute  or  chronic,  in  187  cases, 
or  20.1  per  cent.  In  addition  to  this,  there  were  38  cases  in  which  the  chil- 
dren were  said  to  have  had  "  growing  pains."  In  79  cases,  or  8.5  per  cent., 
there  was  a  distinct  history  of  acute  articular  rheumatism.  The  intervals 
between  the  rheumatism  and  the  attack  of  chorea  varied  from  six  years  to  im- 
mediately preceding.  In  38  cases  the  attack  of  rheumatism  had  occurred 
within  one  year  of  the  chorea ;  in  8  cases  acute  rheumatism  immediately  pre- 
ceded the  chorea,  and  in  7  the  two  afiections  were  coincident. 

The  statistics  of  the  Collective  Investigation  Committee  of  the  British 
Medical  Association  give  a  percentage  of  26  out  of  239  cases  in  which  there 
was  a  history  of  "joint  afiection." 

In  many  cases  of  chorea  there  is  a  history  of  vague  general  pains,  or  flit- 
ting joint  pains,  which  are  probably  not  rheumatic.  Osier  suggests  that  they 
may  be  analogous  to  the  joint  troubles  of  scarlet  fever,  puerperal  fever,  or 
gonorrhoea. 

Heart  Disease.  In  a  large  proportion  of  children  suffering  from  chorea 
there  is  some  abnormal  condition  of  the  heart.  In  many  cases  there  is  dis- 
tinct irregularity  in  the  heart's  action,  and  in  others  reduplication  of  the 
second  sound  is  heard.  Some  writers  believe  that  endocarditis  is  generally 
present  in  this  disease,  and  is  one  of  its  causes,  through  the  washing  of  small 
vegetations  from  the  valves  into  the  brain.  Of  course,  it  is  difficult  to  deter- 
mine in  how  many  of  the  cases  met  with  the  cardiac  affection  has  antedated 
the  chorea.  The  British  Medical  Association  Collective  Committee  found 
that  in  from  one-quarter  to  one-half  of  the  cases  heart-disease  precedes  chorea. 

The  following  table  from  Dr.  M.  Allen  Starr^  shows  the  connection  be- 
tween rheumatism  and  endocarditis  in  2476  cases  of  chorea  : 

1  Medical  News,  Nov.  15, 1886.  -  Practice  of  Medicine,  p.  930. 

3  American  Text-book  of  Diseases  of  Children. 


232 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Table  I. — Showing  the  Relatiokship  of  Chorea,  Eheumatism,  and 
Endocabditis  (Stare). 


Author. 

No.  cases 
chorea. 

Rheuma- 
tism. 

Cardiac. 

Reference. 

Groendal 

Meyer    . 

Koch     . 

Peiper   . 

See         ... 

Leroux  . 

Dale 

Herringham 

Garrod  . 

Cheadle 

Brit.  Col.  Invest.  Com 

Gowers  . 

Sachs    . 

Dana     . 

Sinkler . 

Starr      . 

52 

121 

267 

80 

196 

80 

20 

80 

80 

84 

439 

100 

70 

130 

279 

448 

37 

11 

48 

14 

134 

5 

3 

37 

36 

62 

116 

24 

8 

7 

37 

83 

Majority. 

15 

37 

6 

"5 

8 

20 

45 

141 
40 
12 

8 
82 
83 

Wien.  med.  Woch.,  March  26, 1891. 

Berl.  kiln.  Woch.,  July  14, 1890. 

Arch.  klin.  Med.,  1886. 

Deut.  Med.  Woch.,  July,  1888.' 

La  Med.  Moderne.  October,  1891. 

Rev.  Mens,  des  Mai.  de  I'Enf.,  June,  1890. 

Lancet,  October  31, 1891. 

Lancet,  January  12,  1889. 

Lancet,  January  12,  1889. 

Lancet,  May  4,  1889. 

British  Med.  Jo  urn.,  February  28,  1857. 

Dis.  Nerv.  System,  vol.  ii.  p.  550. 

Keating's  Cyclo.  Child.  Dis.,  vol.  iv.  p.  843. 

Arch,  of  Pediatrics,  April,  1888. 

Pepper's  System  of  Med.,  vol.  iv.  p.  442. 

2476 

662 
26  per  ct. 

502+ 

Nutrition.  In  the  majority  of  cases  of  chorea  Avhich  I  have  seen,  the 
children  are  well  nourished  and  do  not  look  aneeniic.  The  British  Medical 
Association  Investigating  Committee  inquired  into  the  food  of  437  cases,  and 
found  that  in  384  it  was  sufBcient,  in  48  not  quite  sufficient,  and  in  the  re- 
mainder it  was  insufficient. 

Ansemia  is  sometimes  met  with,  and  in  some  cases  the  number  of  red  cor- 
puscles in  the  cubic  millimeter  has  been  found  far  below  normal.  In  the  439 
cases  of  the  Collective  Investigation  Committee,  92  were  recorded  as  being 
anaemic. 

Rachford^  believes  that  in  most  cases  of  chorea  the  underlying  cause  is  a 
"  scrofulous  ansemia." 

Infectious  Diseases.  Of  the  cases  which  I  have  studied,  remarkably  few 
have  had  a  history  of  antecedent  infectious  diseases. 

Osier  found  a  history  of  scarlatina  in  25  joer  cent,  of  his  cases  ;  and  of  853 
cases  which  I  examined  there  were  268,  or  31.4  per  cent.,  in  which  there  was 
an  antecedent  history  of  scarlet  fever.  Of  these  cases,  however,  but  eleven 
occurred  within  a  short  time  of  the  onset  of  the  choreic  attack.  It  is  highty 
improbable  that  there  is  any  relationship  between  this  disease  and  scarlet  fever. 

I  find  no  record  of  any  relationship  between  other  infectious  diseases  and 
chorea,  except  Sturges's  statement  that  he  had  found  a  history  of  previous 
whooping-cough  more  frequently  in  choreic  than  in  other  children. 

Trowbridge  (Alienist  and  Neurologist,  Januar}^,  1892)  believes  that  a  rela- 
tion exists  between  chorea  and  epilepsy.  He  gives  a  table  of  fifteen  cases  in 
which  these  diseases  were  associated  at  different  times  in  the  same  individual. 

Fright  is  a  frequent  cause  of  chorea ;  but  it  is  probably  not  so  common  as 
is  popularly  supposed.  On  inquiring  into  the  history  of  an  attack,  it  is  fre- 
quently attributed  by  friends  of  the  patient  to  fright ;  but  it  is  often  found 
that  there  is  no  direct  relationship  between  the  fright  and  the  attack.  Some- 
times the  supposed  fright  has  taken  j)lace  several  weeks  before  the  onset  of 
the  disease.  Gowers  believes  that  fright  is  a  cause  of  one-fifth  of  the  cases  of 
chorea,  and  in  859  cases  which  I  have  examined,  in  whom  that  point  was 
recorded,  there  was  a  history  of  fright  in  203,  or  23.5  per  cent.     In  order  to 


1  Medical  News,  April  22, 1893. 


CHOREIFORM  AFFECTIONS.  233 

consider  fright  as  a  cause  of  the  attack  of  chorea,  it  is  necessary  that  the 
interval  between  the  alleged  cause  and  the  attack  should  be  less  than  a  month. 

Traumatism  is  occasionally  the  origin  of  chorea ;  and  a  splinter  in  the  flesh 
or  the  extraction  of  a  tooth  has  been  apparently  the  exciting  cause  in  some 
instances.  In  these  cases  there  has,  however,  been  some  accompanying  men- 
tal disturbance  or  a  predisposition  to  kSt.  Vitus's  dance,  which  has  made  the 
traumatism  effective.  Reflex  irritation  has  been  known  to  develop  the  disease. 
Jacobi  reports  a  case  caused  by  nasal  irritation ;  and  Leonard  records  an 
instance  of  chorea  in  a  girl  in  whom  there  was  adhesion  of  the  preputium 
clitoridis,  which  was  cured  by  freeing  the  adhesions.  Other  reflex  causes, 
as  adherent  prepuce  in  the  male,  are  occasionally  met  with,  but  they  are 
rare,  and  I  have  never  seen  a  case  in  which  masturbation  could  be  regarded 
as  a  cause  of  chorea. 

Overstudy  is,  I  believe,  a  frequent  source  of  chorea,  although  there  is  a 
diversity  of  opinion  in  regard  to  school  as  a  factor  in  this  disease.  Sturges 
speaks  of  "school-made  chorea;"  and  refers  to  the  influence  of  school  as 
operating  rather  through  bad  ventillatiou  of  the  school-room  and  injudicious 
discipline  of  teachers,  rather  than  by  overtaxing  the  brain  by  hard  study. 
He  speaks  of  nine  out  of  twenty-five  cases  which  he  had  observed  in  which 
the  attack  was  directly  traceable  to  school. 

My  own  observation  has  led  me  to  believe  that  a  large  number  of  choreas 
in  children  are  the  result  of  either  overstudy  or  overanxiety,  in  connection 
with  examinations  or  standing  in  the  class.  I  have  frequently  found,  on 
making  inquiry,  that  the  patient  held  a  high  place  in  her  class  and  was 
anxious  to  keep  her  position ;  and  a  number  of  cases  have  developed  during 
the  time  of  the  examinations  in  the  public  schools. 

Morris  J.  Lewis,  in  his  paper  above  cited,  states  that  he  doubts  the  influence 
of  overstudy  as  the  exciting  cause  of  chorea;  because,  in  his  table  of  1383 
cases,  collected  in  Boston  and  Philadelphia,  the  greatest  number,  172  cases, 
occurred  in  March ;  and  the  school  examinations  do  not  occur  until  June. 
But  in  his  table  the  number  of  cases  in  April,  May,  and  June  are  almost  as 
great  as  in  March — 159,  160,  and  150,  respectively— and  in  my  table  of  812 
cases,  all  of  which  were  seen  at  the  Infirmary  for  Nervous  Diseases,  there  were 
as  many  cases  in  April  as  in  June,  and  more  than  in  March.  Among  the 
cases  seen  at  the  Infirmary  fox  Nervous  Diseases,  school  as  an  exciting  cause 
was  mentioned  in  42,  and  this  does  not  by  any  means  represent  the  children 
in  whom  the  efiect  of  ambition  and  overstimulation  to  do  well  was  unob- 
served by  the  parents.  Hamilton'  found  20  per  cent,  of  all  school-children 
in  New  York  either  choreic  or  suffering  from  some  similar  disorder. 

Pregnancy.  The  majority  of  cases  in  adults,  exclusive  of  the  hereditary 
form,  are  connected  with  pregnancy.  This  form  is  known  as  chorea  gravida- 
rum. It  is  most  common  in  the  first  pregnancy,  and  seldom  occurs  for  the 
first  time  after  twenty-five  years  of  age.  It  generally  makes  its  appearance 
during  the  first  five  months,  although  it  may  occur  during  the  latter  months 
of  gestation.  Chorea  in  pregnancy  very  closely  resembles  the  same  disease 
in  childhood,  and  frequently  has  predisposing  causes  in  common,  such  as 
rheumatism  and  fright.  The  patients  have  frequently  had  chorea  in  child- 
hood. A  young  woman  who  recently  came  under  my  observation  had  five 
attacks  of  chorea  in  childhood,  married  at  twenty-eight,  and  became  choreic 
in  the  third  month  of  pregnancy.  She  was  treated  with  vigorous  doses  of 
arsenic,  and  the  choreic  movements  were  entirely  cured  in  ten  weeks,  She 
was  safely  delivered  at  term. 

If  chorea  begins  during  the  latter  months  of  pregnancy,  it  is  liable  to  cou- 

1  American  Psychological  Journal,  February,  1876. 


234  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tinue  to  the  eucl,  and  is  more  likely  to  be  fatal.  Gowers  and  Sachs  mention 
cases  of  chorea  which  have  begun  after  delivery,  or  after  abortion.  The 
former  has  made  an  analysis  of  28  cases  which  he  has  collected,  and  states 
that  the  ages  at  which  they  occurred  is  as  follows :  Seventeen  years,  3  ; 
eighteen  years,  3  ;  nineteen  years,  3  ;  twenty  years,  8  ;  twenty-one  years,  2  ; 
twenty-two  years,  2  ;  twenty-three  years,  6  ;  twenty-four  years,  1 . 

Chorea  of  pregnancy  has  been  recorded  by  some  writers  as  a  very  fatal 
disease ;  but  this  has  not  been  my  experience.  I  have  seen  at  least  fifteen 
cases  of  chorea  of  pregnancy,  and  have  not  seen  one  terminate  fatally. 
Barnes  {Transactions  London  Obstetrical  Society,  vol.  x.,  1889)  collected  56 
cases  of  chorea  of  pregnancy,  of  which  17,  or  30  per  cent.,  were  fatal.  These 
probably  represented  the  worse  cases,  and  which  were  recorded  because  they 
were  severe.  An  interesting  case  came  under  my  observation  in  the  nervous 
wards  at  the  Philadelphia  Hospital,  in  which  pregnancy  apparently  cured  an 
attack  of  chronic  chorea  which  has  existed  for  years. 

Mary  G.,  aged  thirty  years,  single,  no  neurotic  family  history.  The  patient 
has  had  scarlet  fever,  measles  twice,  and  diphtheria.  When  she  was  nineteen 
years  of  age  she  dreamed  one  night  of  seeing  her  dead  mother  standing  by 
her  bed,  and  when  she  awoke  she  was  in  such  agitation  and  fright  from  the 
vividness  of  the  dream  that  she  could  not  remain  in  her  room  alone.  The  next 
morning,  on  awaking,  she  had  a  tremor,  confined  to  the  left  side.  Six  years 
later  the  whole  body  became  involved  in  choreic  movements  ;  and  these  were 
violent  and  extreme  in  character.  After  she  had  been  choreic  for  four  years 
she  became  pregnant ;  but  she  was  unaware  of  her  condition  until  three 
months  advanced.  Soon  after  this  the  movements  increased  in  violence  to 
such  an  extent  that  she  was  unable  to  do  any  work,  or  even  to  sit  still  for  more 
than  a  few  minutes.  She  was  admitted  to  the  hospital  when  she  was  in  the 
fifth  week  of  pregnancy.  The  movements  were  then  so  excessive  that  she 
had  to  be  kept  in  bed  constantly.  She  was  delivered  at  eight  months  of  a 
stillborn  child  weighing  three  pounds  and  twelve  ounces.  From  the  time  of 
her  delivery  the  choreic  movements  lessened,  and  in  a  few  months  they  had 
ceased  entirely.  She  has  been  perfectly  well  for  two  years,  and  is  now  em- 
ployed in  the  hospital  as  a  helper,  and  is  active  and  efficient.  Chorea  may 
recur  in  several  pregnancies,  but  this  is  unusual. 

Ocular  Defects.  It  has  been  asserted  by  Stevens  and  others  that  errors 
of  refraction  are  the  cause  of  many  cases  of  chorea.  De  Schweinitz  inade  a 
study  of  fifty  cases  of  children  at  the  Philadelphia  Infirmary  for  Nervous 
Diseases,  and  came  to  the  conclusion  that  while  hypermetropia  and  hyper- 
metropic astigmatism  are  the  preponderating  conditions  in  the  eyes  of  choreic 
children,  being  found  in  about  77  per  cent,  of  the  cases,  evidence  seems 
lacking  that  the  refraction  error  is  the  basal  cause  of  chorea. 

Of  the  cases  which  have  come  under  observation  at  the  Infirmary  for 
Nervous  Diseases,  a  large  part  have  had  their  refraction  errors  corrected  ;  but 
there  has  been  in  no  instance  immediate  improvement  until  medicinal  and 
hygienic  treatment  was  pursued. 

Occasionally,  optic  neuritis  is  met  with  in  a  patient  suffering  from  chorea. 
Gowers  speaks  of  this,  and  de  Schweinitz  has  observed  the  same  condition. 
Oliver'  says  that  in  almost  all  cases  of  chorea  there  exists  a  low  form  of  optic 
neuritis  and  retinitis. 

Among  the  cases  at  the  Infirmary  for  Nervous  Diseases,  there  was  a  history 
of  intestinal  worms  in  but  a  small  percentage ;  in  fact,  there  were  but  three 
children  who  were  said  to  have  worms  at  the  time  of  application  for  treat- 
ment.    On  the  other  hand,  Ogle^  states  that  fourteen  of  eighty  cases  seen  by 

1  Keating's  CyclopEedia  of  the  Diseases  of  Children,  vol.  iv.,  p.  197. 
-  Brit,  and  For.  Med.-Chir.  Review,  vol.  sli.,  p.  233. 


CHOREIFORM  AFFECTIONS.  235 

him  had  kimbricoids  at  the  beginning  of  treatment.  The  same  writer  relates 
the  case  of  a  girl  of  nine  years  who  had  an  attack  of  chorea  of  extreme 
severity.  There  was  a  bed-sore  on  the  sacrum,  and  the  elbows  were  much 
chafed.  Pieces  of  tapeworm  had  been  passing  per  anum  for  three  months, 
A  dose  of  Filix  Mas  brought  away  seven  yards  of  a  tenia,  including  the 
head,  and  within  twenty-four  hours  the  child  was  quiet,  except  for  an  occa- 
sional twitch.  In  ten  days  she  was  entirely  well,  but  a  distinct  mitral  murmur 
remained. 

Malaria  has  been  suggested  as  a  cause  of  chorea.  Vought^  reports  a  case 
in  which  choreic  movements  followed  a  fright.  There  was  a  history  of 
malarial  poisoning,  and  an  examination  of  the  blood  showed  the  j)lasmodia 
characteristic  of  malaria.  The  patient  was  then  treated  with  quinine  and 
arsenic,  and  recovered.  The  cure  seems  hardly  speedy  enough  to  make  one 
regard  the  treatment  as  the  direct  cause  of  improvement,  three  months  having 
elapsed  before  the  child  was  well.  In  another  case  the  same  writer  found  in 
the  blood  of  a  choreic  boy  "pigmented  intercellular  bodies."  A  malarial 
origin  may  explain  the  benefit  which  has  resulted  from  the  administration  of 
large  doses  of  quinine  recommended  by  Wood. 

Symptoms.  The  earliest  change  to  be  observed  in  a  child  threatened  with 
chorea  is  a  general  restlessness  and  inability  to  sit  still.  There  may  be  an 
occasional  shrugging  of  the  shoulders  or  a  restless  movement  of  the  body, 
without  any  special  or  definite  movements  being  noticed.  Sturges-  thinks 
that  the  best  indication  of  the  approach  of  an  attack  of  chorea  is  to  be  found 
in  the  hands,  and  he  suggests  the  following  test :  "  The  child  is  told  to  hold 
both  hands  open,  with  extended  arms  and  the  palms  toward  you.  If  that  be 
done  steadily,  both  hands  upright  and  both  alike,  no  finger  or  thumb  quiver- 
ing, no  falling  back  or  hanging  forward  of  either  hand,  nothing  to  choose 
betAveen  the  position  of  the  two,  then  the  child  may  be  acquitted  of  chorea." 
Frequently,  however,  the  choreic  movements  in  a  child  are  first  observed  by 
the  teacher  at  school,  who  finds  that  the  little  pupil  is  unable  to  sit  as  quietly 
as  formerly,  and  that  there  are  some  occasional  irregular  movements  of  the 
hand  or  body.  The  child's  writing  becomes  bad,  and  the  pencil  is  often 
dropped  from  his  hand,  at  the  same  time  there  may  be  emotional  disturb- 
ances. The  child  becomes  irritable  and  peevish,  and  wakes  in  the  night  with 
attacks  of  crying.  There  may  be  more  or  less  joint  pains,  which  are  con- 
sidered by  the  parents  "  growing  pains,"  and  headache  is  more  or  less  com- 
mon. In  a  few  days  the  irregular  movements  become  more  marked.  The 
child  grows  awkward  in  the  use  of  his  hands,  drops  his  knife  at  table,  or 
spills  a  cup  of  milk,  and  on  being  reproved  becomes  more  awkward  in  his 
movements.  As  the  disease  progresses  the  movements  become  more  constant 
and  more  violent.  They  are  irregular  and  jerky,  and  the  want  of  rhythm 
is  a  striking  characteristic.  At  first  the  movements  are  confined  only  to  the 
arms,  or,  perhaps,  to  one  only ;  but  in  a  short  time  they  extend  to  the  legs, 
and  then  to  the  face.  The  extent  and  severity  of  the  movements  vary  in 
different  cases,  and  it  is  convenient  to  divide  the  cases  into  tw^o  groups,  the 
mild  and  the  severe. 

In  the  mild  cases  the  movements  are  only  moderate  in  extent  and  are,  to 
a  certain  degree,  under  the  control  of  the  patient ;  for  example,  a  voluntary 
eflfort  will,  for  the  time,  arrest  the  movements,  and  fixing  the  child's  attention 
will  also  have  the  same  effect  temporarily.  In  these  cases  it  is  often  possible 
to  arrest  the  movements  by  making  the  child  fix  his  eyes  upon  some  object, 
like  the  tip  of  a  finger,  a  few  inches  from  his  nose.     The  child  is  able  to  go 

1  Familiar  Forms  of  Nervous  Disease,  Starr,  p.  238. 

2  Oa  Chorea  and  St.  Vitus's  Dance,  p.  82. 


236  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

about  and  to  perform  the  various  voluntary  movements  without  trouble.  He 
can  dress  and  undress  himself  and  feed  himself,  and  frequently  is  able  to  con- 
tinue his  studies  at  school  without  interruption. 

In  the  severe  form,  the  movements  become  rapidly  general,  and  are  so 
violent  and  constant  that  the  patient  is  in  a  continual  state  of  muscular  con- 
tortions. Every  muscle  seems  to  be  alternately  thrown  into  contraction,  the 
body  is  twisted  and  turned,  the  limbs  jerked  about,  and  the  features  dis- 
torted, so  that  it  is  almost  impossible  for  the  child  to  remain  seated  upon  a 
chair.  In  extreme  cases  the  patient  has  to  be  kept  in  bed,  and  even  then 
there  is  a  continual  state  of  muscular  agitation,  the  whole  body  being 
thrown  about  so  violently  that  unless  the  bed  is  enclosed  in  high-padded 
sides  the  patient  will  throw  himself  out  of  it.  A  patient  who  was  under  my 
care  a  couple  of  years  ago  had  movements  of  such  extreme  violence  that, 
although  she  was  placed  in  a  bed  with  padded  sides,  two  feet  above  the 
bed,  she  sometimes  managed  to  throw  herself  over  the  sides  on  the  floor.  In 
such  cases  the  child  is  covered  with  bruises,  the  skin  around  the  mouth  is 
abraded  from  the  continual  protrusion  of  the  tongue  and  running  of  the 
saliva,  and  the  lips  are  cracked  and  ulcerated. 

Fig.  57.  Fig.  58. 


Sarah  J.  R.  during  attack  of  chorea.  Sarah  J.  R.  after  recovery  from  chorea. 

The  speech  is  frequently  affected  in  both  the  mild  and  severe  cases.  The 
patient  speaks  in  a  thick  and  indistinct  manner,  as  if  the  tongue  were  be- 
yond control  or  were  too  large  for  the  mouth,  and  sometimes  the  words  are 
jerked  out  sj)asmodically,  as  if  the  patient  was  obliged  to  take  advantage  of 
momentary  opportunities  to  utter  a  few  words  at  a  time.  In  mild  cases  this 
merely  amounts  to  sometimes  breaking  off  in  the  middle  of  a  sentence  or  the 
lengthening  or  cutting  short  of  a  word.  In  some  cases  the  patient  is 
unable  to  articidate  at  all,  owing  to  the  inability  of  the  child  to  control  the 
tongue  and  other  muscles  concerned  in  articulation.  Sometimes  there  occurs 
a  condition  known  as  laryngeal  chorea,  in  which  peculiar  explosive  sounds 
are  made.  At  times  these  are  like  a  bark,  and  in  some  cases  a  word  is  involun- 
tarily uttered.  Echolalia,  or  the  repeating  of  the  last  syllable  of  a  word, 
and  coprolalia,  the  use  of  filthy  or  obscene  language,  are  occasionally  met 
with  in  chorea,  but  these  cases  ai'e  commonly  hysterical.  The  muscles  of  the 
eyeball  in  rare  instances  are  affected,  and  it  is  said  that  momentary  diplopia 
sometimes  results  from  spasms  of  these  muscles.  The  features  of  choreic 
children  un'dergo  extreme  distortion,  Avith  uncouth  grimaces,  and  during  the 
intervals  between  facial  movements  the  face  assumes  a  blank  and  almost 


CHOREIFORM  AFFECTIONS.  237 

vacant  expression,  which  is  characteristic  of  this  disease.  I  have  endeavored 
in  the  accompanying  illustrations,  taken  from  photographs,  to  give  a  repro- 
duction of  the  choreic  face. 

The  muscles  of  respiration,  especially  the  diaphragm,  are  sometimes  also 
affected,  as  well  as  the  voluntary  muscles.  The  respirations  are  irregular  ; 
sometimes  short,  sometimes  deep,  with  occasionally  a  few  rapid,  shallow  res- 
pirations, and  then  a  long,  sighing  respiration.  Occasionally  the  heart's 
action  is  irregular,  but  it  is  doubtful  if  this  is  a  true  choreic  disturbance ;  it 
is  probably  dependent  upon  the  irregular  respirations. 

The  disease  reaches  its  maximum  severity  in  about  two  weeks,  and  by  this 
time,  if  the  case  is  a  severe  one,  all  the  muscular  movements  are  constant  and 
severe.  If  the  patient  is  told  to  protrude  his  tongue,  it  is  thrust  out  after  a 
moment  of  hesitation,  and  then  withdrawn  so  rapidly  that  one  has  hardly 
time  to  see  the  organ.  If  the  mouth  has  been  open  the  jaws  snap  together 
with  violence,  and  there  has  been  a  case  recorded  in  which  the  jaw  was 
broken  through  the  violence  with  which  the  teeth  were  brought  together. 

The  irregular  movements  may  at  first  involve  one  side  only,  and  afterward 
extend  to  the  entire  body,  or  the  movements  may  be  general  from  the  onset. 
There  is  considerable  difference  of  opinion  as  to  the  side  most  frequently 
affected.  Some  writers  hold  that  the  right  side  is  most  frequently  attacked, 
and  others  maintain  that  the  left  side  is  most  likely  to  be  disturbed,  on  ac- 
count of  this  side  being  the  weaker.  My  own  observation  leads  me  to  believe 
that  both  sides  are  about  equally  affected. 

Sturges  believes  that  the  right  hand  is  much  oftener  affected  than  the  left, 
because  he  considers  that  in  school- children  this  hand  is  habitually  over- 
taxed. Gowers,  out  of  64  cases  of  hemichorea,  found  31  on  the  right  side 
and  33  on  the  left.  See  found  that  in  97  of  154  cases  the  movements  were 
either  confined  to  the  left  side  or  were  most  marked  on  that  side.  It  is  prob- 
able that  if  a  sufficiently  large  number  of  cases  were  examined  it  would 
be  found  that  both  sides  are  equally  affected.  In  the  majority  of  cases 
the  disease  does  not  remain  confined  to  one  side,  especially  in  cases  which  are 
severe.     After  a  few  days  both  sides  become  involved. 

The  voluntary  movements  in  cases  of  chorea  are  distinctly  inco-ordinate 
or  ataxic  in  character,  and  are  usually  interrupted  by  the  involuntary  move- 
ments. There  is  distinct  lack  of  power  in  the  patient  to  use  the  will  in 
making  voluntary  movements.  This  condition  is  sometimes  mistaken  for 
paralysis ;  but  it  is  not  from  absence  of  muscular  power  that  the  movements 
cannot  be  made.  A  patient  is  told  to  perform  some  act,  for  example,  to  take 
up  an  object  from  the  table.  He  hesitates  for  a  moment,  as  if  waiting  for 
the  involuntary  movements  to  subside,  and  then  darts  down  upon  the  object 
and  seizes  it.  In  extreme  cases  the  patient  is  often  totally  unable  to  force 
the  muscles  into  obedience  by  a  mandate  of  the  will.  In  a  case  I  studied 
recently  I  told  the  child  to  put  the  palms  of  her  hands  together.  She  made 
no  attempt  to  move  the  arms  for  a  few  seconds,  and  then  they  were  thrown 
about  in  an  inco-ordinate  manner.  There  was  another  pause  in  which  the 
patient  was  apparently  steadying  herself  for  another  effort,  and  then  the 
hands  were  brought  almost  together  for  a  fraction  of  a  second,  and  the  arms 
dropped  to  her  lap.     The  child  then  said  with  tears,  "  I  can't  do  it." 

During  sleep  the  choreic  movements  cease  entirely.  Occasionally  a  case  is 
reported  by  a  parent  in  which  the  child  is  said  to  have  movements  in  sleep, 
but  it  is  doubtful  if  this  is  true.  The  sleep  of  the  choreic  child  is  frequently 
restless,  but  the  choreic  movements  do  not  continue.  However,  Osier  has 
recorded  the  case  of  a  child  in  the  Johns  Hopkins  Hospital  in  whoni  choreic 
movements  were  observed  during  sleep. 

The  electrical  condition  of  the  muscles  has  been  studied,  and  there  is  no 


238  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

distinct  reduction  in  irritability.  Some  writers  have  noted  an  overactive 
response  to  the  galvanic  current ;  but  this  is  admitted  by  these  writers  to  be 
inconstant. 

Sensibility  is  unaffected,  except  in  hysterical  cases,  and  in  ordinary  cases 
of  St.  Vitus'  dance  there  is  no  change  in  tactile  sensibility  or  in  the  pain 
sense,  nor  is  tenderness  over  the  spine  or  nerve  trunks  met  with. 

The  muscular  spasms  in  chorea  occasionally  induce  a  sense  of  fatigue ;  but 
it  is  very  seldom  that  patients  complain  of  being  tired.  They  seem  to  be,  to 
a  great  extent,  unconscious  of  the  extreme  character  of  the  movements ;  and 
children  who  are  suffering  from  chorea  of  extreme  severity  generally  deny  that 
they  feel  tired.  No  muscular  pain  seems  to  be  developed  in  these  cases, 
although  the  joint  soreness  and  stiffness,  already  alluded  to,  are  sometimes 
complained  of. 

The  mental  state  in  the  mild  type  of  chorea  is  seldom  changed,  except 
that  the  patient  may  be  more  irritable  than  usual  and  less  able  to  study ; 
but  in  severe  cases  there  is  usually  distinct  mental  deterioration.  If  the  child 
is  let  alone  it  is  not  often  that  he  complains,  and  I  have  often  been  surprised 
to  see  a  child  lying  in  bed,  thrown  about  from  side  to  side  by  the  movements, 
but  apparently  satisfied,  and  making  no  murmur  or  complaint. 

The  muscles  of  deglutition  are  sometimes  disturbed,  so  that  the  patient  is 
unable  to  properly  masticate  his  food,  and  swallowing  is  occasionally  difficult. 
The  principal  trouble,  however,  is  that  the  child  is  interrupted  in  his  attempts 
to  take  food  by  the  involuntary  movements  which  occur. 

The  temperature  in  ordinary  cases  of  chorea  is  generally  normal,  but 
occasionally  it  is  elevated.  Gowers  states  that  he  has  seen  it  reach  102°.  In 
fatal  cases,  however,  the  temperature  has  been  known  to  reach  a  high  point. 

Muscular  weakness  frequently  exists  in  cases  of  chorea,  but  usually  does 
not  amount  to  more  than  a  condition  of  paresis.  The  weakness  is  shown  by 
a  dragging  of  the  leg  in  walking,  or  by  enfeeblement  of  the  hand  in  using 
it  for  various  purposes.  The  loss  of  power,  however,  in  all  cases,  is  more 
apparent  than  real,  and,  as  already  observed,  it  is  frequently  the  case  that 
the  inability  of  the  child  to  use  the  limb  is  due  to  lack  of  will-control  over 
the  muscular  movements,  rather  than  true  paralysis.  In  some  cases  the 
paresis  is  a  more  prominent  symptom  than  the  movements  (the  paralytic 
chorea  of  Todd),  and  it  is  not  unusual  to  have  a  child  brought  for  treat- 
ment with  the  statement  that  there  is  paralysis  of  one  side,  and  on  investiga- 
tion it  is  found  that  there  is  a  choreic  condition. 

It  has  been  a  question  among  authorities  whether  the  muscles  of  organic 
life  are  ever  involved  in  chorea.  The  action  of  the  heart  is  said  by  some 
writers  never  to  be  affected,  but  there  is  no  doubt  that  in  many  cases  the 
heart's  action  is  irregular  and  disturbed,  although  no  more  so  than  one  meets 
with  in  patients  who  are  suffering  from  some  other  nervous  disorder. 

Heart  Symptoms.  As  just  remarked,  irregular  and  frequent  action 
of  the  heart  is  often  met  with,  and  sometimes  the  action  is  tumultuous. 
There  is  seldom,  if  ever,  any  true  disorder  of  the  rhythm.  Heart  mur- 
murs occur  with  great  frequency.  In  the  majority  of  cases  these  are 
hsemic,  and  are  dependent  upon  the  ansemic  and  weakened  condition 
which  is  usually  found  in  these  cases.  A  systolic  murmur  is  frequently 
heard  at  the  base,  soft  in  character,  and  varying  in  degree  at  different  times. 
Of  813  cases  at  the  Infirmary  for  Nervous  Diseases,  in  which  the  condition 
of  the  heart  was  noted,  there  were  300  in  which  a  murmur  of  some  kind 
was  detected.  The  most  frequent  of  these  murmurs  were  systolic,  and  were 
heard  at  the  apex.  There  were  128  cases  of  this  class.  In  65  cases  there 
was  a  systolic  murmur  heard  at  the  base,  and  in  only  three  was  a  diastolic 
murmur  noted.     In  but  one  case  Avas  an  aortic  regurgitant  murmur  noted. 


CHOREIFORM  AFFECTIONS.  239 

Gowers  states  that  he  met  with  only  two  instances  of  aortic  regurgitation 
among  about  250  cases  of  chorea  which  he  had  observed.  In  the  large 
majority  of  the  cases  studied  at  the  Infirmary  for  Nervous  Diseases  the 
murmur  was  soft  and  was  usually  hsemic. 

Endocarditis  occurs  with  considerable  frequency  in  chorea,  but,  as  a  rule, 
it  is  not  of  an  extreme  kind.  It  is  to  be  expected  that  organic  heart  lesions 
will  occur  in  a  disease  which  is  so  closely  allied  to  rheumatism  as  is  chorea. 
Osier  {American  Journal  of  the  Medical  Sciences,  1887,  vol.  ii.)  examined  a 
number  of  cases  at  the  Infirmary  for  Nervous  Diseases,  two  years  and  longer, 
after  an  attack  of  chorea.  He  found  of  110  patients  that  54  presented 
some  signs  of  organic  heart  disease.  In  many  of  these  cases  the  murmur 
was  only  slight,  and  in  but  few  were  there  any  general  disturbances  resulting 
from  the  valvular  disease. 

Pericarditis  occasionally  occurs  as  a  complication  of  chorea.  I  reported  a 
case  in  the  University  Medical  Magazine,^  in  which  a  boy  of  six  years,  during 
the  course  of  an  attack  of  chorea,  had  a  violent  attack  of  pericarditis,  from 
Avhich,  however,  he  recovered ;  but  a  marked  friction  sound  remained. 
This  child  had  suffered  from  an  attack  of  acute  rheumatism,  preceding  the 
chorea,  and  had  a  mitral  systolic  murmur  when  first  seen.  We  must  re- 
member that  in  some  cases  the  organic  disease  of  the  heart  antedates  the 
chorea  ;  but,  in  many  cases,  it  is  evident  that  the  murmur  has  developed 
during  the  course  of  the  disease.  In  all  cases  it  is  diflacult  to  say  whether 
the  murmur  is  functional  or  organic,  as  the  murmur  is  seldom  harsh  or  loud, 
and,  frequently,  the  only  way  to  determine  whether  the  disease  is  organic  is 
when  it  persists  after  the  patient  has  recovered. 

The  urine  in  chorea  has  been  examined  by  a  number  of  authorities.  It 
contains  usually  an  excess  of  urea  and  phosphates.  The  amount  of  these 
salts  depends  upon  the  severity  of  the  attack.  In  a  patient  recently  under 
my  observation,  in  whom  the  movements  were  of  a  most  violent  character, 
the  deposit  of  urates  and  phosphates  was  enormous.  The  specific  gravity 
is  high,  1024-1030,  and  the  urine  is  of  small  volume  each  day.  The  amount 
of  the  chlorides  is  diminished  in  proportion  to  the  urea. 

Gowers  mentions  a  peculiar  pigment,  "urohsematoporphyrin,"  which  was 
discovered  by  McMunn  in  the  urine  of  rheumatism,  as  having  also  been 
found  in  chorea  by  Garrod.  Herter'^  refers  to  the  peculiar  red  color,  eosin- 
like,  but  which  he  says  is  not  due  to  urobilin. 

Mental  disturbances  are  frequently  met  with  in  choreic  children,  although 
in  the  majority  of  cases  there  is  no  grave  trouble.  The  temper  is  almost 
invariably  irritable,  and  there  are  frequent  hysterical  outbreaks,  and  the 
child  is  likely  to  be  averse  and  headstrong.  There  is  a  marked  change  in 
the  mental  powers,  the  child  is  unable  to  aj)ply  its  mind  to  study  or  to  fix 
its  attention  for  any  length  of  time.  Occasionally  there  is  distinct  evidence 
of  insanity  in  a  mild  degree,  and  melancholia  has  been  met  with.  In  rare 
instances  there  is  an  outbreak  of  acute  mania,  and  when  this  occurs  it  is 
associated  with  a  very  violent  form  of  chorea,  giving  rise  to  what  has  been 
described  as  chorea  insaniens.  We  should  not  overlook  the  fact  of  the 
mental  deterioration  in  cases  of  chorea,  and  it  is  of  great  importance  to  im- 
press upon  the  minds  of  the  parents  that  the  children  are  not  responsible  for 
many  of  their  acts,  and  too  much  should  not  be  expected  of  them. 

Convulsive  attacks  are  rare  as  a  complication  in  chorea.  Gowers  speaks  of 
a  case  in  which  the  choreic  movements  were  severe,  but  which  had  occasional 
attacks  in  which  there  was  apparent  loss  of  consciousness  and  peculiar  con- 
vulsions, in  which  the  head  was  turned  to  the  right,  the  right  arm  and  leg 

1  Vol.  ii.,  1890,  p.  482.  2  Diagnosis  of  Diseases  of  the  Nervous  System,  p.  556. 


240  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

presented  violent  choreic  movements,  while  the  left  arm  was  stretched  out, 
the  fingers  everted,  and  the  whole  limb  in  a  state  of  cataleptic  rigidity. 
Epileptic  seizures  are  also  rare  as  a  complication,  although  they  are  occasion- 
ally met  with,  and  sometimes  one  sees  a  patient  whose  attacks  of  epilepsy 
date  from  an  attack  of  chorea.  Gray^  mentions  cases  which  he  has  seen  in 
which  there  was  temporary  loss  of  consciousness,  like  petit  mal.  These,  he 
says,  may  develop  into  a  grave  form,  with  symptoms  of  meningitis  or  enceph- 
alitis, from  which  the  j)atient  dies. 

The  tendon  reflexes  in  chorea  are  frequently  disturbed  to  some  extent.  I 
have  made  a  study  of  this  condition  and  find  that,  while  in  a  majority  of 
cases  the  knee-jerks  and  other  reflexes  are  normal,  in  quite  a  considerable 
number  the  knee-jerks  are  either  absent  or  they  may  be  described  as  capri- 
cious ;  that  is,  the  knee-jerks  may  be  absent  at  one  moment  and  at  the 
next  an  involuntary  movement  of  the  child  causes  a  re-enforcement,  and  the 
response  to  a  tap  upon  the  patella  tendon  is  prompt  and  energetic.  There 
are  some  cases,  however,  in  which  the  knee-jerks  cannot  be  developed  under 
any  circumstances.  In  614  cases  in  the  series  at  the  Philadelphia  Infirmary 
for  Nervous  Diseases  the  reflexes  were  normal  in  239  ;  in  180  they  were 
increased  ;  in  56  they  were  diminished  ;  and  in  36  they  were  absent  altogether. 
In  42  cases  it  is  recorded  that  the  knee-jerks  were  capricious ;  in  36  they 
were  irregular,  but  diminished ;  and  in  8  they  were  increased,  but  irregular. 
In  14  cases  the  knee-jerks  could  be  elicited  on  one  side  only. 

This  irregularity  in  the  knee-jerks  is  an  interesting  phenomenon,  and  is 
contrary  to  what  one  would  exj)ect.  At  first  sight  it  would  seem  probable 
that  the  knee-jerks  would  always  be  increased,  on  account  of  the  constant 
re-enforcement  which  should  be  present  from  the  ever-moving  muscles  ;  but 
we  found  that  in  only  29  per  cent,  of  the  cases  which  we  examined  were  the 
knee-jerks  increased,  and  in  145,  or  nearly  24  per  cent.,  of  the  cases  the  knee- 
jerks  were  either  absent  or  diminished  in  some  degree.  D.  B.  Lees^  reports 
a  case  of  chorea  in  a  child  in  which  the  patellar  reflexes  were  absent,  and 
believes  that  this  demonstrates  that  the  motor  cells  in  the  cord  are  afiected 
in  this  disease. 

Trophic  changes  are  shown  in  chorea  in  the  ease  with  which  slight  scratches 
or  injuries  become  irritated  and  inflamed.  It  is  very  common  in  children 
who  are  sufiering  from  an  aggravated  form  of  chorea  to  find  them  covered 
with  sores  and  sujDpurating  scratches,  which  heel  slowly.  I  saw  recently  an 
old  woman,  who  had  violent  hemichorea,  in  whom  the  whole  side  was  covered 
with  bruises,  and  the  hand  and  arm  were  of  a  deep  purple  hue,  looking 
almost  like  beginning  gangrene.  The  other  arm  and  hand  were  discolored 
also,  but  in  a  lesser  degree.  Callosities  occur  on  the  knuckles,  elbows,  and 
knees  from  the  friction  to  which  they  are  ex]30sed  in  extreme  cases,  and  they 
are  greater  than  would  occur  in  a  healthy  child  from  the  same  amount  of 
irritation.  Lloyd^  mentions  the  case  of  a  young  girl,  who,  in  the  third 
month  of  pregnancy,  became  choreic.  In  the  fifth  month  an  abscess  of  the 
breast  developed,  and,  although  incised  several  times,  sinuses  formed,  and  it 
did  not  heal  for  several  weeks.  It  was  thought  to  have  resulted  from  an 
injury  in  some  of  the  ]3atient's  violent  movements.  Ogle*  reports  one  case  in 
which  there  was  a  bed-sore  on  the  sacrum ;  and  another,  a  child  of  seven 
years,  in  whom,  during  an  attack  of  chorea,  there  were  subcutaneous  abscesses 
of  the  heels,  shoulders,  and  thorax.  The  case  terminated  fatally.  In  a  third 
patient,  a  girl  of  seventeen  years,  there  was  inflammation  of  the  alveolar 

1  Nervous  Diseases,  p.  406.  2  clinical  Journal,  London,  March  8, 1893. 

3  Hirst's  System  of  Obstetrics,  vol.  ii.,  p.  596. 

*  British  and  Foreign  Med.-Ohir.  Rev.,  vol.  xli.,  p.  233. 


CHOREIFORM  AFFECTIONS. 


241 


tissue,  followed  by  sloughing  and  erysipelas.  The  patient  died,  and  at  the 
autopsy  an  abscess  of  the  mediastinum  and  empyema  were  found. 

Cutaneous  Affections.  In  my  own  experience  it  is  difficult  to  say 
whether  those  met  with  are  due  to  the  disease  or  to  arsenic,  which  has  been 
administered  for  its  cure,  for  most  of  the  cases  which  I  have  seen  have  been 
treated  with  arsenic.  Various  forms  of  herpes  are  met  with,  and  occasionally 
those  eruptions  which  accompany  rheumatism  are  met  with  in  the  course  of 
an  attack  of  chorea.  Osier  says  that  he  has  seen  erythema  nodosum  and 
purpuric  urticara.  He  also  says  that  an  aggravated  condition  of  rheumatic 
purj)ura,  known  as  Schonlein's  peliosis  rheumatica,  sometimes  occurs  in 
chorea.  English  writers  speak  of  subcutaneous  fibrous  nodules,  such  as  are 
associated  with  rheumatism,  being  seen  in  chorea.  The  Collective  Investiga- 
tion Committee  of  the  British  Medical  Association  reports  7  cases  out  of  439 
in  which  they  were  met  with.  These  eruptions  are  further  evidence  of  the 
connection  between  rheumatism  and  chorea. 

Dr.  C.  H.  BroAvn  (Journal  of  Mental  and  Nervous  Disease,  August,  1893) 
reports  a  remarkable  instance  of  subcutaneous  nodules  in  a  case  of  chorea 

Fig.  59. 


Subcutaneous  Nodules.     (Beown.) 


(see  cut).  The  patient  was  a  boy  of  eleven  years,  with  a  rheumatic  family 
history.  He  had  always  been  nervous  and  delicate,  and  at  nine  years  of  age 
had  an  attack  of  chorea,  which  occurred  six  months  after  a  fall,  and  in  which 
was  considerable  mental  perturbation.  He  had  a  second  attack  of  chorea  a 
year  later,  and  eight  weeks  before  coming  under  Dr.  Brown's  observation  had 
erratic  pains  about  the  body,  head,  and  limbs.  There  Avas  no  rise  of  tempera- 
ture and  no  joint  swelling  at  this  time,  but  soon  small  tumors  made  their 
appearance  upon  the  joints,  increasing  rapidly  in  number,  but  were  confined 
to  the  extensor  surfaces.  In  six  weeks  from  the  beginning  choreic  move- 
ments set  in,  and  when  the  patient  was  seen  two  weeks  later  there  was  pain 
in  locomotion  and  swelling  of  the  ankles  and  wrists.     The  heart  was  hyper- 

16 


242  NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 

troj)hied,  its  impulse  was  diffused,  and  its  actiou  markedly  exaggerated.  There 
was  a  mitral  regurgitant  murmur  heard.  One  hundred  and  fifty  tumors  by 
actual  count,  varying  in  size  from  the  head  of  a  j)in  to  an  almond,  were 
discovered  over  the  dorsal  surface  of  the  whole  body,  and  were  especially 
marked  over  the  joints.  They  were  subcutaneous,  of  a  soft  consistency,  and 
under  the  microscope  were  found  to  consist  of  "  j^oung  granulating  connective 
tissue." 

DuRATio^r.  The  duration  of  an  attack  depends  upon  the  severity  of  the 
case,  and  varies  from  three  weeks  to  three  months.  The  average  duration  is 
agreed  by  writers  on  this  subject  to  be  ten  weeks.  The  attack  may  run 
into  months,  and  it  is  not  unusual  to  see  cases  which  have  lasted  six  montks 
and  more.  These  cases,  however,  have  almost  invariably  begun  with  symp- 
toms of  great  severity.  The  violent  movements  rarely  last  more  than  two  or 
three  weeks,  and  under  favorable  circumstances  do  not  persist  even  so  long- 
as  that.  Cases  are  met  with  which  have  lasted  for  two  or  three  years.  These, 
however,  are  rare,  and  the  statement  of  the  parents  in  regard  to  the  duration 
of  an  attack  is  to  be  taken  with  allowance  for  unintentional  misstatements. 
They  frequently  state  that  the  child  has  suffered  from  chorea  continuously 
for  several  years,  but  have  failed  to  take  into  consideration  the  remissions 
which  have  lasted  for  eight  or  nine  months  of  each  year.  ]\Iild  attacks  may 
last  only  for  two  or  three  weeks.  Occasionally  cases  become  chronic,  and 
continue  during  the  entire  life  of  the  patient.  Gowers  cpiotes  a  case  which 
had  begun  in  youth  and  continued  until  sixty-six  years  of  age,  and  I  have 
myself  seen  two  cases  which  began  in  infancy,  and  persisted  in  one  case  up  to 
the  thirtieth  year  and  in  the  other  until  the  thirty-fifth  year.  The  rule 
should  be  borne  in  mind,  however,  that  the  more  severe  the  attack  the  longer 
will  its  duration  be. 

Recurrence.  Relapses  are  comparatively  frequent  in  chorea.  Of  the 
961  cases  of  the  Infirmary  series,  341  had  more  than  one  attack.  This  is  a 
slightly  larger  proportion  than  that  given  by  Gowers,  who  states  that  one- 
third  of  the  cases  which  he  had  analyzed  had  two  or  more  attacks.  Of  the 
341  cases  who  had  more  than  one  relapse,  219  suffered  from  two  attacks,  72 
had  three  attacks,  29  had  four  attacks,  13  had  five  attacks,  2  had  six  attacks, 
2  had  seven  attacks,  1  had  eight  attacks,  2  had  nine  attacks,  and  1  was  said 
to  have  had  twelve  or  more  attacks.  Girls  are  rather  more  liable  to  recur- 
rence than  boys.  The  danger  of  a  relaj^se  usually  ceases  after  sixteen 
years  of  age  in  either  sex.  It  is  unusual  in  boys  to  have  a  relapse  after  twelve 
years  of  age,  but  in  girls  the  relapses  continue  until  they  are  sixteen  or  seven- 
teen. Evidences  of  organic  heart  trouble  are  more  fi-equent  in  cases  which 
have  relapses  than  in  first  attacks,  and  it  is  quite  common  to  find  patients 
who  return  with  a  second  attack  of  chorea  to  have  cardiac  murmurs.  The 
interval  between  the  first  and  second  attack  is  usually  nine  to  twelve  months  ; 
occasionally,  but  rarely,  the  relapse  occurs  after  two  or  three  months ;  but,  as 
a  rule,  the  recurrence  takes  place  at  about  the  same  period  of  the  year  as  that 
in  which  the  first  attack  took  place.  This  statement  is  not  in  accordance  with 
Gowers's  observations,  who  says  that  there  is  no  uniformity  in  the  time  of  the 
year  in  which  recurrences  take  place,  although  he  admits  that  there  are  re- 
markable exceptions.  In  my  own  observation,  however,  a  patient  who  has 
had  an  attack  one  spring  is  liable  to  have  a  return  the  spring  following,  and, 
if  this  period  of  the  year  is  escaped  on  the  first  year,  it  is  likely  that  on  the 
second  year  there  Avill  be  a  recurrence  at  the  same  season. 

Fright  is  an  occasional  cause  of  the  recurrence,  but  in  many  cases  no  direct 
cause  is  to  be  traced,  unless  it  may  be  the  influence  of  overstudy,  or  of  the 
depressing  influences  of  the  combined  causes  connected  with  school,  which 
have  predisposed  to  a  first  attack.     Successive  attacks  of  chorea  are  usually 


CHOREIFORM  AFFECTIONS.  243 

mucli  like  the  first,  but  they  do  not  invariably  afiect  the  same  side  as  anv 
previous  attack.  A  patient  seen  recently  had  the  first  attack  involving  the 
right  side,  and  the  second  attack  in  which  the  left  side  was  only  affected. 
Succeeding  attacks  are  rarely  as  severe  as  the  first,  and  yield  more  promptlv 
to  treatment ;  occasionally,  however,  the  second  or  even  the  third  attack 
may  be  of  great  severity. 

Morbid  Anatomy  and  Pathology.  There  is  scarcely  any  disease  in  which 
the  pathology  is  so  unsettled  as  in  St.  Vitus'  Dance,  notwithstanding  the 
fact  that  a  great  number  of  carefully  made  autopsies  have  been  recorded. 
Almost  every  observer,  however,  has  reported  difierent  conditions.  See  col- 
lected 84  cases  in  which  post-mortem  examinations  had  been  made,  but  in  16 
of  these  no  changes  in  the  brain  or  nervous  centres  were  found.  In  32  there 
were  discovered  lesions  of  some  kind  in  the  brain  and  nervous  centres,  and 
in  the  remainder  some  inflammatory  changes  were  found  in  the  serous 
membranes.  In  29  of  these  cases  there  were  evidences  of  cardiac  disease. 
This  writer  believed  that  in  but  few  cases  of  chorea  was  death  the  result  of 
heart-disease,  but  considered  that  the  majority  of  deaths  should  be  referred 
to  nervous  excitement  and  anaemia.  On  the  other  hand,  of  80  fatal  cases 
collected  by  Sturges,  the  heart  was  healthy  in  only  5.  The  embolic  theory 
which  was  advanced  by  Hughlings  Jackson  has  been  accepted  by  many 
writers  as  a  plausible  and  attractive  view.  The  fact  of  the  frequent  associa- 
tion of  endocarditis  with  chorea,  with  the  possibility  that  minute  vegetations 
may  be  washed  into  the  capillaries  of  the  brain,  gives  strength  to  this  theory. 
It  doas  not  prove  it,  however,  because  in  a  large  number  of  cases  of  chorea 
in  which  death  has  occurred  no  endocarditis  has  been  found,  and  Gowers 
and  others  have  examined  the  brain  of  many  fatal  cases  of  chorea  without 
finding  emboli. 

The  experiments  of  Angel  Money  on  animals  also  lent  some  force  to  the 
embolic  theoxy.  This  writer  injected  lycopodium  into  the  carotids  of  ani- 
mals, producing  thereby  movements  like  chorea,  and  after  death  he  found 
capillary  plugging  in  the  brain  and  cord ;  the  symptoms,  however,  in  the 
subjects  of  Money's  experiment  were  difierent  from  those  in  true  chorea,  and, 
moreover,  it  is  well  known  that  many  lesions  in  the  brain  give  rise  to  choreoid 
movements.  The  symptoms  of  capillary  embolism  in  the  brain,  such  as 
vertigo  and  drowsiness,  are  absent  in  chorea,  as  has  been  pointed  out  by 
Sturges.  Golgi  found  calcification  of  the  cells  of  Purkinje  in  the  cerebellum 
of  one  case. 

Lastly,  the  theory  of  microbic  infection,  as  a  cause  of  chorea,  has  been 
advanced  within  the  past  few  years.  Donkin  and  Hobb  {Medical  Times  and 
Gazette,  Nov.  1,  1884)  found  rod- like  bodies  in  the  blood  of  a  patient  dying 
of  chorea,  and  Richter  (  Western  Lancet,  vol.  xii.,  p.  529)  discovered  cocci  in 
the  blood  of  another  case.  Berkeley,  in  a  valuable  paper  on  chorea  insaniens 
(Johns  Hopkins  RejioHs,  vol.  i.,  1891),  strongly  urges  the  infectious  origin  of 
chorea,  and  in  the  fatal  case  Avhich  he  described,  in  which  the  most  elaborate 
and  thorough  microscopic  and  bacteriological  examinations  were  made,  evi- 
dences of  microbic  infection  were  discovered.  Pianise^  accepts  the  theory  of 
an  infectious  orign  as  the  result  of  bacteriological  examinations  in  a  case  of 
acute  chorea  which  terminated  fatally.  This  author  obtained  a  bacillus  from 
the  cervical  cord  of  the  patient,  which,  inoculated  in  dogs,  caused  the  appear- 
ance of  the  disease.  Dana  is  also  an  advocate  of  this  view,  and  sup2:)orts  it  by 
the  report  of  the  following  case  (American  Journal  of  the  Medical  Sciences, 
January,  1894)  :  The  patient  was  thirty-four  years  of  age,  and  had  repeated 
attacks  of  chorea  folloAving  acute  rheumatism  at  the  age  of  fourteen  years.    The 

1  Annual  Medical  Sciences,  1894,  vol.  ii.,  C.  p.  29. 


244  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

last  attack  was  of  eight  months'  duration,  and  was  excessive^  violent  until  the 
death  of  the  patient,  which  resulted  from  exhaustion.  At  the  autopsy  chronic 
leptomeningitis  of  the  convexity  of  the  brain  was  found,  and  meningitis  of 
the  upper  part  of  the  spinal  cord.  There  was  also  a  slight  degree  of  meningo- 
encephalitis. Hyaline  bodies  were  found  in  the  brain  cortex,  and  diplococci 
in  small  numbers  were  found  in  the  proliferating  tissues  between  the  meninges 
and  the  brain.    There  was  no  endocarditis,  and  the  heart  was  otherwise  normal. 

Dana's  deductions  from  this  case  are  that  it  shows  that  there  is  a  close 
relationship  between  many  of  the  chronic  spasmodic  disorders  of  irregular 
types  and  the  chorea  of  Sydenham.  Secondly,  that  it  confirms  the  view  now 
generally  accepted  that  chorea  is  a  vascular  and  humoral  disease,  and  through 
that  it  gives  weight  to  the  belief  that  there  is  in  some  cases,  at  least,  a  microbe 
which  produces  the  disease.  He  thinks  that  there  is  nothing  which  would 
explain  the  phenomena  of  the  disease  so  well  as  to  suppose  that  the  specific 
virvis  producing  chorea  is  a  microbe,  and  perhaps  some  special  form  of  the 
diplococcus. 

It  seems  to  me  that  the  explanation  of  all  these  difierences  in  the  post- 
mortem findings  which  have  been  recorded  by  numerous  observers  is 
to  be  found  in  the  fact  that  the  autopsies  have  been  made  in  many 
different  forms  of  chorea,  and  usually  in  cases  of  long  standing,  and 
that  the  observers  have  examined  their  cases  from  varying  standpoints. 
In  nearly  all  of  the  fatal  cases  of  chorea  which  have  been  examined  post 
mortem,  totally  different  conditions  have  existed  from  what  are  present  in  the 
ordinary  chorea  of  childhood.  In  many  some  grave  complication  like  endo- 
carditis or  meningitis  was  the  cause  of  death.  In  Berkeley's  case  the  patient 
died  of  chorea  insaniens,  which  is  altogether  unlike  Sydenham's  chorea  in 
many  respects,  and  in  this  case  not  only  were  there  many  symptoms  of  organic 
disease  during  life,  the  patient  having  had  a  distinct  attack  of  meningitis 
followed  by  choreic  movements  four  years  before  the  final  attack,  but  at  the 
autopsy  endocarditis  was  found,  and  the  microscope  revealed  leptomeningitis. 
In  Dana's  case  the  patient  had  had  repeated  attacks  of  chorea,  the  last  of  which 
had  persisted  for  eight  months,  and  he  died  at  the  age  of  thirty-four  years. 
As  was  to  have  been  expected,  coarse  brain  lesions  were  found.  Chronic 
leptomeningitis  and  some  meningitis  of  the  upper  part  of  the  cord  were 
present.  The  age  of  this  patient  and  the  duration  of  the  attacks  make  it 
unlike  a  case  of  Sydenham's  chorea ;  nevertheless  the  findings  were  of  value 
as  pointing  to  the  seat  and  nature  of  the  lesions  likely  to  exist  in  the  chorea 
of  childhood. 

We  must  bear  in  mind  the  fact  that  there  are  several  separate  forms  of 
chorea,  and  the  pathology  of  each  must  necessarily  be  more  or  less  different ; 
also,  we  should  not  forget  that  coarse  brain  lesions  in  many  regions  give  rise 
to  choreic  movements  which  do  not  constitute  typical  chorea.  It  is  impossible 
to  believe  that  an  attack  of  chorea  which  has  been  brought  on  by  fright,  and 
which  has  been  completely  cured  in  seven  or  eight  weeks,  can  have  been  the 
result  of  structural  changes  such  as  have  been  described  by  the  writers  quoted 
above. 

In  chorea  most  of  the  symptoms  point  to  the  cerebral  cortex  as  the  seat  of 
the  disease,  with  the  motor  region  principally  involved.  This  view  is  borne 
out  by  the  fact  that  in  many  cases  the  movements  are  markedly  unilateral, 
and  this  could  hardly  be  the  case  were  the  spinal  cord  the  seat  of  the  disease ; 
besides,  in  chorea,  the  movements  cease  during  sleep.  The  face  is  frequently 
affected,  and  the  arm  more  frequently  than  the  leg.  The  intellectual  disturb- 
ances which  are  present  in  chorea  also  point  to  the  brain. 

The  pathology,  then,  of  chorea  may  be  stated  as  follows : 

That  in  acute  cases  the  disease  is  due  to  nutritive  changes  in  the  cortex  of 


CHOREIFORM  AFFECTIONS.  245 

the  brain,  the  motor  region  being-  more  affected  than  elsewhere ;  that  the 
cause  of  these  nutritive  changes  may  be  either  fright  or  mental  strain,  like 
overstudy ;  and  in  some  cases  the  changes  are  due  to  an  alteration  in  the 
blood.  This  blood  change  is  the  result  of  some  toxic  condition,  which,  while 
not  identical  with  acute  rheumatism,  is,  no  doubt,  allied  to  it. 

It  is  more  than  likely  that  in  some  cases  there  is  an  infectious  process  from 
a  bacillus ;  but  in  the  present  state  of  our  knowledge  we  are  without  facts  to 
prove  that  transient  nervous  diseases  are  caused  by  microbic  infection.  In 
acute  chorea  there  are  no  gross  changes  in  the  nerve  centres,  and  in  many 
cases  even  the  microscope  will  not  reveal  any  departure  from  health.  If  the 
disease  lasts  long  enough,  changes  will  invariably  be  found  by  the  micro- 
scope. The  most  constant  of  these  ai'e  vascular.  The  capillary  vessels  of 
the  cortex  will  probably  be  found  dilated,  and  there  may  be  plugging  of  the 
calibre  of  the  vessels.  Hyaline  bodies  are  to  be  looked  for  in  the  cortex,  and 
the  nerve  cells  Avill  be  more  or  less  altered.  In  some  cases  lesions  will  be 
found  in  the  pyramidal  tracts,  lenticular  nuclei,  and  in  the  spinal  cord. 

Diagnosis.  There  is  seldom  any  difficulty  in  recognizing  a  case  of  chorea, 
as  the  symj)toms  are  usually  characteristic,  and  atyj^ical  cases  are  rarely  met 
with.  Imitative  and  hysterical  chorea  may  be  mistaken  for  that  of  Syden- 
ham ;  but  in  the  first  the  history  of  the  patient  and  the  character  of  the 
movements  will  show  the  true  nature  of  the  affection.  Hysterical  chorea  is 
almost  always  seen  in  patients  over  seventeen  years  of  age,  and  the  move- 
ments are  more  rhythmical  and  appear  to  be  under  the  influence  of  the 
patient's  will,  as  they  increase  in  severity  whenever  the  patient  is  under  ob- 
servation ;  moreover,  the  general  aspect  and  conduct  of  the  patient  shows  the 
presence  of  hysteria.  The  athetoid  movements  in  infantile  hemiplegia  some- 
what resemble  chorea,  but  the  presence  of  i^aralysis  and  contractures  and  the 
different  character  of  the  movements  in  the  former,  together  with  the  chronicity 
of  the  affection  and  the  want  of  influence  of  treatment,  make  the  diagnosis 
clear.  Chorea  can  scarcely  be  confounded  with  epilepsy,  although  Sachs  has 
referred  to  a  case  of  petit  mal,  in  which  the  patient  was  supposed  to  have 
chorea.  The  irregular  movements  in  disseminated  sclerosis  may  be  mistaken 
for  chorea,  and  this  affection  is  also  met  with  in  children.  The  movements, 
however,  consist  in  an  intention  tremor,  and  there  is  frequently  nystagmus ; 
the  onset  of  the  disease  is  gradual ;  it  is  of  long  duration,  and  is  not  bene- 
fited by  treatment. 

Prognosis.  This  is  almost  invariably  favorable.  Death  from  chorea  is  rare. 
In  the  report  of  the  British  Medical  Association  Investigating  Committee 
there  was  found  a  mortality  of  only  2  per  cent.  Guillemot  (These  de  la 
Faculte  de  Paris,  Annual  Medical  Sciences,  1894,  vol.  ii.,  c.  30),  in  a  study  of 
720  cases,  observed  18  deaths,  or  2.5  per  cent.,  and  in  none  of  his  cases  was 
there  a  death  under  seven  years  of  age.  In  Philadelphia  in  seventy-four 
years,  from  1807  to  1881,  among  the  deaths  from  all  causes  there  were  but 
sixty-four  attributed  to  chorea.  Of  these  thirty-eight  were  under  twenty 
years  and  twenty-six  over  that  age.  It  is  seldom  fatal  in  young  children,  and 
death,  as  a  rule,  is  the  result  of  some  intercurrent  disease,  like  endocarditis 
or  meningitis.  Hutchinson  {Philadelplda  Medical  Times,  vol.  vi.,  page  535) 
recorded  a  fatal  case  in  a  boy  of  twelve  years,  who  died  two  days  after  his 
admission  to  the  Pennsylvania  Hospital.  The  chorea  began  after  several 
days  of  headache  and  rheumatic  pains.  The  movements  were  excessive,  and 
the  child  died  apparently  from  exhaustion.  In  this  case  the  heart  was  found 
diseased,  the  aortic  valves  especially  being  involved.  In  chorea  insaniens  the 
mortality  is  great.  Fatal  cases  usually  ai^e  met  with  in  first  attacks,  but  Sachs 
mentions  a  case  which  occurred  in  his  own  practice  of  a  child  who  died  in  his 
second  attack. 


246  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Occasionally,  an  attack  of  chorea  runs  a  rapidly  fatal  course.  Cook  and 
Beale^  have  reported  the  case  of  a  girl  of  nine  years  who  died  after  an  attack 
of  but  five  days'  duration.  After  the  first  two  days  the  movements  were 
excessively  violent,  and  the  child's  face  wore  a  terrified  expression.  There 
was  a  systolic  murmur  heard  at  the  apex.  The  pulse  ranged  from  160  to  170 
per  minute,  but  the  temperature  never  rose  above  101°.  There  was  no  diffi- 
culty in  deglutition.  At  the  autopsy  the  lungs  were  congested,  and  vegetations 
were  found  on  the  mitral  valves  at  the  insertion  of  the  cordse  tendinese.  The 
brain  and  cord  appeared  healthy,  but  the  pons  and  medulla  were  auEemic. 

Recovery  usually  takes  place  after  a  few  weeks,  and  the  child  then  seems 
as  well  as  ever,  although  it  is  not  infrequently  the  case  that  for  several  months 
after  the  child  is  apparently  well  there  may  be  occasionally  detected  slight 
movements  or  some  awkwardness  in  the  actions,  if  the  child  is  closely  ob- 
served. In  giving  a  prognosis  as  to  the  length  of  an  attack  we  must  be 
guarded,  as  the  circumstances  surrounding  the  case  influence  recovery  largely. 
The  care  and  attention  which  can  be  given  to  a  patient  make  a  great  differ- 
ence as  to  the  duration  of  the  attack. 

Treatment.  Like  all  diseases  which  are  either  self-limited  in  duration,  or 
are  incurable,  chorea  has  almost  an  unending  number  of  remedies.  It  is 
hardly  necessary  to  go  over  the  long  list  of  therapeutic  agents  which  have 
been  employed,  but  I  will  refer  only  to  those  which  have  borne  the  test  of 
experience  and  are  principally  used  at  the  present  day.  The  first  and  most 
important  factor  in  the  treatment  of  chorea  is  complete  rest  of  mind  and 
body  and  the  removal  of  all  excitement  and  external  irritants.  Every  case 
should  be  carefully  examined  for  reflex  irritation,  and  should  any  be  present 
it  should,  if  j)ossible,  be  removed  at  once.  An  examination  of  the  eyes  is 
important  in  all  choreic  children,  and  although  it  is  rarely  the  case  that  cor- 
rection of  ocular  defects  has  an  immediate  influence  on  the  choreic  move- 
ments, the  course  of  a  case  is  tedious  and  prolonged  unless  any  existing  eye- 
strain is  removed.  Genital  irritation  should  be  looked  after,  and  an  adherent 
prepuce  or  clitoris  should  be  relieved. 

In  almost  all  cases  it  is  essential  that  the  child  should  be  removed  from 
school  and  study,  and  disturbing  influences,  like  exciting  games,  should  be 
forbidden.  The  other  children  in  a  family  are  often  irritating  to  a  child 
whose  nervous  system  is  so  much  disturbed  as  it  is  in  chorea,  and  it  is  fre- 
quently of  great  importance  to  remove  the  patient  from  home,  or,  at  any  rate, 
to  seclude  him  as  much  as  possible.  But  little  physical  exercise  should  be 
allowed,  and  in  many  cases  absolute  rest  in  bed  is  requisite.  In  the  violent 
forms  of  chorea  the  patient  is  compelled  to  keep  in  bed,  as  he  is  unable  to  sit 
up  ;  but  even  where  the  violence  of  the  movements  does  not  necessitate  the 
recumbent  position,  rest  in  bed,  with  quiet  surroundings,  is  often  the  best 
plan  of  treatment.  Should  the  patient  be  kept  in  bed,  it  is  well  to  have 
gentle  massage  given  once  or  twice  a  day,  as  it  keeps  up  the  nutrition  of  the 
muscles  and  also  has  a  soothing  influence.  It  is  of  great  importance  to  avoid 
mental  irritation  and  restlessness  by  means  of  a  cheerful  room  and  a  pleasant 
nurse.  In  cases  in  which  the  movements  are  excessive  care  must  be  taken  to 
prevent  the  patient  from  injuring  himself.  He  should  be  put  in  a  bed  with 
padded  sides,  and  it  is  necessary  to  have  these  extend  high  above  the  mat- 
tress, so  that  the  patient  may  not  throw  himself  out  of  bed  in  his  contortions. 
This  accident  has  come  under  my  observation,  even  where  the  sides  of  the 
bed  were  two  feet  high.  If  a  suitable  bed  cannot  be  obtained,  the  patient 
may  be  placed  on  a  mattress  upon  the  floor.  Dr.  John  Abercrombie  has  sug- 
gested the-use  of  a  hammock  in  which  the  patient  may  be  slung.     The  injuries 

1  British  Medical  Journal,  April  14,  1S8S. 


CHOREIFORM  AFFECTIONS.  247 

which  may  be  received  by  a  choreic  patient  by  striking  himself  against  hard 
objects  sometimes  take  an  unfavorable  course,  owing  to  the  cachectic  condi- 
tion of  the  patient,  and  may  run  into  blood-poisoning  and  cause  death  in  this 
way.  Should  bed-sores  occur  it  may  be  necessary  to  use  a  water  bed,  but 
the  water  bed  is  not  always  a  satisfactory  arrangement  for  a  choreic  patient, 
on  account  of  the  ease  with  which  it  is  shaken  by  every  movement. 

One  should  not  forget  the  risk  of  taking  the  temperature  of  a  choreic 
patient  in  the  mouth  for  fear  of  the  thermometer  being  bitten. 

The  utmost  cleanliness  should  be  observed  in  the  patient  and  his  surround- 
ings by  means  of  daily  bathing  and  frecj^uent  changes  of  the  bed  linen,  and 
the  bowels  should  be  kept  open  and  the  skin  in  a  healthy  condition.  In 
many  cases  the  skin  is  harsh  and  dry,  and  it  is  beneficial  to  give  an  occa- 
sional hot-air  bath  or  to  administer  diaphoretics.  The  patient's  hair  should 
be  cut  short,  so  as  to  avoid  the  irritation  which  arises  from  combing  it,  and 
closely  cropped  hair  also  keeps  the  scalp  cooler.  Plenty  of  wholesome  food 
should  be  provided,  and  in  cases  in  which  deglutition  is  interfered  with  minced 
meat,  broths,  and  milk  should  be  given  freely.  Cocoa  or  chocolate  is  taken 
readily  by  children  and  are  extremely  valuable  articles  of  diet. 

Many  patients  do  very  well  without  the  use  of  drugs,  provided  rest,  quiet, 
and  seclusion  can  be  enforced.  In  hospitals  it  is  seldom  necessary  to  adminis- 
ter medicines,  except  Avhen  the  movements  are  extremely  violent.  In  private 
practice  it  is  difficult  to  enforce  absolute  rest,  except  in  those  cases  where  the 
means  of  the  family  will  permit  of  the  employment  of  a  trained  nurse.  The 
advantages  of  rest  are  often  seen  in  cases  which  have  resisted  treatment  by 
drugs  for  weeks,  and  who  are  cured  after  a  few  days  of  absolute  rest  in  bed. 
Drugs,  however,  are  not  without  distinct  influence  on  the  course  of  chorea, 
and  we  have  daily  evidence  of  this  in  the  cases  which  are  cured  at  the  out- 
patient services  of  our  hospitals.  The  duration  of  an  attack  is  undoubtedly 
cut  short  by  certain  medicines,  and  we  frequently  see  cases  which  have  had 
no  treatment  and  have  remained  stationary,  or  have  been  growing  worse  for 
months,  which  are  cured  within  a  short  time  by  the  administration  of  suitable 
remedies. 

Among  the  various  drugs  which  have  been  given  in  chorea  arsenic  is,  by 
far,  the  most  efficacious.  There  can  be  but  little  question  as  to  the  marked 
curative  influence  which  it  has  upon  the  disease.  Among  the  other  remedies 
which  have  been  used  with  success  may  be  mentioned  strychnine,  the  salts  of 
zincj  the.  sulphate,  oxide  and  bromide,  nitrate  of  silver,  belladonna,  cimici- 
fuga,  conium,  antipyrine,  and  salicylate  of  sodium.  The  use  of  sedatives  in 
ordinary  cases  of  chorea  is  not  only  unscientific  and  irrational,  but  is  dan- 
gerous and  cannot  fail  to  leave  ill  effects,  which  must  unfavorably  influence 
convalescence.  Dujarden-Beaumetz  {Bulletin  Gener.  de  Therapeutique,  March 
15,  1894),  in  a  review  of  the  therapeutics  of  chorea,  gives  his  own  experience 
and  that  of  others.  Antipyrine  in  doses  of  4  grammes  (60  grains)  per 
diem  is  recommended  in  chorea  of  rheumatic  origin.  According  to  Legroux 
this  drug  brings  about  a  cure  in  from  fifteen  to  twenty  days  of  treatment. 
It  is  to  be  observed  however,  that  the  author  states  that  the  result  is  best 
attained  if  the  remedy  is  used  in  the  declining  period  of  the  malady.  In 
serious  cases  antipyrine  is  not  sufficient,  and  then  chloral  in  large  quantities  is 
advised.  Bouchet  has  given  it  in  doses  of  from  3  to  5  grammes  in  twenty- 
four  hours  (45  to  75  grains).  Bromide  of  potassium  in  large  doses,  30  to  60 
grains  a  day,  is  also  I'ecommended  by  these  writers.  Dujarden-Beaumetz  has 
tried  exalgine  in  doses  of  45  grains  daily,  and  Dana  and  Lowenthal  have 
given  it  in  still  larger  quantities,  60  to  100  grains  daily.  Morphine  has 
been  advised  as  a  routine  treatment,  but  I  place  it  in  the  same  category  with 
the  drugs  named  above.     Churton  recommends  its  administration  as  follows  : 


248  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Begin  with  \  grain  (0.01  gramme)  hjqjodermically,  immediately  following  by 
inhalation  of  chloroform  for  a  few  minutes.  Gradually  increase  the  morphine 
to  \  grain,  (0.03  gramme),  ahvays  following  with  chloroform.  If  necessary  the 
chloroform  may  precede  the  injection.  (T.  Churton,  British  Medical  Journal, 
March  24,  1894.) 

When  we  consider  the  dangerous  results  which  have  followed  the  use  of  all 
these  drugs,  especially  exalgine,  it  seems  to  be  unjustifiable,  to  say  the  least, 
to  administer  these  remedies  in  such  doses. 

Ratchford  {Medical  News,  April  22,  1893),  believing  that  the  pathology  of 
chorea  is  a  scrofulous  anaemia,  recommended  large  doses  of  the  iodide  of  iron. 
I  have  used  it,  however,  without  as  good  results  as  from  arsenic.  Pianese, 
whose  views  on  the  infectious  origin  of  chorea  have  been  referred  to,  treated 
13  cases  with  salol,  and  found  in  his  experience  that  it  is  superior  to  all  other 
drugs  ;  he  also  considered  the  favorable  effect  of  this  remedy  an  argument  in 
behalf  of  the  infectious  origin  of  the  disease.  Wood  (Boston  Medical  and 
Surgical  Journal,  August  24,  1893)  advanced  the  theory  of  the  spinal  origin 
of  chorea,  and  gave  large  doses  of  quinine,  because  he  found  that  in  dogs 
this  drug  produced  a  marked  inhibitory  influence  upon  the  cord.  Potts  has 
recorded  a  series  of  cases  which  were  successfully  treated  by  quinine,  and  I 
have  seen  one  or  two  in  which  the  effect  of  quinine  was  good,  but  it  is  by  no 
means  universally  aj)plicable. 

The  best  mode  of  administering  arsenic  is  to  give  Fowler's  solution  in 
ascending  doses.  In  children  of  seven  years,  5  drops  three  times  a  day  may 
be  given  as  an  initial  dose,  and,  if  no  idiosyncrasy  against  the  drug  is  mani- 
fested within  three  or  four  days,  the  dose  can  be  increased  by  1  droj)  three 
times  a  day  until  physiological  effects  are  seen.  Children  frequently  bear 
from  15  to  20  drops  three  times  a  day  before  saturation  occurs,  and  it  is  very 
rare  to  meet  with  any  grave  effects  when  the  maximum  dose  is  reached. 
Vomiting  or  diarrhoea,  with  puffiness  of  the  face,  headache,  or  pain  in  the 
stomach,  are  indications  for  stojDping  the  arsenic.  When  toxic  symptoms 
occur  the  remedy  should  be  susjjended  for  two  or  three  days,  and,  as  by  this 
time  tolerance  of  the  drug  is  usually  established,  the  patient  may  begin  again 
with  the  dose  which  was  borne  before  the  toxic  symptoms  were  shown.  In 
the  majority  of  cases,  however,  at  this  period  the  choreic  symptoms  are  so 
much  diminished  that  it  is  well  to  resume  the  arsenic  in  small  doses.  If 
arsenic  is  not  well  borne,  it  is  better  to  increase  the  dose  more  gradually,  giv- 
ing but  1  drop  additional  each  day.  At  the  Infirmary  for  Nervous  Diseases 
we  are  in  the  habit  of  giving  the  parents  of  each  child  who  is  taking  arsenic 
for  chorea,  a  printed  slip  of  directions  for  the  gradual  increase  of  the  dose 
and  the  indications  which  should  cause  the  withdrawal  of  the  medicine. 
For  example,  a  child  is  told  to  begin  with  three  drops  three  times  a  day. 
On  the  second  day  the  dose  is  four  drops  in  the  morning,  three  drops  at 
noon,  and  three  drops  at  night ;  on  the  third  day,  the  dose  is  four  drops  in 
the  morning,  four  drops  at  noon,  and  three  drops  at  night ;  the  increase  to  be 
continued  in  the  same  way. 

It  is  quite  frequent  to  meet  with  various  inflammatory  conditions  of  the  skin 
from  the  large  doses  of  arsenic  which  are  given  in  chorea,  and  arsenical  conjunc- 
tivitis is  compai'atively  common  in  children  who  are  taking  the  drug.  We 
must  bear  in  mind,  however,  that  untoward  effects  have  been  reported  from 
arsenic  given  in  medicinal  doses,  and  the  patient  should  never  be  allowed  to 
take  arsenic  in  ascending  doses  unless  he  is  under  the  supervision  of  a  phy- 
sician. 

Bars  showed  a  case  before  the  West  Riding  Medico-Chirurgical  Society 
(British  Medical  Journal,  1893,  vol.  i.,  p.  239)  in  a  boy  aged  twelve  years, 
who  was  totally  disabled  by  multiple  neuritis  which  followed  the  admin- 


CHOREIFORM  AFFECTIONS.  249 

istration  of  liquor  arseuicalis  in  the  treatment  of  an  attack  of  chorea.  The 
maximum  close  of  arsenic  which  was  given  was  twelve  drops.  The  symp- 
toms subsided  speedily  on  the  withdrawal  of  the  arsenic,  and  the  boy  was 
discharged  from  the  hospital  perfectly  well ;  but  a  month  later  he  was  read- 
mitted with  loss  of  f)Ower  in  the  arms,  legs  and  trunk,  and  with  some  anaes- 
thesia and  tenderness  over  the  nerve  trunks.  The  tendon  reflexes  were  absent. 
Bars  considered  the  polyneuritis  due  to  the  arsenic  which  had  been  admin- 
istered. 

As  soon  as  the  acute  symptoms  have  subsided  the  dose  of  Fowler's  solu- 
tion should  be  reduced  to  two  or  three  drops  three  times  a  day ;  and  as  soon 
as  the  symptoms  have  entirely  ceased  the  arsenic  should  be  withdrawn  en- 
tirely. 

When  arsenic  is  not  tolerated  by  the  stomach,  I  have  found  cimicifuga  in 
doses  of  from  ten  to  fifteen  drops  of  the  fluid  extract,  three  times  a  day, 
useful,  and  the  fluid  extract  of  conium  pushed  to  fifty  or  sixty  drops  three 
times  a  day  is  a  good  remedy.  Salicylate  of  sodium  has  been  recommeded 
in  cases  of  rheumatic  origin.  I  have  given  it  a  faithful  trial  in  a  large  num- 
ber of  cases  without  finding  it  of  sj)ecial  value.  It  is  decidedly  inferior  to 
arsenic,  even  where  there  is  a  clear  rheumatic  history  preceding  the  attack. 
Of  course,  should  there  be  any  symptoms  of  acute  rheumatism  present,  the 
salicylates  are  indicated. 

During  convalescence  iron  may  be  given  in  full  doses,  and  should  be  con- 
tinued until  the  child  is  entirely  restored  to  health.  In  all  cases  in  which 
there  is  marked  anaemia,  iron  should  be  given  from  the  beginning ;  but, 
unless  the  patient  is  distinctly  deficient  in  red  blood  cells,  there  is  no  advan- 
tage in  giving  iron  in  conjunction  with  arsenic.  As  far  as  my  observation 
goes,  there  is  no  specific  action  in  iron.  Cod-liver  oil  is  often  advantageous 
in  children  who  are  badly  nourished  and  feeble.  General  sustaining  reme- 
dies are  more  or  less  useful  in  all  cases. 

During  the  decline  of  the  disease  light  gymnastics  and  Swedish  movements 
may  be  used  with  advantage,  but  it  is  not  desirable  to  employ  these  during 
the  acute  stages  of  the  disease. 

In  severe  cases  with  incessant  and  violent  contortions,  in  which  there  is 
sleeplessness  and  sometimes  delirium,  it  is  essential  that  rest  should  be  ob- 
tained. Chloral,  in  moderate  doses,  usually  answers  admirably  in  these  cases. 
Hyoscine  hydrobromate  is  sometimes  better  than  chloral  in  producing  quiet 
sleep.  If  these  remedies  fail,  then  morj^hine  should  be  administered  hypo- 
dermically. 

A  case  of  excessively  violent  chorea  is  reported  by  Himmelsbach,  of  a 
young  girl,  aged  eighteen  years,  who  was  admitted  to  the  Buffalo  General 
Hospital  with  such  an  extreme  case  of  chorea  that  nourishment  could  not 
be  administered  by  either  the  mouth  or  the  rectum  for  some  days.  Chloral 
and  hyoscine  both  failed  to  give  relief,  but  after  a  hypodermic  injection  of  a 
quarter  of  a  grain  of  morphine  the  patient  at  once  improved. 

Occasionally  inhalations  of  chloroform  or  ether  may  be  necessary,  and  the 
former  is  most  efficacious.  Sometimes  the  wet-pack  is  very  soothing  in  these 
cases.  In  cases  of  extreme  violence  it  is  of  the  utmost  importance  to  use 
supporting  measures  and  to  carefully  watch  the  heart's  action,  lest  there  be 
failure  of  this  organ.  Should  the  case  become  chronic,  change  of  air  to  the 
seashore  or  to  the  mountains  often  will  result  in  a  speedy  cure. 


250 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


CHOREA  INSANIENS. 

Chorea  insaniens,  or  maniacal  chorea,  is  a  variety  of  chorea  which  should 
be  considered  separately  from  the  common  type/  It  occurs  chiefly  in  females 
at  or  soon  after  the  age  of  puberty,  or  as  the  result  of  pregnancy.  The 
mental  disturbance  may  precede  the  choreic  movements,  or,  what  is  more 
common,  the  maniacal  symptoms  occur  after  the  choreic  movements  become 
violent  and  excessive.  Chorea  insaniens,  however,  must  not  be  confounded 
with  the  form  of  chorea  which  occurs  in  the  chronic  insane.  The  attack  may 
begin  with  movements  of  moderate  intensity,  which  become  rapidly  exces- 
sive, but  frequently  within  a  short  time  the  muscular  spasms  are  violent  in 
the  extreme,  and  delirium  develops  speedily.  If  the  attack  should  be  acute 
and  severe  and  the  temperature  runs  high,  the  case  is  likely  to  terminate 
fatally  within  a  few  days.  In  milder  cases  there  are  merely  delusions  of  a 
slight  form,  and  the  patient  has  extreme  loquaciousness  similar  to  that  seen 
in  acute  mania.  In  some  cases  the  excitement  subsides  in  a  few  days,  and 
leaves  the  patient  in  a  dull,  listless  and  depressed  state,  and  sometimes  with 
persistent  delulsions.  A  patient  in  this  condition  may  refuse  all  nourishment, 
which  then  has  to  be  administered  by  force.  This  state  may  pass  away  by 
degrees,  but  in  some  cases  it  has  lasted  for  months  after  chorea  has  ceased. 
Golgi  has  re]Dorted  a  case  in  which  after  the  subsidence  of  the  acute  stage 
there  was  gradually  increasing  mental  failure  during  a  period  of  ten  years, 
and  death  at  the  end  of  this  time. 

Table  II.— Chorea  Ixsa>^iens — 41  Cases. 


Age. 

Male. 

Fe- 
male. 

Recov- 
ered. 

Died. 

Insanity 
contin'd. 

Reference. 

14-2.5 

5 

18 

8 

10 

5          Gay,  Brain,  vol.  xii.  p.  149. 

23 

1 

1 

Clouston,  Mental  Diseases,  p.  324. 

Adult 

i 

1 

"           "              ''           " 

23 

"i 

i 

Bueknell  and  Take,  Psychological  Med.,  p.  372. 

17 

1 

"i 

"         "        "              "                  "           " 

24 

1 

1 

"         "        "              "                  "           " 

19 

"i 

"i 

Powell,  Brain,  vol.  xii.  p.  157. 

20 

"i 

1    ' 

18 

1 

1 

Osier,  Practice  of  Medicine,  p.  93-5. 

70 

1 

"i 

... 

Ferrier,  Lancet,  1S91,  vol.  i.  p.  1379. 

20 

1 

1 

... 

Banks,  Dublin  Hospital  Gazette,  vol.  vii.  p.  53. 

22 

1 

1 

L.  Mever,  Archiv  fiir  Psvchol.,  vol.  vii.  p.  535. 

19 

"i 

1 

J.  Russell,  Med.  Times  a"nd  Gaz.,  1869,  vol.  i.  p.  64. 

20 

1 

"i 

1 
1 

',',       !i       !i     ci     X     .1      ■<      .i 

56 

i 

"i 

B.  Lewis,  Med.  Times  and  Gaz.,  1876,  voL  ii.  p.  280. 

27 

"i 

1 

Berkeley.  Johns  Hopkins  Reports. 

7 

i 

"i 

Gav,  Brain,  vol  xii.  p.  149. 

18 

"i 

"i 

...        '  Gobdell,  Amer.  Jourh.  of  Obstetrics,  vol  iii.  p.  140. 

11 

30 

19 

17               5 

Gay'^  records  a  case  of  chorea  insaniens,  and  has  made  an  analysis  of  23 
cases.  I  have  been  able  to  coUect  IS  additional  cases  from  other  sources. 
Of  these  41  cases  11  were  in  males  and  30  in  females.  The  ages  varied  from 
seven  to  seventy  years  of  age,  the  majority  of  the  cases,  however,  being  be- 
tween seventeen  and  twenty-seven.  In  the  case  recorded  by  Gay  of  a  boy 
of  seven  years,  it  is  rather  doubtful  if  the  patient  had  genuine  chorea,  and 
the  writer  himself  admits  that  the  case  was  open  to  question.     Seventeen  of 

1  Chorea  insaniens  was  described  by  Marce,  Memoire  lu  ii  I'Academie  Imperiale  de  Medicine, 
April,  18.59,  who  says  that  this  name  was  first  used  by  Bernt,  of  Prague,  in  1810. 

2  Brain,  vol.  xii.,  1889. 


CHOREIFORM  AFFECTIONS.  251 

these  cases  terminated  fatally,  a  mortality  of  40.1  per  cent.,  and  19  recovered. 
In  five  cases  the  insanity  continued. 

Osier  decribes  the  case  of  a  girl  of  eighteen  years  of  age,  who  was  employed 
in  a  hotel.  She  was  very  much  frightened  by  seeing  two  men  fighting,  and 
droj)ped  a  tray  of  dishes  which  she  was  carrying.  For  this  she  was  severely 
reprimanded,  and  within  two  days  developed  choreic  movements.  She 
almost  immediately  became  maniacal.  The  temperature  rose  to  105°,  and 
death  occurred  at  the  end  of  ten  days.  There  is  no  note  of  an  autopsy 
having  been  made. 

Berkeley'  records  the  results  of  an  elaborate  examination  made  in  a  case 
of  chorea  insaniens.  The  patient  was  twenty-seven  years  of  age,  and  had  a 
history  of  rheumatism  at  sixteen  years  of  age.  When  she  was  twenty-three 
she  had  a  second  attack  of  rheumatism,  after  a  period  of  intense  application 
to  her  studies.  After  she  had  been  ill  for  a  few  days  her  mind  became 
afiected ;  she  was  delirious  for  five  weeks,  and  during  three  weeks  of  this 
time  she  had  choreic  movements.  The  mental  symptoms  and  choreic  move- 
ments disaj^peared  entirely,  and  the  patient  remained  well  except  that  she 
had  headaches.  The  fatal  illness  began  suddenly  with  jerking  of  the  mus- 
cles, which  awakened  her  in  her  sleep.  "Within  a  few  days  mental  symptoms 
developed.  There  was  extreme  restlessness  and  wild  delirium,  and  the  tem- 
perature rapidly  rose,  reaching  105°.  Death  occurred  at  the  end  of  eighteen 
days.  During  the  illness  a  parotid  abscess  developed.  On  the  admission  of 
the  patient  to  the  hospital  there  was  a  papular  bronze-colored  rash  over  the 
body,  which  was  scaly  in  places ;  ulceration  of  the  pharynx,  and  enlarged 
cervical  and  inguinal  glands.  On  the  under  surface  of  the  clitoris  was  "  an 
elevated  and  excoriated  non-indurated  sore."  At  the  autopsy  were  found 
acute  endocarditis,  catarrhal  pneumonia  of  both  lungs,  and  an  abscess  of  the 
parotid  gland.  Neither  the  brain  nor  membranes  showed  gross  changes,  but 
under  the  microscope  a  number  of  lesions  were  found  in  the  brain  and  mem- 
branes. These  were  principally  vascular ;  and  Berkeley  believes  that  the 
disease  in  this  case  was  of  infectious  origin. 

Clouston-  considers  that  maniacal  chorea  and  rheumatic  insanity  are  anal- 
ogous conditions,  and  that  the  mental  disorder  is  the  result  of  rheumatic 
poison  in  both,  although  he  admits  we  may  have  choreic  insanity  both  in 
early  youth  and  in  advanced  life  without  any  acute  rheumatic  symptoms. 
The  delirium  in  these  cases  he  points  out  as  being  of  an  inco-ordinate  jerky 
kind,  like  the  muscular  movements. 

Pathology.  Chorea  insaniens  is  usually  due  to  either  a  blood-poison  like 
rheumatism,  or  the  absorption  of  septic  material,  or  it  may  occur  in  connec- 
tion with  pregnancy.  Several  cases  have  been  recorded  where  the  disease 
was  the  result  of  fright.  In  the  few  autopsies  which  have  been  recorded 
there  ha.s  been  found  meningitis  or  vascular  changes  in  the  brain,  and  endo- 
carditis has  been  met  with. 

The  prognosis  is  grave,  especially  in  connection  Avith  pregnancy,  but  the 
younger  the  case  the  greater  is  the  prospect  of  recovery.  The  duration  of 
the  disease  varies  from  a  few  days  to  several  weeks,  and  occasionally  a  chronic 
condition  remains  which  lasts  for  years. 

Treatment.  This  consists  in  quieting  the  mental  excitement  and  in  giving 
the  patient  rest.  H}qonotics  are  necessary,  and  various  forms  have  been  used 
with  diffei'ent  degrees  of  success.  Morphine  has  been  found  useful  in  many 
cases,  and  in  other  instances  chloral  and  hyoscine  hydrobromate  have  been  of 
greater  efficacy  than  opiates.     It  is  important  to  keep  the  patient  from  in- 

1  Johns  Hopkins  Hospital  Reports,  August,  1891. 

2  Clinical  Lectures  on  Mental  Disorders,  p.  319. 


252  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

juring  herself  by  keeping  her  in  a  bed  with  padded  sides,  and  sometimes 
strapping  the  patient  down  is  found  necessary,  as  such  cases  frequently  injure 
themselyes  by  the  yiolence  of  their  moyements.  As  much  food  as  can  be 
giyen  should  be  used,  and  if  the  patient  is  unable  or  unwilling  to  take  it 
voluntarily  nourishment  must  be  administered  by  the  stomach-tube  or  by 
enemata. 

CHRONIC  CHOREA. 

Clu'onic  chorea  embraces  four  classes  of  cases  :  Fii'st,  a  form  which  is  essen- 
tially chronic  from  its  beginning,  and  may  be  congenital  or  have  its  origin 
at  any  period  of  life  ;  secondly,  the  hereditary  form  ;  thirdly,,  senile  chorea, 
and,  lastly,  those  cases  which  begin  with  an  acute  attack,  but  become  chronic 
and  last  for  montlxs  or  years,  although  ultimately  they  recover.  The  first 
form  includes  all  of  the  chronic  choreas  which  are  usually  met  with  in  adults, 
and  depends  almost  invariably  upon  some  gross  lesion  of  the  brain  or  spinal 
cord.     We  meet  with  two  types  of  the  affection  :  the  cerebral  and  the  spinal. 

The  first  form  may  begin  at  any  period  of  life,  and  Ls  frequently  congen- 
ital. The  movements  are  more  rhythmical  and  more  continuous  than  those  of 
Sydenham's  chorea,  and  have  been  said  by  some  writers  to  resemble  the  chorea 
which  occurs  in  dogs.  This  is  more  especially  the  case  in  the  spinal  form  of 
chronic  chorea.  In  this  variety  there  is  no  mental  disturbance,  and  but  slight 
movements  of  the  face  and  head.  In  the  cerebral  iy^Q  there  is  more  likely 
to  be  mental  enfeeblement,  and  disorders  of  speech  are  liable  to  occur.  The 
progress  of  the  disease  is  very  gradual,  and  the  patient  may  live  to  an  ad- 
vanced age  without  any  material  increase  in  the  symptoms.  As  a  rule,  how- 
ever, the  patients  do  not  live  beyond  fifty  years  of  age. 

There  is  no  doubt  that  many  cases  of  post-hemiplegic  chorea  or  infantile 
diplegias  are  confounded  with  chi'onic  chorea,  but  the  distinction  can  readily 
be  made  if  the  history  and  symptoms  of  the  case  are  closely  followed.  Mit- 
chell and  Burr^  have  related  the  case  of  a  young  man,  nineteen  years  of  age, 
in  whom  the  choreic  movements  began  in  infancy  and  were  probably  con- 
genital. His  maternal  grandmother  and  mother  suffered  from  chorea  during 
most  of  their  lives.  The  movements  in  this  case  involved  all  of  the  limbs, 
trunk,  and  face,  and  in  it  there  were  occasional  spasmodic  attacks,  accom- 
panied with  rigidity  of  the  legs.  The  patient's  condition  varied :  at  times  he 
was  well  enough  to  earn  his  living,  while  at  other  times  there  were  exacer- 
bations in  which  the  movements  were  quite  violent.  Chronic  chorea  is  incur- 
able, and  no  medication  seems  to  alleviate  the  severity  of  the  movements, 
except  for  brief  periods. 


HEREDITARY   CHOREA. 

Syxoxyms  :  Huntington's  chorea  and  chi'onic  progressive  chorea. 

Hereditary  chorea  was  first  described  by  Dr.  C.  O.  Waters  in  a  letter  to 
Dr.  Dunglison^  in  1841.  This  letter  contained  an  excellent  description  of  a 
remarkable  and  undescribed  form  of  St.  Vitus'  dance,  which  he  says  was 
somewhat  common  in  the  southeastern  j^art  of  Xew  York,  and  was  known 
among  the  common  people  as  the  "Megrums."  He  notes  the  characteristic 
features  of  the  disease,  namely,  heredity,  the  fact  of  its  rarely  occurring  be- 
fore adult  life,  and  its  incurability.     He  also  refers  to  the  fact  of  there  being 

1  Transactions  American  Xeurological  Association,  1890,  p.  S. 

2  Practice  of  Medicine,  vol.  ii.,  p.  245. 


CHOREIFORM  AFFECTIONS.  253 

in  all  cases  a  state  of  mental  deterioration  sooner  or  later ;  in  short,  in  this 
brief  communication,  Dr.  Waters  gives  as  lucid  a  description  of  the  disease 
as  has  been  presented  by  anyone. 

Irving  W.  Lyon^  also  presented  a  report  on  chronic  hereditary  chorea. 
His  cases,  like  those  Waters,  were  residents  of  the  State  of  Xew  York ;  and 
he  also  alludes  to  the  fact  that  the  families  in  which  these  cases  occurred 
were  popularly  called  "Megrim  Families." 

Huntington,^  however,  wrote  the  first  paper  on  this  disease  which  attracted 
the  attention  of  the  medical  world.  His  account  was  one  of  great  interest 
and  clearness,  and  he  believed  that  this  form  of  chorea  which  he  described 
was  peculiar  to  the  eastern  end  of  Long  Island.  His  father  and  grandfather, 
who  had  practised  medicine  in  this  locality  for  seventy-eight  years,  had  been 
acquainted  for  many  years  with  certain  families  in  which  chorea  had  existed 
for  generations.  The  name  Huntington's  chorea  has  been  used  in  connection 
with  this  disease  ever  since  this  writer's  account  of  the  disease  was  published. 

The  cases  of  this  malady  observed  in  America  have  been  chiefly  m  the 
States  of  Xew  York,  Connecticut,  Xew  Jersey,  and  Pennsylvania.  From  the 
fact  that  these  are  adjoining  States,  it  seems  probable  there  has  been  some 
common  ancestry  in  all  of  these  cases. 

East  Hampton,  according  to  King,^  was  settled  in  1649,  and  choreic  fami- 
lies have  resided  there  since  then,  and  several  emigrations  have  occurred,  one 
of  them  to  Delaware  County,  Xew  York,  where  Dr.  Waters's  original  case 
lived. 

A  number  of  cases,  however,  have  been  reported  in  Germany  and  France 
since  the  publication  of  Huntington's  paper,  and  a  complete  list  of  these  will 
be  found  in  my  paper  on  "  Hereditary  Chorea."* 

Lanois  has  written  an  admirable  article  on  hereditary  chorea,^  in  which  he 
records  cases  of  his  own,  and  also  a  review  of  the  entire  subject.  Huet's 
monograph  contains  the  complete  literature  of  the  disease.* 

In  hereditary  chorea  there  Is  almost  invariably  a  history  of  the  disease  in 
the  generation  preceding.  The  distinction  between  hereditary  chorea  and  an 
hereditary  tendency  to  chorea  must  be  borne  in  mmd.  In  the  first  there  is  a 
specific  disease,  with  characteristic  symptoms ;  in  the  other,  several  cases  of 
chorea  may  occur  in  a  family,  or  one  of  the  parents  may  have  had  chorea  In 
childhood.  It  occurs  between  the  ages  of  thirty-five  and  forty  years,  although 
it  may  occur  earlier  or  later.  It  rarely  begins,  however,  after  forty-five  years 
of  age,  and  there  are  but  few  instances  in  which  it  has  occurred  j)revious  to 
thirty.  Gray"  detailed  the  case  of  a  child  which  he  considered  one  of  con- 
genital Huntington's  chorea,  although  there  had  been  no  other  members  of 
the  family  similarly  affected.  Dr.  S.  C.  Stevens  reported,  in  a  paper  read 
before  the  South  Carolina  Medical  Association,  two  brothers,  one  of  eleven 
and  the  other  twelve  years  of  age,  both  of  whom  were  sufiering  from  chorea 
which  had  existed  in  one  from  birth,  and  in  the  other  the  disease  was  noted 
during  the  first  year.  They  belonged  to  a  family  in  which  the  hereditary  form 
of  chorea  had  existed  for  several  generations. 

Two  cases  of  hereditary  chorea  occurring  in  twins  are  re^Dorted  by  James 
W.  Russell.®  The  father  and  his  mother  suffered  fr-om  the  same  malady  ;  one 
brother  was  attacked  at  the  age  of  tAventy-six,  and  the  other  a  little  earlier. 

1  American  Medical  Times,  December  19, 1863. 
-  Medical  and  Surgical  Reporter,  April  15, 1872. 

3  Xew  York  Medical  Journal,  April,  1885. 

4  Medical  Record,  March  12,  1892. 

5  Revue  de  Medecine,  August,  1888. 
0  Chorea  Chronique,  Paris,  1SS9. 

■  Transactions  of  the  American  Neurological  Association,  1892. 
8  Birmingham  Medical  Review,  January,  1894,  p.  31. 


254 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Fig.  60. 


The  fbllowiug  table  is  from  Huet's  memoir,  and  gives  the  age  of  onset  in 
67  cases : 

Table  III. 

10  years 1 

10  to  15  years 1 

15  to  20  " 2 

20  to  25  " 1 

25  to  30  " 5 

SO  to  35  " 16 

35  to  40  " 13 

40  to  45   " n 

45  to  50  " 7 

50  to  55  " 8 

60  to  65  " 1 

65  to  70  " 1 

As  a  rule,  if  one  member  of  a  choreic  family  escapes  the  disease,  his 
descendants  do  not  have  it.  There  are,  occasionally,  exceptions  to  this  rule, 
but  in  most  cases  the  rule  holds  good. 

As  many  cases  occur  in  males  as 
in  females.  In  families  who  suffer 
from  this  strange  affection  the  sexes 
are  equally  affected.  The  disease 
sometimes  begins  during  pregnancy. 
In  two  families,  which  I  have  re- 
ported, there  were  eleven  males  and 
fifteen  females  who  suffered  from 
chorea.  The  women  in  families  in 
which  this  malady  exists  are  usually 
prolific,  and  large  families  seem  to 
be  the  rule. 

The  movements  in  hereditary  cho- 
rea begin  usually  in  the  upper  ex- 
tremities, and  are  slight.  They  are 
similar  in  their  features  to  those  of 
Sydenham's  chorea;  but  as  the  dis- 
ease progresses  the  movements  be- 
come more  general,  and  involve  the 
upper  and  lower  extremities  equally  ; 
the  trunk  and  facial  muscles  are  also 
involved,  and  speech  and  degluti- 
tion become  greatly  interfered  with. 
When  the  disease  is  fully  developed, 
the  movements  present  quite  differ- 
ent features  from  those  of  ordinary 
chorea.  They  are  more  extreme, 
more  rhythmical,  and  more  inco-ordi- 
nate.  A  wider  range  of  movements 
come  into  play,  and  whole  groups  of 
muscles  are  brought  into  action. 

The  gait  is  characteristic.  The  pa- 
tient takes  a  few  long  steps  naturally, 
then  makes  a  long  step  Avith  one  leg, 
bringing  up  the  other  quickly  to  it, 
and  makes  one  or  two  hops,  giving 
the  appearance  of  dancing ;  he  then 
takes  several  more  natural  steps,  which  are  again  interrupted  by  the  dancing 
steps.  Another  feature  which  has  been  observed  in  these  cases  is  a  tendency 
which  the  patient  has  to  remain  standing  in  one  position  for  a  length  of  time. 


Adult  chorea,  showing  the  dramatic  position  in- 
voluutarily  assumed.     (Dercuji.) 


CHOREIFORM  AFFECTIONS. 


255 


Oue  of  King's  patients  was  accustomed  to  stand  for  many  hours,  especially 
when  trying  to  masticate  food,  Avith  her  body  thrown  back  on  a  level  with 
her  hips,  and  her  arms  extended  backward  by  the  sides  of  the  body,  the 
palms  looking  forward. 


Fig.  01. 


Adult  chorea,  showing  excessive  and  rapid  movements.    The  arms  are  blurred  in  the 
figure  in  consequence.    (Deecum.) 

Speech  is  very  much  interfered  with,  but  it  is  seldom  that  any  involuntary 
ejaculations  are  made.  The  words  are  indistinctly  and  haltingly  pronounced, 
but  there  is  no  scanning.  Deglutition  is  also  difficult  in  most  cases.  As 
the  disease  progresses  the  movements  become  more  violent,  more  continuous, 
and  less  under  the  control  of  the  i^atient's  will.  In  the  early  stages  the 
movements  may  be  arrested  by  voluntary  effort,  and  some  writers  have  re- 
garded this  ability  to  control  the  movements  as  a  point  of  distinction  between 
this  malady  and  Sydenham's  chorea ;  but  in  the  later  stages  not  only  does 
voluntary  effort  fail  to  control  the  movements,  but  when  a  patient  is  told  to 
try  and  keep  still  the  contortions  become  raore  violent.  Strange  to  say,  that 
in  spite  of  the  unceasing  and  extreme  character  of  the  movements,  the  patient 
never  complains  of  fatigue,  and  prefers  to  remain  out  of  bed.  In  many  cases 
there  appears  to  be  a  remarkable  insensibility  to  pain.  Patients  bruise  and 
injure  themselves,  and  do  not  suffer. 

Mental  disorder  is  found  in  all  cases,  and  usually  in  the  terminal  stages. 
There  are  cases,  however,  in  which  mental  disease  occurs  first,  and  a  number 
of  instances  of  this  form  of  chorea  have  been  met  with  in  insane  asylums. 
Diller^  recorded  39  cases  of  hereditary  chorea,  33  of  which  were  found  in 
asylums. 

From  these  facts  I  have  come  to  the  conclusion  that  there  are  two  forms  of 


1  American  Journal  of  the  Medical  Sciences,  1892. 


256  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

hereditary  chorea ;  one  in  which  the  muscular  disorder  begins  first,  and  after 
a  number  of  years  mental  deterioration  begins ;  and  another  type  in  which 
insanity  precedes  for  some  years  the  chorea. 

The  usual  form  of  insanity  which  occurs  is  melancholia,  with  sometimes  a 
suicidal  tendency.  There  are  delusions  of  various  forms ;  at  times  of  perse- 
cution, and  at  other  times  delusions  of  grandeur.  The  patients  are  suspicious 
and  unsociable.  Occasionally,  they  may  be  violent.  Rheumatism  has  been 
present  in  a  number  of  cases  which  have  been  recorded  ;  and  in  several  there 
has  been  disease  of  the  heart.  The  knee-jerks  are  exaggerated,  and  ankle 
clonus  is  sometimes  present.  There  is  aj^parently  but  little  change  in  the 
sexual  functions,  several  women  having  been  recorded  as  having  borne  healthy 
children  after  having  become  choreic. 

Pathology.  The  pathology  is  undoubtedly  like  that  of  other  developmental 
diseases,  like  Friedreich's  ataxia,  and  the  disease  is  due  to  a  hereditary  or  con- 
genital defect  in  the  motor  tracts  of  the  brain  and  cord.  This  is  shown  by  the 
fact  that  a  number  of  cases  are  known  to  have  begun  in  early  childhood.  The 
disease  is  distinctly  difierent  from  Sydenham's  chorea  in  its  pathology  as  well 
its  other  features.  A  number  of  autopsies  have  been  made  within  the  past 
few  years,  with  more  or  less  uniform  results.  There  has  generally  been  found 
evidence  of  disease  in  the  motor  region  of  the  brain  and  inflammation  of  the 
meninges. 

An  interesting  point  in  the  pathology  of  hereditary  chorea  which  points  to 
the  possibility  of  its  being  an  infectious  disease  is  the  fact  that  in  Long  Island, 
where  the  disease  has  existed  for  years,  tetanus  is  also  extremely  common. 

Lesions  in  the  cord  are  frequently  present.  In  an  autopsy  which  was  made 
in  a  case  of  mine^  there  was  found  congestion  of  the  meninges,  with  sub- 
arachnoid oedema  and  adhesions  between  the  dura  and  the  skull.  Owing  to 
an  accident,  the  brain  was  not  examined  microscopically.  In  the  spinal  cord, 
however,  there  was  found  an  increase  in  the  connective  tissue  in  the  white 
matter  and  thickening  of  the  walls  of  the  bloodvessels.  The  region  of  the 
central  canal  was  occupied  by  a  mass  of  nuclear  tissue  much  more  abundant 
than  in  normal  cords.  Greppin^  reports  an  autopsy  in  a  patient  in  whose 
family  chorea,  insanity,  brain,  and  spinal  disease  had  occurred.  He  became 
choreic  at  the  age  of  fifty,  and  died  in  a  condition  of  dementia.  The  post- 
mortem examination  showed  pachymeningitis  and  leptomeningitis.  The 
convolutions  of  the  brain  w^ere  flattened,  and  slight  atheroma  of  the  vessels  of 
the  base  was  found.  Everywhere  were  found  through  the  gray  and  white 
matter  accumulations  of  cellular  elements,  with  "  not  much  developed  mem- 
brane and  nucleus,  and  composed  of  many  granular  nuclei,  so  that  here  and 
there  ganglion  cells  and  nerve  tubes  were  completely  obliterated  by  them.  In 
many  places  the  cells  were  conglomerated,  and,  having  lost  their  nuclei,  made 
a  deformed  mass.  These  masses  were  most  numerous  in  the  white  matter  of 
the  frontal,  parietal,  and  temporal  convolutions.  Osler^  found,  in  one  autopsy 
which  he  made,  meningitis  and  atrophy  of  the  convolutions  and  some  blood- 
vessel changes.  Phelps^  calls  attention  to  the  analogy  between  hereditary 
chorea  and  paresis.  Both  diseases  begin  in  the  adult  life ;  in  both  the  mental 
symptoms  are  of  the  same  character ;  both  are  essentially  chronic ;  and  the 
post-mortem  findings  in  both  are  similar. 

The  diagnosis  of  hereditary  chorea  depends  upon  the  history  of  the  disease, 
but  may  be  confounded  with  Friedreich's  ataxia.  In  the  latter  disease  patients 
are  attacked  in  early  life,  and  the  movements  are  athetoid  rather  than  choreic. 
In  disseminated  sclerosis  the  movements  cease  while  the  patient  is  at  rest, 

1  Medical  Record,  March  12,  1892.  2  Schmidt's  Jahrblicher,  June  15, 1893. 

3  Practice  of  Medicine,  pase  914. 

4  Journal  of  Nervous  and  Mental  Diseases,  October,  1892. 


CHOREIFORM  AFFECTIONS.  257 

and  occur  only  on  voluntary  effort.  In  paralysis  agitans  the  tremor  is  fine 
and  rhythmical,  and  there  is  no  disturbance  of  speech  or  deglutition. 

Prognosis.  The  disease  is  incurable  and  terminates  fatally  by  exhaustion 
or  some  intercurrent  disease.  It  may  last  for  fifteen  or  twenty  years,  during 
which  time  there  is  a  progressive  increase  in  all  of  the  symptoms.  The  dis- 
ease is  seldom  arrested. 

Treatment.  There  is  no  treatment  for  this  affection  which  affords  positive 
relief.  Arsenic  has  been  recommended  and  has  been  given  in  large  doses, 
but  without  benefit.  Hyoscine  in  full  doses  sometimes  gives  temporary  relief, 
but  the  influence  of  the  drug  is  soon  exhausted.  Sulphonal  has  afforded 
temporary  amelioration  of  the  symptoms,  bvit  with  no  lasting  good.  In  one 
case  that  I  have  seen  the  patient  was  made  much  more  comfortable  by  being 
kept  in  bed.  In  all  cases  it  is  important  to  keep  the  patient  clean  by  fre- 
quent bathing,  and  to  give  food  which  can  be  easily  masticated.  Excitement 
and  disturbances  of  all  kinds  make  the  patient  worse. 


SENILE    CHOREA. 

Irregular  choreic  movements  are  not  infrequently  met  with  in  the  aged, 
and  sometimes  fully  developed  and  tyj)ical  chorea  occurs  in  persons  after  the 
age  of  sixty.  A  number  of  cases  have  been  reported  of  late  years,  and  I 
have  seen  several  myself.  Of  the  cases  which  have  been  under  my  care  one 
was  eighty-two  years  of  age,  another  eighty-six,  and  another  eighty.  The 
movements  in  senile  chorea  are  seldom  violent,  and  are  frequently  capable  of 
being  controlled  by  voluntary  effort.  The  legs  are  less  affected  than  the  arms. 
Sometimes  the  movements  are  extreme  and  involve  the  face  and  muscles  of 
speech  to  such  an  extent  that  the  patient  cannot  articulate  intelligibly. 
Speech  is  seldom  affected,  and  the  facial  muscles  are  not  involved.  It  is  by 
no  means  an  incurable  disease,  and  in  two  cases  which  I  have  seen  the  move- 
ments ceased  entirely  after  treatment.  Charcot'  thought  that  in  old  persons 
suffering  from  chorea  there  was  almost  invariably  a  condition  of  dementia, 
but  he  probably  refers  to  a  different  class  of  cases  from  those  in  which  the 
chorea  is  the  result  of  mental  deterioration.  In  some  of  the  cases  which  I 
have  seen  there  was  a  history  of  rheumatism,  and  valvular  disease  of  the 
heart  was  present. 

Senile  chorea  may  be  mistaken  for  paralysis  agitans  and  senile  trembling. 
In  senile  trembling  the  movements  are  generally  confined  to  the  head,  and 
consist  of  a  continuous  rhythmical  tremor.  In  paralysis  agitans  there  is  loss  of 
power  in  the  parts  involved,  the  tremor  is  regular  and  gesticulatory,  and 
there  is  a  history  which  shows  that  at  first  the  tremor  was  under  the  influence 
of  the  will,  and  afterward  became  more  violent  and  continuous ;  moreover, 
the  peculiar  facial  expressions  of  paralysis  agitans  help  in  clearing  up  the 
diagnosis. 

The  treatment  of  this  form  of  chorea  is  like  those  for  other  forms  of  chronic 
chorea,  and  consists  in  keeping  the  patient  as  free  from  excitement  as  possible, 
and  enforcing  quiet.  Arsenic  has  a  distinctly  curative  influence  in  the  treat- 
ment of  these  cases,  and  some  are  benefited  by  the  use  of  moderate  doses  of 
strychnine. 

In  senile  chorea  there  is  probably  some  degenerative  changes  in  the  motor 
area  of  the  cortex.  In  one  of  my  patients,  a  man  of  eighty  years,  there  had 
been  for  several  years  distinct  choreic  movements  of  the  left  arm,  which  did  not 
increase  in  severity,  but  rather  diminished  in  their  extent.     He  became  sud- 

1  Medical  Times  and  Gazette,  March  9,  1878. 
17 


258  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

clenly  hemiplegic  on  the  left  side,  and  died  after  a  few  days'  illness.  This  case 
would  seem  to  indicate  that  there  had  been  disease  in  the  cortex  which  had 
at  first  been  merely  sufficient  to  cause  the  irregular  movements,  but  that 
finally  the  degeneration  became  so  great  that  there  was  loss  of  function  in 
the  motor  region.  Changes  have  been  frecjuently  found  in  the  brain  of 
patients  dying  from  senile  chorea,  but  there  have  been  no  constant  lesions 
discovered.  Berkeley  made  a  post-mortem  examination  in  a  case  of  seven 
years'  duration,  and  found  many  lesions  in  the  cortex,  but  they  were  prob- 
ably secondary  in  character. 


CHOREA    MAJOR. 

Chorea  major  of  the  French  is  simply  a  form  of  hysteria.  The  name  has  also 
been  applied  to  jDandemic  chorea  which  occurred  in  the  ^Middle  Ages,  and  which 
has  likewise  occurred  in  Kentucky  and  elsewhere.  The  movements  of  hys- 
terical chorea  are  usually  violent  and  continuous,  and  are  never  controlled  by 
voluntary  efibrt ;  on  the  contrary,  they  appear  to  be  exaggerated  when  the 
patient  is  told  to  try  to  arrest  the  movements.  Other  stigmata  of  hysteria 
are  also  present,  and  the  diagnosis  is  therefore  not  difficult.  In  a  case  of 
hysterical  chorea  which  I  saw  some  years  ago  in  a  young  married  woman,  the 
j)atient's  movements  were  continuous  and  so  violent  that  she  was  very  much 
emaciated,  and  sleep  could  not  be  obtained  except  under  the  influence  of 
large  doses  of  chloral,  and  there  was  distinct  mental  disturbance.  She  re- 
covered completely  under  moral  influences  and  the  Avithdrawal  of  the  di'ug-s 
to  which  she  had  become  habituated. 


HABIT    CHOREA. 

This  affection  has  been  called  by  Gowers  "  habit  spasm,"  as  he  does  not 
consider  it  a  true  form  of  chorea,  and  the  term  "  couATilsive  tic "  has  also 
been  given  it  by  the  French.  The  latter  name,  however,  is  unfortunate,  as 
it  has  also  been  used  for  painless  facial  spasm.  This  affection  was  described 
by  Weir  Mitchell.^  He  found  that  it  was  most  frequent  in  girls  from  seven  to 
fourteen  years  of  age.  In  many  cases  there  is  a  simple  grimace,  or  a  motion 
made  in  some  part  of  the  body.  The  affection  lasts  for  a  few  months  and 
disappears.  In  other  cases  the  habit  movement  first  formed  does  not  last, 
but  another  takes  its  place,  and  thus  a  variety  of  other  movements  may 
be  produced  which  become  more  troublesome  and  more  persistent.  In  many 
cases  there  is  some  failure  in  the  general  health  of  the  child,  but  in  others 
the  odd  grimaces  or  movements  seem  to  have  developed,  as  it  were,  by  acci- 
dent, and  the  child  becomes  unable  to  control  them.  The  movements  are 
fr*equently  confined  to  the  face,  and  consist  in  winking  of  the  eyes  or  wrin- 
kling of  the  forehead.  Sometimes  the  movements  are  confined  to  the  muscles 
about  the  mouth,  and  twitching  of  the  corners  of  the  mouth,  or  the  protru- 
sion of  the  tongue  occurs,  ancl  is  suddenly  repeated.  In  other  cases  the 
movement  consists  in  a  shrugging  of  the  shoulders,  and  in  one  or  two  cases 
that  I  have  seen  the  muscles  of  the  ear  which,  as  we  know,  are  usually  not 
capable  of  being  moved  voluntarily,  are  thrown  into  frequent  contractions. 
In  a  patient  twenty-eight  years  of  age,  who  came  under  my  observation  some 
years  ago,  there  was  a  frequent  shrugging  of  the  neck  to  one  side,  and  the 
chin  was  drawn  upward  with  an  occasional  shoulder  movement.     This  man 

1  Lectures  on  Xervous  Diseases,  Philadelphia,  1881. 


CHOREIFORM  AFFECTIONS.  259 

told  me  that  these  movements  began  when  he  first  wore  suspenders,  and  that 
he  had  never  been  able  to  rid  himself  of  them. 

Habit  chorea  frequently  is  the  result  of  overwork  at  school  or  too  close 
attention  to  tasks  of  any  kind  in  a  child.  Fright  is  also  occasionally  the 
cause  of  an  attack,  and  Growers  mentions  a  case  in  which  an  unexpected  fall 
into  the  water  caused  an  immediate  attack.  Eye  defects,  such  as  conjunti- 
vitis  and  errors  of  refraction,  are  among  the  commonest  causes  of  habit  chorea, 
especially  those  forms  in  which  the  movements  are  confined  to  the  face.  De 
Schweinitz'  has  related  a  number  of  cases  of  habit  chorea  which  were  due  to 
refraction  errors,  and  which  were  entirely  relieved  by  properly  adjusted 
glasses.  Diseases  of  the  nose  of  an  obstructive  nature  are  also  liable  to 
produce  this  affection.  In  boys  masturbation  is  said  to  be  a  cause  of  severe 
and  intractable  cases  of  habit  chorea.  In  many  cases  imitation  can  be 
traced  as  a  direct  cause.  It  is  quite  common  to  see  more  than  one  child  in  a 
family  with  some  form  of  choreic  twitching,  and  it  is  not  uncommon  to  find 
that  the  affection  in  a  parent  or  an  older  member  of  the  family  has  been 
acquired  by  one  of  the  children. 

The  character  of  the  movements  vary  in  different  persons  in  extent  and 
degree,  and  may  occur  at  intervals  of  a  minute  or  two,  or  there  may  be 
only  a  few  in  the  course  of  a  day,  or  the  choreic  spasm  may  be  almost  con- 
tinuous. 

AVhen  confined  to  the  face  the  affection  often  occurs  in  the  form  of  blink- 
ing of  the  eyes,  or  as  a  series  of  spasmodic  contractions  of  the  orbicularis 
palpebrarum,  simulating  blepharospasm  ;  in  some  cases  there  are  twitchings 
of  the  mouth  involving  the  zygomatic  muscles,  and  in  others  a  broad  smile 
is  repeated  at  intervals  without  any  occasion  for  mirth.  Gowers  refers  to  a 
clergyman  Avho  was  in  the  habit  of  making  meaningless  smiles,  and  was  un- 
able to  control  the  habit  until  he  was  treated  for  the  affection ;  and  I  have 
seen  one  or  two  cases  myself  in  which  this  involuntary  smiling  was  rej)eated 
at  intervals,  much  to  the  embarrassment  of  persons  speaking  to  the  patient, 
who  seemed  to  be  laughing  at  some  serious  remark. 

Wrinkling  of  the  brow"  is  a  frequent  form  of  the  malady,  and  alternate  con- 
tractions of  the  occipito-frontalis  muscles  give  rise  to  active  twitching  of  the  en- 
tire scalp.  In  a  lady  whom  I  have  seen  there  was  spasm  involving  the  occipito- 
frontalis  muscles.  The  effect  upon  her  bonnet,  in  which  some  long  feathers 
were  placed,  was  very  striking.  In  other  cases  movements  of  the  head  are 
met  with,  either  in  the  form  of  nodding  or  shaking,  and  these  movements 
may  either  be  continuous  when  the  head  is  unsupported,  or  may  occur  at 
long  intervals.  I  have  seen  one  patient  who  was  so  much  annoyed  by  the 
nodding  of  her  head  that,  being  unable  to  control  it  otherwise,  she  acquired 
the  habit  of  biting  her  cheek  whenever  the  tendency  to  nod  was  perceived 
by  her. 

Respiratory  spasms  are  not  uncommon,  and  jerky  or  sobbing  respiration  is 
the  result.  Laryngeal  sounds  are  occasionally  made,  resembling  a  cough  or 
a  bark.  The  clearing  of  the  throat  and  sniffling  of  the  nose  is  a  frequent 
form  of  this  affection.  In  short,  innumerable  tricks  of  movement  of  the  face 
or  hands  which  are  met  with  are  the  result  of  habit  chorea.  This  affection 
sometimes  may  be  the  remnant  of  an  attack  of  Sydenham's  chorea,  which 
has  been  cured,  with  the  exception  of  the  choreic  movement  which  has 
lingered  in  one  part. 

The  movements  of  habit  chorea  are  generally  increased  when  the  patient 
is  observed,  and  by  severity  on  the  part  of  parents,  who  usually  think  they 

1  Habic  Chorea  and  its  Treatment.  Transactions  of  the  Philadelphia  County  Medical  Society, 
May  9, 1888. 


260  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

can  be  checked  by  vokmtary  effort.  lu  many  cases  the  disease  is  of  short 
duration,  but  in  others  the  habit  once  formed  continues  throughout  life,  and 
resists  every  form  of  treatment. 

In  nearly  all  cases  it  is  of  first  importance  to  look  after  the  general  health 
of  the  patient.  The  child,  who  should  be  taken  from  school,  should  be  made 
to  take  sufficient  outdoor  exercise,  cold  baths,  frictions,  massage,  and  the 
liberal  administration  of  iron  are  almost  alwaj^s  of  benefit.  If  the  disease 
fails  to  yield  to  these  means,  arsenic  should  be  given  in  ascending  doses,  just 
as  it  is  administered  in  the  treatment  of  Sydenham's  chorea.  Mitchell  has 
found  that  arsenic  given  hypodermically  is  successful  in  cases  which  have 
resisted  the  same  remedy  when  given  by  the  stomach.  Scolding  and  severity 
never  help  in  the  cure  of  a  case,  but  frequently  the  promise  of  reward  to  a  child 
will  aid  greatly  in  bringing  about  recovery.  It  is  quite  common  with  me  to 
promise  the  child  some  favor  or  reward  when  he  is  able  to  control  the  move- 
ments for  a  certain  number  of  minutes,  and  some  new  favor  is  granted  with 
the  increase  in  the  length  of  time  that  the  movement  can  be  controlled. 

In  all  cases  in  which  the  orbicularis  palpebrarum  and  occipito-frontalis 
muscles  are  affected  the  eyes  should  be  examined  for  defects,  and  the  throat 
and  nose  should  also  be  investigated.  In  fact,  every  possible  sovirce  of  reflex 
irritation  should  be  traced  and  relieved. 

"Button-makers'  chorea"  has  been  described  as  occurring  in  girls  who  are 
employed  in  button  mills,  as  the  result  of  too  close  application  to  their  trade. 
The  movements  of  the  fingers  continue  when  they  are  not  at  work,  following 
the  same  motions  as  those  employed  when  making  buttons.  This  may  be 
regarded  as  a  form  of  habit  chorea. 


ELECTRICAL    CHOREA. 

Electrical  chorea,  or  Dubini's  disease,  is  met  with  in  Lombardy  and  parts 
of  Italy.  The  term  has  also  been  applied  to  varieties  of  hysterical  chorea 
and  to  cases  of  ordinary  chorea  in  which  the  movements  were  violent  and 
shock-like.  Dubini's  disease,  however,  is  a  totally  different  affection,  and  is 
not  a  true  chorea.  It  resembles  chorea,  however,  in  the  spasmodic  move- 
ments which  occur,  but,  in  adition,  there  is  a  progressive  palsy  and  muscular 
wasting.  The  muscular  movements  are  sudden  and  shock-like,  resembling 
the  movements  which  are  produced  by  a  sudden  current  of  electricity ;  hence 
the  name  electric  chorea.     The  disease  ends  fatally  in  many  cases. 

The  etiology  of  the  affection  is  obscure.  It  has  been  ascribed  to  malarial 
influences,  on  account  of  the  fact  that  it  is  prevalent  in  low,  marshy  districts. 

The  peculiar  shock-like  contractions  in  Dubini's  disease  begin  usually  in 
the  arm,  and  spread  thence  to  the  leg  of  the  same  side ;  and  later  the  oppo- 
site side  becomes  affected.  In  a  few  months  the  members  which  were  first 
affected  become  feeble,  and  muscular  atrophy,  with  loss  of  faradic  irrita- 
bility, is  present.  The  paralysis  extends  by  degrees  and  soon  becomes 
general.  Occasionally  epileptiform  convulsions  are  met  with  during  the 
course,  of  the  disease ;  in  acute  cases  there  is  elevation  of  temperature. 

Autopsies  which  have  been  made  in  fatal  cases  have  I'evealed  no  constant 
lesions  in  the  central  nervous  system.  It  has  been  suggested  that  it  is  a  form 
of  infectious  myelitis,  due  to  malaria,  but  no  proof  of  this  has  been  offered. 
Treatment  has  not  been  of  any  avail. 


CHOREIFORM  AFFECTIONS.  261 


SALTATORIC    SPASM. 


Synonyms.  Latah;  Miryacliit ;  Tic  Convulsif;  Palmus;  the  Jumpers; 
Gilles  de  la  Tourette's  Disease. 

Under  these  various  names  is  described  a  peculiar  affection  which  most 
writers  classify  with  chorea,  but  which  is  not  a  form  of  that  disease.  For 
convenience,  however,  it  may  be  treated  of  here.  The  malady  was  first  de- 
scribed by  Bamberger  in  1859.  It  occurs  more  frequently  in  males  than  in 
females,  and  it  may  exist  at  any  age — from  ten  to  seventy  years.  In  the 
cases  described  by  Bamberger  there  is  frequently  a  history  of  hysteria  and 
epilepsy  or  some  other  disturbance  of  the  nervous  system ;  and  in  other  in- 
stances there  has  been  some  depressing  influence  upon  the  system  at  large. 

There  are  sometimes  premonitory  symptoms,  such  as  tremor  or  stiffness  of 
the  legs  ;  but  in  other  cases  the  attack  is  sudden.  When  the  patient  attempts 
to  stand  there  are  violent  contractions  of  the  flexors  and  extensors  of  the 
muscles  of  the  entire  leg,  so  that  a  jumping  and  springing  movement  is  pro- 
duced. These  jumps  are  frequently  so  violent  and  often  repeated  that  the 
patient  is  thrown  upon  the  floor.  The  movements  occur  only  upon  attempts 
to  stand,  and  while  the  patient  is  either  lying  or  sitting  there  are  no  invol- 
untary contractions  of  the  legs.  The  disease  may  be  of  only  short  duration, 
or  it  may  last  for  many  years.  All  of  the  subjects  of  it  are  neurotic,  and 
there  is,  no  doubt,  a  large  underlying  hysterical  element. 

This  affection  has  been  met  with  in  epidemics  in  diflferent  parts  of  the 
world  ;  at  least,  I  believe  that  the  affections  described  by  different  writers  as 
occurring  in  Russia,  Canada,  Java,  and  other  places,  characterized  by  jump- 
ing and  imitative  movements,  are  identical  with  the  saltatoric  spasm  of 
Bamberger.  Beard^  describes  a  malady  which  occurs  in  certain  parts  of 
Maine  and  Canada.  The  subjects  of  this  affection  are  known  as  "jumpers  " 
or  "jumping  Frenchmen."  This  writer  found  that,  in  addition  to  the  jump- 
ing movements  which  were  made  involuntarily  by  these  patients,  they  had  a 
tendency  to  do  whatever  they  were  told.  For  example,  Beard  ordered  one 
man  who  was  sitting  on  a  chair,  with  a  knife  in  his  hand,  to  throw  it.  The 
knife  was  at  once  thrown  so  quickly  and  violently  that  it  struck  a  house 
opposite  ;  at  the  same  time  he  repeated  the  order  to  throw  the  knife  with  a 
loud  cry.  In  the  subjects  of  this  disease  there  was  also  echolalia  and  copro- 
lalia ;  that  is,  they  would  imitate  any  Avords  given  to  them  and  made  use  of 
indecent  language.  Beard  repeated  the  first  lines  of  the  ^neid  to  one  of 
these  illiterate  jumpers,  and  he  immediately  repeated  the  sounds  of  the  words 
as  they  came  to  him  in  a  quick,  sharp  voice,  and  at  the  same  time  he  jumped 
or  shrugged  his  shoulders  and  made  other  violent  muscular  movements. 

Hammond'^  gave  an  account  of  a  similar  affection  which  occurred  in 
Siberia,  and  was  known  there  as  "  miryachit."^  O'Brien*  also  has  given  an 
account  of  this  disease  as  met  with  among  the  Malays,  and  called  by  them 
"  latah."  He  states  that  on  one  occasion  he  was  talking  with  a  respectable 
Malay  Avoman,  whom  he  did  not  suspect  to  be  a  subject  of  the  disease.  Sud- 
denly a  friend  who  was  with  him  took  oflf  his  coat,  and  the  Avoman  immedi- 
ately began  to  undress  herself  and  entirely  disrobe  herself,  in  spite  of  his 
remonstrances,  although  she  AA'as  violently  angry  at  the  outrage  to  her  sex, 

1  Journal  of  Nervous  and  Mental  Diseases,  vol.  vii.,  p.  487. 

-  New  York  Medical  Journal,  February  16,  1884 

3  Neuroses  from  a  demographic  point  of  view.    Journal  of  Nervous  and  Mental  Diseases,  June,  1891. 

*  Journal  of  the  Straits  Branch  of  the  Royal  Asiatic  Society,  June,  1883.  O'Brien,  who  was  not  a 
medical  man,  defines  latah  as  "  including  all  persons  of  a  peculiar  nervous  organization,  who  from 
their  mental  constitution  seem  absolutely  subservient  to  another's  will."  I  am  indebted  to  Mr. 
Talcott  Williams  for  the  opportunity  of  seeing  the  above  article. 


262  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  called  him  an  abandoned  hog  and  other  abusive  names  all  the  time  she 
was  undressing.  This  writer  also  says  that  the  cook  of  a  steamer,  "  a  latah," 
one  day  was  carrying  his  child  in  his  arms ;  one  of  the  crew  stood  before 
him  with  a  log  of  wood  in  his  arms,  which  he  nursed  in  the  same  way  as 
"the  latah"  was  nursing  his  baby.  The  sailor  amused  himself  by  throwing 
the  log  of  w^ood  on  an  awning  and  allowing  it  to  roll  down,  catching  it  in 
his  arms.  The  cook  repeated  every  motion  with  his  child,  and,  when  the 
sailor  allowed  the  log  of  wood  to  fall  upon  the  deck,  he  let  the  baby  fall  and 
killed  him  on  the  spot. 

In  some  of  these  cases  there  is  a  tendency  to  persistent  and  continuous 
ideas,  and  even  a  slight  delusional  insanity,  with  other  forms  of  mental  dis- 
turbance. 

According  to  Rosse,  the  proper  spelling  of  this  name  is  "  emeryaki." 

Rosse^  gives  an  interesting  letter  from  Lieutenant  Schuetze,  United 
States  Navy,  who  saw  much  of  this  disease  during  a  prolonged  stay  on 
the  Lena  Delta  in  connection  with  the  Jeanette  search  expedition.  The 
symptoms  of  the  disease,  as  portrayed  by  Lieutenant  Schuetze,  are  singu- 
larly like  those  met  with  in  the  "jumpers"  of  Maine  and  Canada.  He 
remarks  that  it  is  common  to  meet  with  persons  afflicted  with  this  disease  in 
the  streets  and  market-places  of  Yakutsk  and  other  towns ,  and  his  belief  is 
that  the  exciting  causes  of  the  disease  are  the  extreme  cold,  often  87°  below 
zero,  the  lonely  life,  and  excessive  vodka  and  tea-drinking. 

The  first  case  which  he  observed  was  a  Russian  exile,  who  held  the  posi- 
tion in  Yakutsk  of  assistant  to  the  Chief  of  Police.  At  an  evening  card 
party  he  was  standing  back  of  the  chair  of  one  of  the  players,  a  district 
judge,  watching  the  game.  At  the  suggestion  of  another  guest.  Lieutenant 
Schuetze  threw  a  small  pellet  of  bread  at  the  patient,  striking  him  lightly 
on  his  bald  head,  his  back  being  turned  away.  "  He  at  once  threw  up  his 
hands,  gave  vent  to  a  yell  or  shriek — a  sort  of  a  loud  chatter — boxed  the  ears 
of  the  judge,  and  disturbed  the  game  generally ;  at  the  same  time  he  trem- 
bled violently.  Of  course,  the  judge  indignantly  inquired  for  the  cause  of 
the  attack,  and  the  victim  replied  by  indignantly  demanding  why  he,  the 
judge,  touched  him  on  the  back  of  the  head,  as  he  knew"  what  effect  it  would 
have." 

Lieutenant  Schuetze  had  a  servant,  a  Cossack,  who  suffered  from  this 
affection,  and  on  one  occasion  he  called  the  servant  by  name  when  he  was 
leaning  out  of  the  window.  Not  hearing  him,  his  master  touched  him  on 
the  shoulder,  and  he  at  once  began  to  chatter  and  was  on  the  point  of  jump- 
ing out  of  the  window. 

In  other  cases,  simply  pointing  the  finger  at  a  person  who  was  a  victim  of 
the  disease  would  cause  wild  excitement  and  gesticulatory  movements,  as 
well  as  imitation  of  anything  that  was  said,  the  sufferer  continually  begging 
to  be  let  alone.  Another  patient  would  imitate  anything  that  was  done 
before  her,  and  Lieutenant  Schuetze  was  told  that  in  such  cases  among  the 
natives  it  would  be  dangerous  to  draw  a  knife  across  your  throat  as  if  you 
were  cutting  it,  as  they  would  repeat  the  operation  on  themselves  in  a  serious 
manner.  In  all  of  the  instances  described  by  the  writer  as  soon  as  the  ex- 
citing cause  was  withdi-awn  the  subject  would,  after  an  interval  of  two  or 
three  minutes,  resume  his  ordinary  manner. 

Gilles  de  la  Tourette,  who  quotes  O'Brien's  observations,  described  nine 
cases  of  this  affection,  all  of  w^hich  began  in  early  life,  and  heredity  existed 
in  more  than  half  of  these. 

The  movements  which  occur  in  these  cases  may  begin  in  the  face  or  upper 

1  Loc.  cit. 


CHOREIFORM  AFFECTIONS.  263 

extremities,  and  soon  after  the  lower  extremities  are  affected.  The  move- 
ments are  sudden  and  are  not  continuous,  but  are  abrupt  and  shock-like, 
resembling  electric  chorea.  The  patient's  body  is  usually  bent  forward,  as  in 
jumping,  and  he  leaps  upward.  These  jumping  movements  occur  as  the 
result  of  a  command  to  jump,  or  from  some  sudden  excitement,  like  striking 
the  patient  on  the  shoulder  or  clapping  the  hands.  The  movements  gener- 
ally represent  an  exaggeration  of  natural  gestures,  such  as  raising  the  brow, 
elevating  the  shoulders,  or  making  a  movement  of  deference.  They  are  often 
so  violent  that  the  patient  is  brought  into  contact  with  hard  objects  near  him, 
and  he  frequently  injures  himself.  Voluntary  efforts  do  not  induce  the 
bizarre  movements.  The  patient  can  control  his  muscular  movements  so  as 
to  feed  himself  properly  or  to  use  his  hands  and  limbs  in  various  ways.  In 
this  respect  the  malady  differs  markedly  from  Huntington's  chorea  or  chronic 
non-hereditary  chorea. 

Prognosis.  The  prognosis  is  unfavorable.  Most  of  the  cases  described 
lasted  throughout  life.  In  a  few  the  attack  is  temporary,  and  these  cases 
are  probably  hysterical ;  but  in  other  cases,  especially  those  in  which  there  is 
a  hereditary  taint,  the  affection  lasts  throughout  life,  although  there  may  be 
remissions  of  months  or  years.  Gray'  says  that  he  has  seen  several  cases  in 
which  there  was  absolute  intermission  of  the  symptoms  for  many  months,  so 
that  he  was  justified  in  believing  that  a  cure  had  been  effected. 

Diagnosis.  The  affection  resembles  chronic  adult  chorea  and  electric 
chorea,  but  differs  from  these  affections  in  the  imitative  tendencies,  and  in 
the  fact  that  the  movements  are  produced  by  a  shock  or  a  mandate  from 
another  person.  In  the  treatment  of  these  cases  bromide  of  potassium, 
arsenic,  and  anti-spasmodics  have  been  recommended. 


POST-PARALYTIC  OR  POST-HBMIPLBGIC  CHOREA.     (Post- 
hemiplegic Mobile  Spasm.     Go'wers.) 

Many  years  ago  Weir  Mitchell  called  attention  to  certain  choreiform 
movements  which  sometimes  occurred  in  partially  paralyzed  limbs  after  an 
attack  of  hemiplegia.  Charcot  shortly  afterward  recognized  the  affection, 
and  detailed  the  symptoms  with  his  usual  clearness.  This  condition  never 
occurs  in  completely  paralyzed  limbs,  but  commonly  makes  its  appearance  at 
the  period  when  the  paralysis  is  disajDpearing.  The  choreiform  movements 
become  more  established  as  power  returns  to  the  limbs,  or  they  may  appear 
suddenly.  The  movements  are  most  marked  in  the  fingers  and  toes,  and 
become  less  as  the  shoulder  and  hip-joints  are  reached. 

Clonic  choreiform  movements  occur  much  more  frequently  in  the  arm  than 
in  the  leg,  and  when  they  exist  in  both  the  former  is  always  most  affected. 
The  muscles  of  the  face  are  occasionally  affected  by  the  mobile  spasms,  caus- 
ing distortion  of  the  features  on  the  paralyzed  side  when  the  patient  laughs 
or  cries.  The  movements  in  the  upper  extremities  most  commonly  met  with 
are  inco-ordinate  gyrations  of  the  fingers  and  thumbs,  flexion  and  extension 
of  the  wrist  and  elbow,  and  shrugging  and  other  movements  of  the  shoulder- 
joints.  The  interossei  are  particularly  affected,  and,  consequently,  the  move- 
ments of  the  hand  most  generally  observed  consist  of  varying  degrees  of 
flexion  and  extension  at  the  metacarpo-phalangeal  articulations.  The  move- 
ments are  disorderly  and  irregular,  and  may  or  may  not  continue  during 
rest.  They  invariably  cease  during  sleep.  The  movements  are  more  athetoid 
than  choreic  in  character,  but  are  quicker  than  the  movements  of  athetosis, 


1  Nervous  and  Mental  Diseases,  page  418. 


264  NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  almost  always  occur  principally  on  voluntary  eiFort.  Associated  with 
the  choreiform  movements  is  always  a  considerable  degree  of  inco-ordination 
in  the  manner  in  which  muscular  acts  are  performed.  Post-paralytic  chorea 
may  be  met  with  at  any  age,  but  is  more  frequent  in  the  hemiplegias  of  chil- 
dren than  in  those  of  adults.     (Fig.  62.) 


Post-hemiplegic  chorea.    (Spastic  diplegia.)    Philadelphia  Hospital. 

Pre-hemiplegic  chorea  is  occasionally  met  with  preceding  an  attack  of 
hemiplegia.  The  patient  complains  of  numbness  and  feebleness  of  the  ex- 
tremities of  one  side,  and  the  arm  of  the  affected  side  is  attacked  with  irregu- 
lar choreic  movements.  These  symptoms  may  continue  for  some  days,  and 
possibly  months,  as  in  the  case  of  senile  chorea  above  quoted,  when  complete 
hemiplegia,  which  is  frequently  associated  with  hemiangesthesia,  is  established. 


ATHETOSIS. 

This  disease  was  first  described  by  W.  A.  Hammond,'  and  named  by  him 
athetosis — 'Aferof ,  ivithout  fixed  position.  Considerable  confusion  exists  as  to 
the  character  of  the  affection,  from  the  fact  that  it  has  been  frequently  con- 
founded with  post-hemiplegic  chorea,  which  it  closely  resembles.  It  is  an 
open  question  as  to  whether  it  is  best  to  regard  athetosis  as  a  separate  disease, 
for  the  symptoms  which  characterize  it  belong  to  many  lesions  of  the  brain, 
more  especially  those  of  the  motor  tract  and  caudate  nucleus.  As  originally 
described  by  Hammond,  athetosis  was  not  associated  with  or  preceded  by 
paralysis  of  the  affected  parts ;  indeed,  in  the  first  cases  described  by  him,  he 
expressly  notes  the  fact  that  the  muscular  power  of  the  members  affected 
with  athetoid  movements  is  not  at  all  impaired.  In  the  great  majority  of 
cases,  however,  there  has  been  hemiplegia  preceding  the  athetoid  movements  ; 
and  it  is,  therefore,  best  to  divide  the  affection  into  a  primary  and  secondary 
form. 

Primary  athetosis  occurs  without  premonitory  symptoms.  In  many  in- 
stances no,  direct  cause  can  be  traced.     In  Hammond's  classical  case  the 

1  Diseases  of  the  Nervous  System,  1871 . 


CHOREIFORM  AFFECTIONS. 


265 


patient  was  strongly  addicted  to  alcohol ;  in  other  cases  intemperance,  expos- 
ure to  severe  cold,  injuries,  and  fright  have  been  assigned  as  causes. 

In  the  secondary  form  hemiplegia  or  diplegia  precedes  the  irregular  move- 
ments, and  there  is  always  some  gross  cerebral  lesion,  such  as  polioencephalitis 
(Striimpell),  porencephalus,  softening,  or  other  lesion. 


Fig.  63. 


Examples  of  the  position  of  the  fingers  in  the  movements  of  athetosis.    (StrI^mpell.) 

Symptoms.  The  movements  of  athetosis  are  usually  confined  to  the  fingers 
and  toes,  but  in  most  cases,  especially  in  secondary  athetosis,  the  whole  arm 
is  involved.  The  leg  is  seldom  affected,  but  the  feet  and  toes  are  occasionally 
the  seat  of  the  athetoid  movements.  The  peculiar  feature  of  the  movements 
is  that  they  take  place  while  the  part  is  at  rest ;  that  they  are  contnuious. 


266  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  that  they  are  slow,  differing  in  all  these  particulars  from  post-hemijDlegic 
chorea.  There  is  every  variety  and  degree  of  movement  met  with.  They 
begin  usually  in  the  fingers  and  hand,  and,  as  the  interossei  are  most  fre- 
quently involved,  the  movements  consist  of  flexion  of  the  metacarpo-phalan- 
geal  articulations  and  extension  of  the  fingers,  with  abduction  and  adduction. 
The  spasm  involves  first  one  finger,  then  another,  and  sometimes  all  are  in 
spasm  at  the  same  time.  A  favorite  position  of  the  hand  is  that  in  which  all 
of  the  fingers  are  widely  separated  and  the  thumb  is  in  extreme  extension  ; 
or  the  forefinger  alone  may  be  extended  and  the  others  flexed.  The  accom- 
panying drawings  from  Striimpell  show  more  graphically  than  I  can  describe 
them  some  of  the  various  positions  in  which  the  fingers  are  placed  (Fig.  63). 
The  whole  arm  may  be  contorted  into  many  bizarre  postures.  Often  the 
upper  arm  is  abducted,  while  the  elbow  is  flexed ;  occasionally  the  forearm 
is  extended,  and  is  in  a  position  of  extreme  supination.  In  a  young  woman 
recently  under  my  care  the  arm  was  rotated,  the  forearm  pronated,  and  the 
whole  arm  carried  behind  the  back,  with  the  palm  turned  outward,  this 
movement  being  followed  by  flexion  of  the  forearm  and  supination  of  the 
wrist.  In  this  case  the  head  of  the  radius  was  almost  dislocated  by  the  ex- 
treme supination,  and  the  patient  usually  sat  with  the  hand  of  the  afiected 
side  under  the  thigh,  so  as  to  control  the  movements. 

Fig.  64. 


Athetoid  movements  in  a  case  of  spastic  diplegia.    Pliiladelphiia  Hospital. 

Subluxation  of  the  distal  phalangeal  joints  often  occur  as  the  result  of 
long-continued  overaction  of  the  interossei,  so  that  the  head  of  the  second 
phalanx  is  very  prominent  on  the  palmar  surface  of  the  finger.  The  con- 
tinual muscular  activity  causes  hypertrophy  of  the  limb.  In  the  patient 
just  referred  to,  the  left  arm,  which  was  the  one  affected,  was  much  larger 
than  the  other,  and  the  muscles  stood  out  like  a  blacksmith's.  Fatigue  in 
the  affected  side  is  never  complained  of. 

In  athetosis  the  movements  are  always  involuntary,  slow,  wavy,  and  exten- 
sive, and  are  generallj^  rhythmical,  occurring  often  in  regular  order.  The 
movements  proceed  at  all  times ;  but  they  increase  when  the  patient  is  aware 
of  being  observed,  or  when  he  attempts  a  voluntary  movement.  They  are 
diminished  when  the  patient's  attention  is  distracted.  They  can  occasionally 
be  controlled  by  strong  will  power,  but  even  then  for  only  a  short  time.  In 
one  of  Hammond's  cases  violent  compression  of  the  wrist  controlled  the 
movements.     As  a  rule,  the  movements  do  not  cease  during  sleep. 

Bilateral  athetosis  is  common,  and  is  almost  invariably  the  sequel  of  spastic 


CHOREIFORM  AFFECTIONS.  267 

diplegia.  The  illustration  shows  the  typical  athetoid  movements  in  a  case  of 
spastic  diplegia  (Fig.  64).  The  patient  was  nineteen  years  of  age  at  the 
time  the  photograph  was  taken,  and  the  trouble  was  first  noticed  when  she 
was  five  years  of  age. 

The  muscles  of  the  fiice  are  occasionally  affected  with  the  athetoid  spasm, 
and  the  tongue  is  at  times  involved  to  such  an  extent  as  to  make  speech  in- 
articulate. Athetosis  has  been  met  with  in  cases  of  locomotor  ataxia,  and  in 
these  instances  it  is  always  bilateral. 

Diagnosis.  x4.thetosis  is  to  be  distinguished  from  chorea  and  post-hemiplegic 
spasm  by  the  character  of  the  movements  and  the  parts  involved.  In  chorea 
the  movements  are  quick,  jerky,  iri'egular  and  misdirected ;  in  athetosis  the 
movements  are  slow,  rhythmical  and  consecutive.  In  the  majority  of  cases  of 
athetosis,  paralysis  or  imbecility  exists.  As  already  remarked,  athetosis  and 
post-hemiplegic  chorea  are  confounded  by  many  observers.  The  main  points 
of  distinction  are  that  in  post-paralytic  chorea  the  movements  occur  on 
voluntary  effort,  are  in  co-ordinate  and  spastic,  and  are  quicker  than  those  of 
athetosis.  In  post-paralytic  chorea  they  usually  cease  during  sleep.  The 
latter  is  usually  accompanied  by  hemiansesthesia.  Gowers  says  that  this 
exists  in  fifty  per  cent,  of  the  cases. 

Pathology.  The  lesions  jDroducing  athetosis  depend  on  the  nature  of  the 
case,  and  vary  in  extent  and  location  in  different  cases.  In  Hammond's 
original  case,  in  which  it  will  be  recalled  that  there  was  no  paralysis,  it  was 
found  after  death  that  there  was  a  degeneration  consisting  of  fibrous  connec- 
tive tissue,  which  extended  from  the  posterior  third  of  the  thalamus  and 
posterior  third  of  the  internal  capsule  to  the  lenticular  nucleus.^  In  this 
case  the  motor  tract  was  not  imjDlicated.  In  many  cases  it  will  be  found  that 
the  thalamus  and  posterior  portion  of  the  internal  capsule  are  involved ;  but 
in  other  cases,  in  which  there  is  an  associated  paralysis,  the  lesions  must  be 
disseminated,  and  include  the  cortex  and  motor  tract.  Cases  have  been 
recorded  in  which  absolutely  no  lesion  was  visible  in  the  brain  to  the  naked 
eye. 

In  twelve  autopsies  collected  by  Kuhler  and  Pick  the  parts  mainly  in- 
volved were  the  thalamus,  internal  capsule,  and  lenticular  nucleus.  In  one 
of  Oulmont's  cases'  an  area  of  softening  Avas  found  in  the  lenticular  nucleus 
and  corpus  striatum  of  one  side.  Lauenstein  reported  a  case  of  primary 
athetosis  in  which  the  movements  were  confined  to  the  fingers  of  the  left 
hand,  the  athetoid  movements  having  been  observed  but  eleven  days  before 
death.  At  the  autopsy  a  fresh  lesion  was  discovered  at  the  anterior  end  of 
the  right  thalamus.  In  a  patient  of  my  own,  in  which  there  was  a  tumor  of 
the  left  thalamus,^  in  the  early  part  of  the  case  the  movements  of  the  right 
hand  were  inco-ordinate,  and  later  paresis  developed.  At  the  autopsy  the 
left  thalamus  was  found  to  be  occupied  by  a  tumor  as  large  as  a  hen's  egg, 
which  involved  the  corpus  striatum  and  internal  capsule  to  a  slight  extent, 
but  the  caudate  nucleus  was  not  affected.  It  seems,  therefore,  that  athetoid 
movements  are  liable  to  occur  as  the  result  of  an  irritative  process  in  any 
part  of  the  pyramidal  tract  in  its  course  where  it  ascends  between  the  thal- 
amus and  internal  capsule. 

Athetosis  is  more  likely  to  follow  hemiplegia  from  cerebral  softening  due 
to  the  occlusion  of  a  vessel  than  to  apoplexy,  and  it  is  also  much  more  fre- 
quent after  infantile  hemiplegias.  Gowers*  remarks  that  the  significance  of 
these  facts  are :  First,  that  in  softening  slight  damage  to  cei'ebral  tissue  is 

1  G.  M.  Hammond  :  Trans.  Amer.  Neurological  Association,  1891. 

-  Etudes  Cliniques  sur  I'Athetose.    Paris,  1878. 

3  University  Medical  Magazine,  October,  1893. 

*  Diseases  of  the  Nervous  System,  2d  edition,  p.  88. 


268  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

more  extensive  than  actual  destruction  of  tissue,  and  that  the  spontaneous 
spasms  are  probably  due  to  overaction  of  the  gray  matter  which  is  in  a  state 
of  altered  function  and  nutrition.  The  significance  of  the  second  fact, 
namely,  the  frequency  with  which  athetoid  movements  follow  infantile  hemi- 
plegia, is  the  greater  facility  with  which  growing  and  developing  nerve  cells 
recover,  and  their  greater  susceptibility  to  disorder  of  nutrition  when  their 
develojDment  is  interfered  with. 

Prognosis  The  outlook  in  all  cases  of  athetosis  and  post-paralytic  chorea 
is  unfavorable.  .  Occasionally  a  case  of  athetosis  is  met  with  which  is  func- 
tional, and  this  may  recover. 

Treatment  There  is  pi-actically  no  remedy  for  the  conditions  associated 
with  athetosis.  The  use  of  galvanism  and  massage  has  proved  of  some  ben- 
efit in  certain  cases,  but  no  permanent  relief  is  aflforded  by  these  or  other 
remedies.  In  functional  cases  arsenic  has  been  found  of  value,  and  in  other 
cases  there  has  been  undoubted  benefit  from  the  use  of  alteratives,  such  as 
iodide  of  potassium  and  mercurials. 


MYOCLONUS    MULTIPLEX. 

Synonyms.     Paramyoclonus  Multiplex  ;  Convulsive  Tremor  ;  Myospasm. 

This  rare  disease  is  closely  related  to  convulsive  spasms  and  to  chorea.  It 
is  characterized  hj  quick  clonic  spasmodic  contractions  of  the  muscles  of  the 
trunk  and  extremities.  The  spasms  are  bilateral,  involving  the  symmetrical 
muscles,  and  occur  only  at  intervals.  The  affection  was  originally  pointed 
out  by  Friedreich,'  and  since  his  paper  several  other  writers  have  recorded 
cases. 

Many  different  forms  of  spasm  have  been  described  under  the  name  of 
myoclonus  multiplex,  but  a  large  number  of  these  are  instances  of  hysterical 
chorea  or  saltatoric  spasm.  In  the  typical  form  of  the  disease  the  patient  is 
rather  abruptly  attacked,  the  muscles  of  the  trunk  and  hips  are  seized  with 
violent  and  rapid  contractions,  which  may  throw  him  down  if  standing,  or 
hurl  him  from  a  chair  or  bed  in  which  he  may  be  sitting.  The  muscles 
most  involved  are  those  of  the  trunk  and  upper  part  of  the  limbs,  especially 
the  deltoids,  biceps,  triceps,  supinators,  quadriceps  extensor  femoris,  the 
flexors  of  the  leg,  and  the  calf  muscles.  Sometimes  the  facial  and  neck 
muscles  are  affected,  but  those  of  the  feet  and  hands  are  seldom  implicated. 
The  diaphragm  is  sometimes  affected,  producing  hiccough,  or  a  violent  expi- 
ratory sound  may  be  made,  in  the  production  of  which  the  larynx  also  takes 
part,  resembling  that  made  by  a  man  when  cutting  wood.  The  spasmodic 
muscular  contractions  are  bilateral,  differing  in  this  respect  from  ordinary 
chorea.  They  begin  in  most  instances  in  the  shoulders  and  arms,  and  extend 
to  the  trunk.  The  tendon  and  skin  reflexes  are  increased,  but  there  are  no 
disturbances  of  sensation,  either  anaesthesia  or  hypersesthesia.  These  is  no 
mental  disorder,  but  the  subjects  of  this  affection  are  usually  neurasthenic, 
and  may  be  hysterical.  The  causes  which  have  been  met  with  are  fright, 
shocks,  overmuscular  exertion,  and  mental  strain.  The  muscular  spasms 
occur  at  intervals,  sometimes  of  only  a  few  minutes,  and  sometimes  an  entire 
week  will  elapse  between  paroxysms.  The  muscular  movements  ai'e  violent 
and  rapid,  varying  from  5  to  180  per  minute,  but  are  commonly  about  50 
per  minute.  In  a  case  related  by  Starr''  the  contractions  were  counted  by 
him,  and  reached  90  j)er  minute.     In  this  patient  the  disorder  resulted  from 

1  Virchow's  Archiv.,  Bd.  Ixxxvi.  p.  421. 

2  Familiar  Forms  of  Nervous  Diseases,  p.  244. 


CHOREIFORM  AFFECTIONS.  269 

a  strain  in  lifting  a  heavy  box,  and  the  muscles  first  affected  were  those  of 
the  abdomen  and  back.  There  were  short  and  quick  alternate  contractions 
of  the  dorsal  muscles  and  recti  abdominis.  As  these  movements  became 
more  violent  the  body  and  head  were  thrown  backward  and  forward  until 
the  patient  became  dizzy,  and  he  would  almost  be  pitched  out  of  the  chair 
in  which  he  was  sitting. 

I  have  seen  one  case  of  this  affection,  who  was  a  patient  of  my  colleague, 
Dr.  James  Hendry  Lloyd,  in  the  Philadelphia  Hospital.  In  this  case  the 
muscles  of  the  trunk  and  upper  part  of  the  limbs  were  affected  with  violent 
clonic  spasms  which  were  almost  continuous.  During  the  attacks  the  patient 
would  be  almost  thrown  from  his  bed.  He  was  bathed  in  perspiration,  and 
sharp  expiratory  sounds  were  made  by  the  sj^asms  of  the  diaphragm.  His 
speech  was  interfered  with,  and  the  words  were  uttered  in  a  short  and  explo- 
sive manner.  The  patient's  mental  condition  was  not  markedly  impaired. 
The  patient  died  from  exhaustion  after  five  or  six  years.  At  the  autopsy  no 
naked-eye  lesions  were  discovered  in  the  brain  or  cord. 

In  the  majority  of  cases  tapping  the  tendons  or  irritating  the  skin  will 
bring  on  an  attack.  In  Lloyd's  case  an  attack  was  brought  on  when  he  tried 
to  speak,  and  any  emotion  exaggerated  the  movements  excessively.  In  some 
cases  voluntary  effort  has  arrested  the  spasm. 

This  affection  has  been  recorded  by  many  as  merely  a  form  of  chorea,  and 
others  regard  it  as  hysterical.  Gowers  thinks  that  it  is  most  closely  allied 
to  senile  chorea.  It  differs  from  this  disease,  however,  in  that  it  is  usually 
bilateral,  and  the  movements  are  far  more  violent  and  are  paroxysmal.  Age 
has  little  to  do  with  the  development  of  the  malady ;  but  it  is  far  more  fre- 
quent in  males  than  in  females.  But  two  cases  in  females  have  been 
recorded,  and  this  is  an  additional  fact  against  the  hysterical  origin  of  the 
disease.  It  is  a  variety  of  chorea,  functional  in  character,  and  is  more  nearly 
allied  to  chronic  adult  chorea  than  any  other  form. 

The  pathology  is  unknown.  In  a  case  which  died  of  phthisis  and  was 
examined  by  Professor  Schultze^  no  lesion  was  revealed;  and  in  Lloyd's 
case,  which  I  have  just  quoted,  the  result  of  the  autopsy  was  negative. 

Prognosis.  The  prognosis  is  usually  favorable.  In  many  cases  the  disease 
lasts  but  a  few  months,  but  in  some  instances  it  is  fatal. 

Treatment.  Galvanism  and  static  electricit}^  have  been  found  most  useful 
in  the  treatment  of  this  affection  ;  the  latter  has  been  especially  recommended. 
When  galvanism  is  used  strong  currents  to  the  spine  should  be  ajDplied,  and 
the  anode  should  be  placed  over  painful  points  on  the  spine,  should  they 
exist.  Antispasmodics  and  nervines  are  occasionally  useful,  but  attention  to 
the  general  health  and  the  administration  of  iron  and  arsenic  is  always 
likely  to  prove  useful.  In  severe  cases  it  may  be  necessary  to  administer 
morphine  hypodermically. 

1  Starr  :  Op.  cit. 


CHAPTER   VIII. 

LOCAL  SPASMS.  OCCUPATIO:^  SPASMS. 

By  C.  W.  burr,  M.D. 

FACIAL  SPASM.     MIMIC   SPASM. 

Etiology.  In  many  cases  no  cause  can  be  traced.  It  is  mainly  met  with 
in  adults,  and  is  far  more  frequent  in  women  than  in  men.  Anaemia,  general 
ill-health,  grief,  and  worry  predispose  to  it.  It  is  alleged  to  arise  sometimes 
from  peripheral  irritation  acting  reflexly ;  for  example,  a  decayed  and  pain- 
ful tooth.  In  many  cases,  however,  removal  of  the  supposed  reflex  cause 
will  not  cure  the  afiection.  It  occasionally  is  associated  with  pregnancy. 
Cold  is  sometimes  causative.  It  may  result  from  the  extension  of  the  spasm 
in  torticollis.  Besides  these  cases  that  we  are  compelled  to  call  idiopathic,  it 
may  be  caused  by  organic  disease  of  the  nervous  system.  The  lesion  then  is 
situated  in  the  motor  cortex,  or  in  or  near  the  nucleus  of  origin  of  the  nerve. 
Thus  Berkeley  reports  a  case  of  cortical  tumor.  Moos  a  tumor  pressing  on  the 
nerve  at  the  base  of  the  brain,  and  Gowers  an  aneurism  of  the  vertebral 
artery. 

Symptoms.  The  onset  of  the  disease  is  usually  gradual,  and  at  first  only 
one  or  two  muscles — the  orbicularis  palpebrarum  most  frequently  —  are 
affected.  Thence  the  spasm  spreads  until  the  patient  has  lost  all  control 
of  the  muscles  of  one  side  of  the  face.  Xot  infrequently  there  is  slight 
twitching  on  the  opposite  side,  but  serious  involvement  of  both  sides  is  rare. 
The  spasm  is  both  clonic  and  tonic — either  frequent  momentary  contractions 
like  those  from  an  electric  shock,  or  irregularly  recurring  single  contractions. 
More  frequently  there  are  short  paroxysms  of  combined  tonic  and  clonic 
spasm.  Motion  and  emotion,  speaking,  eating,  or  excitement  of  any  kind 
wiU  often  precipitate  an  attack.  The  paroxysms  vary  in  frequency  from 
two  or  three  in  a  day  up  to  thirty  or  forty  in  an  hour.  The  muscles  most 
affected  are  the  orbicularis  palpebrarum,  the  levator  superioris  alaeque  nasi, 
the  zvgomatici,  and  the  corrugator  supercilii.  The  fr-ontalis  and  the  platysma 
are  rarely,  and  the  muscles  of  the  ear  very  rarely  attacked.  The  stylohyoid, 
the  digastric,  and  the  velum  palati  are  almost  never  affected.  The  muscles 
of  mastication  are,  of  course,  affected  only  if  the  motor  portion  of  the  tri- 
geminus is  involved  by  the  disease.  The  spasm  decreases  greatly  or  ceases 
during  sleep.  In  true  facial  spasm  there  is  no  pain  save  perhaps  the  fatigue 
ache  of  muscular  overaction.  Usually  there  is  no  paralysis,  but  it  must  be 
remembered  that  spasm  may  develop  in  a  case  of  long-standing  Bell's  palsy. 
There  may  be  an  increase  in  the  electrical  irritability  of  the  nerve,  but  no 
other  change.  Gowers  notes  the  loss  of  the  sense  of  taste  on  the  fi'ont  of  the 
tongue,  and  in  one  of  his  cases  of  bilateral  spasm  there  was  a  temporary 
increase,  in  the  secretion  of  the  saliva.  Occasionally  the  spasm  extends  far 
beyond  the  region  of  the  facial  nerve,  involving  successively  the_  neck,  shoul- 
der, and  arm  muscles.     There  may  or  may  not  be  tender  points  in  the  course 


LOCAL  SPASMS.     OCCUPATION  SPASMS.  271 

of  the  trifacial  nerve,  and  pressure  on  certain  points  of  the  face  may  cause 
the  spasm  to  cease.  In  one  case,  for  example,  so  long  as  eye-glasses  pressing 
strongly  against  the  nose  were  worn,  the  spasm,  never  very  severe,  remained 
absent. 

We  know  nothing  of  the  morbid  anatomy  and  pathology  of  the  disease 
beyond  the  few  facts  given  under  etiology — namely,  that  a  chronic  irritative 
lesion  in  the  facial  cortical  centre,  in  the  nucleus,  in  the  pons,  or  of  the  nerve 
itself,  may  cause  the  disease. 

Diagnosis  is  usually  easy.  The  most  important  point  is  the  differentiation 
from  the  secondary  spasm  occurring  after  facial  paralysis.  In  this  condition 
there  is  always  a  persistent  contracture  and  weakness  along  with  the  occa- 
sional spasm.  If,  in  chorea,  the  face  is  much  involved  and  the  extremities 
but  little,  mistakes  may  arise.  In  habit  chorea  the  character  of  the  move- 
ments is  different.  The  diagnosis  of  the  seat  of  lesion  is  difficult.  The 
more  limited  the  spasm  and  the  more  confined  to  muscles  accustomed  physi- 
ologically to  act  together,  the  greater  the  probability  that  the  lesion  is  cortical. 
Increasing  weakness  and  the  addition  of  other  symptoms  point  to  a  progressive 
organic  cause. 

Prognosis.  The  duration  of  the  disease  is  long,  often  till  death.  Occa- 
sional remissions  and  intermissions  are  not  rare.  In  cases  that  have  lasted 
more  than  a  few  months  the  chance  of  complete  and  permanent  recovery  is 
slight.  The  danger  to  life  is  only  of  importance  when  the  cause  is  organic 
and  progressive,  not  from  the  spasm  itself. 

Treatment.  In  recent  cases  hot  apj)lications  to  the  face  and  the  produc- 
tion of  free  diaphorasis  should  be  employed.  In  chronic  cases  many  medi- 
cines have  been  used,  none  of  which  are  of  any  great  value  or  to  be  greatly 
depended  upon  in  any  given  case.  The  general  health  should  be  looked 
after,  and  all  possible  sources  of  peripheral  irritation  removed.  Sedatives, 
for  example,  gelsemium  and  conium,  are  much  used,  and  sometimes  in  ascend- 
ing doses  do  good.  Morphine  alone,  or  in  combination  with  atropine,  given 
hypodermatically,  often  stops  the  spasm  entirely,  but  the  very  grave  risk  run 
of  establishing  the  morphine  habit  must  never  be  lost  sight  of.  Faradism  is 
always  harmful.  A  weak,  uninterrupted  galvanic  current,  the  anode  placed 
in  front  of  the  ear  and  the  cathode  on  the  muscles,  exerts  sometimes  a  good 
influence.  Mitchell  recommends  freezing  the  cheek  daily  with  a  rhigolene 
spray.  Operative  measures  usually  cause  the  spasm  to  cease  for  a  time,  only 
to  return  after  a  longer  or  shorter  time.  In  a  collection  of  twenty  cases 
made  by  Keen,  in  only  two  did  the  spasm  remain  absent  more  than  six 
months.  For  details  of  ojDeration  see  chapter  on  Surgery.  On  the  whole, 
treatment  is  thoroughly  unsatisfactory. 

Blepharospasm  is  a  tonic  or  clonic  paroxysmal  spasm  of  the  orbicularis 
palpebrarum,  completely  closing  the  lids.  It  is  not  infrequent  in  23ainfol 
diseases  of  the  eye,  and  may  be  due  to  refractive  errors.  The  clonic  form  is 
called  nictitating  spasm,  and  is  frequent  in  habit  chorea  and  hysteria.  A 
paroxysm  of  tonic  spasm  may  be  caused  by  voluntary  firm  closure  of  the 
eyelids,  eye  strain,  or  a  bright  light.  In  children  a  curious  condition  occurs, 
first  noted  by  von  Graefe,  in  which  for  weeks  at  a  time  there  is  a  persistent 
lid  cramj),  and  when  the  eyes  are  finally  opened  there  may  be  temporary 
blindness,  without  visible  lesion  or  permanent  blindness,  with  gross  ophthal- 
moscopic changes.  In  the  common  form  the  spasm  can  often  be  relieved  by 
pressure  over  certain  points,  especially  the  supraorbital  foramen.  The  posi- 
tion of  the  points  is  variable,  and  they  should  be  sought  for  throughout  the 
distribution  of  the  trifacial  nerve. 


272  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


MASTICATORY  SPASM.     (Romberg.) 

Masticator}^  spasm  is  an  affection  of  the  muscles  supplied  by  the  fifth  nerve, 
the  temporals,  masseters,  and  pterygoids.  It  may  be  tonic  (trismus)  or  clonic. 
In  the  former  the  teeth  are  firmly  pressed  against  each  other,  so  that  the  jaws 
cannot  be  separated,  and  the  muscles  of  mastication  are  strongly  contracted  and 
as  hard  as  "wood.  Attempts  at  forcible  movement  of  the  lower  jaw  cause  pain, 
which  may  also  result  from  the  intensity  of  the  spasm  itself.  The  condition  is 
almost  alwaj's  bilateral,  but  may  be  confined  to  one  side.  It  is  the  beginning 
symj)tom  in  tetanus.  As  a  manifestation  of  hysteria  it  is  quite  common. 
It  may  also  be  caused  by  peripheral  irritation  from  injury  as  shown  by  Rom- 
berg, and  from  irritation  of  the  fifth  nerve  caused  by  decayed  teeth.  Cases 
due  to  organic  disease  have  been  reported.  Marot  and  Wernicke  have  seen 
it  occur  in  tumor  of  the  pons,  and  Gowers  had  a  case  which  he  thinks  was 
due  to  disease  of  the  basilar  artery.  It  may  occur  during  an  attack  of  facial 
neuralgia.  Very  rarely  only  single  muscles  are  affected,  as  in  a  case  of 
Leube's,  in  which  the  jaw  was  held  laterally  displaced  for  several  days — 
probably  on  account  of  spasm  of  the  pterygoids  on  one  side. 

The  most  common  example  of  clonic  spasm  is  that  which  occurs  during  a 
chill.  It  is  a  not  infrequent  beginning  symptom  of  a  general  convulsion. 
Hirt  speaks  of  an  old  gentleman  who  for  several  hours  daily  would  go 
through  the  movements  of  cheAving,  sometimes  even  unintentionally  biting 
off  the  end  of  his  cigar.  Romberg  relates  the  case  of  an  old  lady  whose 
teeth  chattered  constantly,  ceasing  only  during  sleep  and  mastication.  In 
the  later  stages  of  paralysis  agitans  tremor  of  the  lower  jaw  may  be  suflEi- 
ciently  extreme  to  be  called  spasm. 

In  another  form  of  the  condition  there  are  single  and  sudden  contractions 
of  the  muscles,  severe  enough,  it  may  be,  to  bite  the  tongue  or  cheek.  It  is 
not  infrequent  in  hysteria,  and  may  occur  in  anyone  with  an  enfeebled 
nervous  constitution. 

The  diagnosis  of  masticatory  spasm  is  easy.  The  only  condition  with 
which  it  can  be  confounded  is  anchylosis  of  the  jaw.  The  history  of  the  case, 
and  the  fact  that  spasm  relaxes  under  ether  are  sufiicient  to  differentiate  it. 

The  prognosis  is  good,  except  in  the  rare  cases  in  which  it  is  due  to  organic 
disease. 

NODDING  SPASM. 

Not  very  rarely  in  improperly  fed  and  rickety  children  there  occurs  a  con- 
dition of  clonic  spasm  of  the  sterno-cleido  mastoids  and  adjacent  muscles, 
causing  nodding  and  rotatory  movements  of  the  head.  Nystagmus,  and 
more  rarely  strabismus,  may  be  present.  The  condition  in  older  children 
may  be  merely  a  trick,  a  form  of  habit  spasm.  See  p.  258.  If,  as  sometimes 
happens,  instead  of  there  being  constant  movements  there  are  occasionally 
one  or  two  movements,  accompanied  by  momentary  unconsciousness,  we  have 
to  do  with  a  much  more  serious  matter — namely,  an  attack  of  petit  mal.  See 
Chapter  XI. 

SPASMODIC  'SATRY-NECK  (Spinal  Accessory  Spasm  ;    Tic 
Rotatoire.     Nickkrampf). 

Under  this  head  are  included  all  types  of  spasm  occurring  in  the  muscles 
of  the  neck,  whether  they  be  supplied  by  the  spinal  accessory  nerve  or  not. 


LOCAL  SPAS2IS.     OCCUPATION  SPASMS.  273 

Etiology.  There  is  never,  or  almost  never,  direct  inheritance,  but  epilepsy 
and  other  functional  nervous  diseases  in  the  parents  create  a  predisposition 
toward  it.  It  is  a  disease  of  middle  adult  life,  though  rare  and  usually 
aberrant  cases  have  been  reported  in  infants.  It  is  slightly  more  frequent  in 
women  than  in  men.  Exposure  to  cold  seems  sometimes  to  be  an  exciting 
cause.  Not  infrequently  patients  give  a  history  of  exposure,  pain  and  stiff- 
ness in  the  neck,  and  later  spasm.  The  opinion  that  palsy  of  the  muscles  of 
the  opposite  side  produces  spasm  from  unopposed  muscular  action  has  little 


Spasmodic  torticollis. 

grounds  for  belief.  A  case  of  Annandale's,  due  apparently  to  excessive  use  of 
the  muscles,  ought  probably  to  be  placed  rather  among  the  occupation  spasms. 
It  was  a  young  girl,  a  weaver,  whose  work  required  her  to  turn  her  head  fre- 
quently from  side  to  side.  When  any  attempt  was  made  to  turn  the  head 
away  from  the  left  clonic  spasm  developed.  Simon  records  a  curious  case  in 
which  malarial  poison  seemed  to  be  the  cause.  The  attacks  were  periodic, 
and  were  cured  by  quinine. 

Symptoms.  In  rare  cases  the  onset  is  very  acute.  Ordinarily  it  is  slow, 
the  spasm  coming  on  only  occasionally,  affecting  but  one  or  a  few  muscles, 
and  occurring  only  under  excitement.  As  time  passes  the  spasm  becomes 
more  sevei'e,  involves  more  muscles  and  endures  longer,  until  finally  it  is 
constant.  Though  spasm  is  usually  the  first  symptom,  it  may  be  preceded 
by  dull,  aching,  or  even  sharp  pain  in  the  muscles  or  in  particular  points  in 
the  occiput,  behind  the  ear,  the  cervical  spine,  or  even  in  the  arm. 

The  spasm  may  be  tonic  or  clonic,  or,  as  is  most  frequent,  mixed.  The 
position  of  the  head  and  the  direction  of  movement  depend  upon  the  muscle 
or  muscles  affected.  Usually  several  are  involved.  If  only  one  muscle  be 
affected,  it  is  usually  the  sterno-cleido  mastoid.  In  Gowers's  series  of  thirty 
cases  it  happened  thus   in   seven.      In  this  condition   the  chin  is  turned 

18 


274  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

toward  the  opposite  side  and  tilted  up,  while  the  ear  is  brought  toward  the 
clavicle.  Tonic  spasm  fixes  the  head  in  this  position.  If  both  sterno-cleido- 
mastoids  be  affected  the  head  is  drawn  first  to  one  and  then  to  the  other  side, 
or,  if  the  spasm  be  tonic  and  equal  on  both  sides,  strongly  forward  and  bent 
uj^on  the  chest.  Spasm  of  the  trapezius  draws  the  head  back  and  toward 
the  diseased  side,  at  the  same  time  elevating  the  shoulder  and  bringing  the 
scapula  nearer  to  the  spine.  In  cases  of  posterior  bilateral  spasm  (retrocoUic 
spasm)  the  head  is  drawn  backward,  usually  moderately  only,  but  sometimes 
so  strongly  as  to  make  the  face  look  directly  upward. 

The  intensity  of  the  spasm  varies  from  time  to  time,  and  is  more  or  less 
increased  by  emotional  excitement.  It  can  often  be  controlled  by  the  will 
for  a  few  moments,  but  soon  the  imjDcrative  need  to  move  becomes  so  great 
it  cannot  be  resisted  and  the  sj^asm  returns — at  first  more  violently  than 
before. 

Not  very  infrequently,  as  time  passes,  the  spasm  extends  to  the  muscles  of 
the  arm.  In  such  cases  there  is  almost  always  involvement  of  both  sides  of 
the  neck.  In  one  case  of  Gowers's  only  the  deltoid  was  affected.  Again, 
the  spasm  may  begin  in  the  arm  and  extend  to  the  neck  muscles.  There 
may  also  be  involvement  of  the  face,  twitching  of  the  eyelids  or  of  the  mu-s- 
cles  of  mastication.  If  the  spasm  be  forcibly  stopped  it  may  appear  tem- 
porarily in  other  muscles. 

There  is  always  more  or  less  discomfort  and  often  dull,  aching  pain,  which, 
though  not  acute,  may  cause  great  suffering.  The  overacting  muscles  always 
hypertrophy.     Electrical  irritability  is  either  normal  or  increased. 

Morbid  Anatomy.  In  many  cases  nothing  has  been  found  post-mortem. 
In  some,  tumors  of  the  brain,  meningitis,  cervical  caries,  and  tumors  of  the 
medulla  have  been  present.  The  seat  of  lesion  must  be  either  in  the  cortex 
or  the  pons.  It  cannot  be  a  disease  of  the  muscles  themselves.  Further 
than  this  we  cannot  go. 

Prognosis  as  to  life  is  good,  unless  it  be  secondary  to  some  organic  disease. 
As  to  recovery  the  outlook  is  not  so  good.  AVhile  the  tendency  is  to  increase 
until  several  muscles  are  affected,  it  may  remain  slight  and  confined  to  one 
muscle.  There  may  be  intermissions,  even  without  treatment,  lasting  a  shorter 
or  a  longer  time.  Of  course,  the  more  severe  the  spasm,  and  the  greater  the 
number  of  muscles  affected,  the  less  the  chance  of  recovery. 

Treatment,  Morphine,  chloral,  cannabis  indica,  conium,  gelsemium,  the 
bromides  all  do  good  for  the  time  at  least,  though  their  discontinuance  is  apt 
to  be  followed  by  a  return  or  increase  of  the  spasm.  Morphine  is  the  most 
useful,  but  the  danger  of  forming  the  habit  is  in  no  disease  greater,  and  in 
few  so  great.  Gelsemium,  in  the  form  of  the  fluid  extract,  is  of  distinct  value 
in  many  cases.  Electricity,  though  much  lauded,  seldom  has  any  permanent 
influence.  Instruments  intended  to  forcibly  check  the  spasm  cannot  be  worn 
for  any  length  of  time.  Many  times  the  tendons  of  the  aflfected  muscles  have 
been  cut,  but  with  no  good  result.  Nor  could  good  result,  since  section  of  a 
tendon  cannot  prevent  the  contraction  of  a  muscle.  If  the  spasm  be  con- 
fined to  the  distribution  of  the  spinal  accessory  nerve,  stretching  it  will 
arrest  the  spasm  for  a  time  at  least,  and  cutting  it  cause  arrest  until  reunion 
takes  place,  which,  unfortunately,  is  too  apt  to  occur,  even  though  quite  a 
large  section  be  removed.  This  operation  is,  however,  sometimes  followed  by 
complete  recovery.  Keen  has  shown  that,  even  if  other  muscles  be  aflfected, 
the  spasm  in  them  is  greatty  reduced,  or  made  to  disappear,  by  subsequent 
section  of  the  posterior  branches  of  the  two  or  three  upper  cervical  nerves. 
(See  chapter  on  Surgery.) 


LOCAL  SPAS3LS.     OCCUPATION  SPAS3IS.  275 


CESOPHAGEAL    SPASM. 

Spasmodic  dysphagia  is  not  uncommon  in  hysteria ;  it  occasionally  follows 
dyspeptic  symptoms,  long-continued  vomiting,  or  irritation  from  hot  or  irri- 
tating foods.  It  is  alleged  to  sometimes  arise  reflexly  from  uterine  disorders. 
As  an  independent  affection  it  is  rarely  observed.  It  is  characterized  by 
periodic  or  permanent  painless  difficulty,  or  even  inability  in  swallowing. 
The  food,  after  reaching  a  certain  point,  is  regurgitated.  On  passing  a  pro- 
bang  it  is  stoj^ped  at  a  certain  point.  The  diagnosis  is  from  organic  stricture. 
Under  ether,  the  spasm  relaxes  and  the  sound  passes  without  difficulty.  Mis- 
takes may,  however,  be  made.  In  one  case  of  supposed  oesophageal  spasm 
known  to  the  writer,  on  post-mortem  examination  myelomalacia  of  the  gullet 
was  found,  and  death  Avas  due  to  rupture,  not,  however,  caused  by  examination. 


RECTAL    SPASM. 

Occasionally  in  association  with  vaginismus,  spasmodic  dysmenorrhoea,  or 
from  pressure  of  a  misplaced  uterus,  there  is  sj)asm  of  the  rectum  and 
sphincter,  producing  the  flattened  stools  and  other  symptoms  found  in 
organic  stricture. 

Urethral  sjxism  may  be  caused  by  irritant  substances  in  the  urine,  as,  for 
example,  cantharides,  by  strictly  surgical  causes,  or  it  may  be  hysterical.  It  is 
characterized  by  sudden  inability  to  micturate  or  a  great  lessening  in  the  size 
of  the  stream,  with  great  pain  and  straining,  often  accompanied  by  a  feeling 
of  weight  in  the  j^erineum. 

SPASM    OF    THE    TONGUE.     (Aphthongia.) 

Berger,  Dochmann,  Hirt,  and  others,  have  reported  a  very  curious  condi- 
tion in  which,  paroxysmally,  the  tongue  is  protruded  and  retracted  violently, 
rolled  roughly  around  in  the  mouth,  and  pressed  so  firmly  against  the  teeth 
that  it  may  be  injured.  In  some  instances  there  occur  short  rhythmical  twitch- 
ings  of  the  whole  organ.  In  a  case  of  Berger's  there  was  a  preceding  attack 
in  which  the  tongue  felt  thick  and  swollen.  In  Hirt's  case  the  muscles  of 
mastication  were  involved.  As  an  accompaniment  of  hysteria  the  condition 
is  not  rare. 

PHANTOM    TUMOR. 

Most  frequently  this  condition  is  found  in  the  abdomen,  and  is  probably 
produced  by  relaxation  of  the  rectus  and  spasmodic  contraction  of  the  dia- 
phragm. Ordinarily  there  is  local  bulging  of  the  abdominal  wall  near  the 
middle  line  and  below  the  umbilicus,  simulating  a  solid  mass.  There  may, 
however,  be  enlargement  of  the  entne  abdomen.  The  intestines,  inflated 
with  gas,  are  pushed  forward.  The  local  swelling  simulates  a  true  abdominal 
tumor  not  only  in  appearance  and  feeling,  but  also  by  sometimes  giving  a 
dull  note  on  percussion.  The  spasm,  and  with  it  the  tumor,  disappears  under 
ether.  The  condition  is  always  a  manifestation  of  hysteria.  Usually  there 
is  great  abdominal  pain.  In  some  cases  it  appears  and  disappears  several 
times  in  the  day,  and  may  be  brought  back  by  the  slightest  handling  of  the 
belly.  It  is  chiefly  of  importance  because  the  mimicry  of  organic  disease  has 
sometimes  been  so  close  as  to  lead  to  operation. 


276  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Much  more  rare  are  j^hantom  tumors  occurring  in  other  parts  of  the  body. 
AYeir  Mitchell  describes  a  hard,  dense  "  tumor  "  in  or  on  the  left  great  pectoral 
muscle  above  the  breast.  It  was  an  oval,  flattened  swelling  with  quite  abrupt 
edges.  Hard  rubbing  gradually  dispersed  it,  only  to  form  again  in  a  few 
hours.  In  another  case  there  was  a  similar  "  tumor "  situated  on  the  calf. 
There  is  probably  a  close  relation  between  certain  phantom  tumors  occur- 
ring over  muscular  masses  and  angio-neurotic  csdema. 


TRIGEMINAL    COUGH. 

Schadewald  described  under  this  title  an  aflection  characterized  by  par- 
oxysmal cough,  occurring  in  persons  whose  respiratory  apparatus  was  in 
normal  condition,  and  due  to  trigeminal  irritation  in  the  nose,  pharynx,  or 
external  auditory  meatus.  Schadewald  regards  it  as  a  reflex  neurosis.  Hack 
believes  that  the  erectile  tissue  of  the  nose  is  responsible. 


OCCUPATION    SPASMS. 

In  certain  occupations  requiring  the  constant  repetition  of  particular  move- 
ments, usually  complicated  and  fine,  but  sometimes  simple  and  coarse,  there 
often  arises  a  condition  in  which  the  person,  while  well  able  to  perform  all 
other  movements,  cannot  make  the  special  movements  required  by  his  work. 
This  condition  is  called  an  occupation  neurosis  or  occupation  spasm.  jST either 
designation  is  exactly  true,  for  the  first  assumes  that  there  is  no  organic 
causative  lesion,  while  probably  such  lesion  exists,  but  is  too  delicate  to  be 
shown  by  our  present  means  of  examination,  and  the  second  misleads,  since 
in  many  cases  there  is  as  much  paralysis  as  spasm.  The  most  important 
example  of  the  disease  and  one  that  may  be  taken  as  a  type  of  all  the  others 
is  -^Titers'  cramp.     Therefore  we  shall  study  it  first  and  most  carefully. 

Writers'  Cramp  (Scriveners'  palsy,  graphospasmus,  cheirospasmus, 
mogigraphia)  was  first  described  by  Sir  Charles  Bell  in  1830. 

Etiology.  The  disease  is  most  apt  to  occur  in  the  neurotic.  Hence,  though 
it  is  not,  properly  speaking,  ever  inherited,  the  tendency  to  it  may  be,  and  a 
pseudo-inheritance  result.  Thus  Gowers  speaks  of  a  lady  whose  father  also 
suffered,  and  Gallard  saw  it  occur  in  mother,  son,  and  daughter.  Vance  had 
a  patient  who,  on  going  to  visit  a  distant  brother,  was  surprised  to  find  him 
a  co-sufferer.  Its  occurrence  in  groups  is  in  some  cases  at  least  certainly  due 
to  unconscious  mimicry.  Everyone  who  has  much  writing  to  do  has  at  times 
twinges  of  pain  and  much  aching,  and  in  certain  dispositions  it  needs  but 
little  fire  to  make  a  great  smoke.  Indirect  inheritance  through  epileptic  or 
insane  parents  is  a  quite  strong  factor.  Prolonged  or  sudden  grief  and  sheer 
stress  of  life  is  the  greatest  predisposing  cause.  For  example,  a  man  may 
for  years  write  many  hours  daily  without  discomfort,  but  let  him  become  in- 
volved in  financial  or  domestic  difficulty,  and  the  first  signs  of  breakdown 
may  be  writers'  cramp.  A  lady  played  upon  the  piano  many  hours  daily  for 
years  without  any  trouble,  but  lier  husband  failing  in  business  she  became  a 
music  teacher,  and  almost  immediately  piano-players'  cramp  developed.  She 
has  never  recovered.  Venereal  and  alcoholic  excess  predispose  to  the  dis- 
ease. Local  injury  in  the  hand  or  arm  may  precipitate  an  attack,  as  in  an 
army  officer  mentioned  by  Gowers,  who,  having  sprained  his  thumb,  was  com- 
pelled to  write  a  great  deal  before  it  had  recovered,  and  soon  characteristic  pain 
and  cramp  appeared.  Sleeves  too  tight  around  the  wrist,  and  even  the  pres- 
sure of  a  large  sleeve-button  have  been  blamed.     Runge  reports  a  case  in 


LOCAL  SPAS3LS.     OCCUPATION  SPASMS.  277 

which  periostitis  of  the  humerus  was  the  cause.  Vance  saw  it  in  slight  cases 
of  hemiplegia,  and  in  one  case  of  not  severe  brachial  monoplegia,  it  was  the 
only  symptom  left.  In  the  last  there  was  absolutely  no  palsy  and  no  inter- 
ference with  any  other  movements,  no  matter  how  fine,  except  those  of  writ- 
ing, any  attemj^t  at  which  would  cause  spasm.  There  was  no  agraphia. 
Rarely  a  distinct  neuritis  of  the  median,  radial,  or  ulnar  nerve,  or  of  the 
brachial  plexus  has  seemed  to  be  the  cause.  But  it  is  probable  that  in  most 
cases  the  nerve  tenderness,  which  is  common,  is  neuralgic ;  is  a  part  of  the 
affection  and  not  its  cause.  It  is  far  more  common  in  men  than  in  women. 
It  occurs  most  frequently  between  the  twentieth  and  the  fiftieth  year.  Curi- 
ously, it  is  never  found  in  children  learning  to  write,  nor  do  the  other  trade 
spasms  occur  in  beginners,  but  only  in  those  who  have  worked  some  time. 
The  great  cause  is  an  improper  method  of  writing.  The  way  the  pen  is  held 
is  of  much  less  importance  than  the  muscles  brought  into  action  in  the  move- 
ments of  writing.  According  to  Gowers  the  worst  method  is  that  in  which 
the  little  finger  is  used  as  a  fixed  support.  The  use  of  the  wrist  as  a  fixed 
point  is  better,  but  still  bad.  In  both  these  methods  small  muscles  have  all 
the  work  thrown  on  them,  and  consequently  fatigue  comes  on  sooner.  Un- 
doubtedly the  only  proper  way  of  writing  is  by  using  the  upper  arm  and 
shoulder  muscles,  allowing  the  forearm,  wrist,  and  little  finger  to  rest  upon 
the  table  to  take  off  the  weight  of  the  limb,  but  making  them  move  along 
from  left  to  right  as  the  writing  progresses.  The  advantage  of  a  free  hand 
is  shown  by  the  fact  that  stenographers  who  are  bound  to  adopt  it  to  attain 
speed  seldom  if  ever  suffer.  Steel  pens  have  been  blamed,  but  scarcely  justly, 
since  the  disease  was  known  before  their  invention.  Finally,  it  must  not  be 
forgotten  that  the  disease  may  occur  in  those  who  write  but  little,  being  then 
a  local  manifestation  of  a  general  neurasthenia. 

Symptoms.  Moritz  Benedict  described  three  types — the  paralytic,  the 
spasmodic,  and  the  tremulous.  They  are  rarely  absolutely  separate,  two 
being  usually  present,  with  one  predominating.  Spasm,  accompanied  by  pain 
is  the  most  frequent.  In  rare  cases  the  onset  is  sudden.  Ordinarily  it  is  slow. 
Usually  at  the  beginning  there  is  fatigue,  pain  in  the  fingers,  and  dull  aching 
in  the  metacarpal  and  wrist  joints.  There  is  often  formication  and  numb- 
ness, but  no  true  hypersesthesia  or  angesthesia.  The  nerve  trunks  may  be 
slightly  tender.  At  first  all  discomfort  passes  away  soon  after  the  patient 
ceases  to  write,  and  does  not  return  until  he  has  written  again  for  a  longer  or 
shorter  time.  Later  the  sense  of  fatigue  becomes  permanent,  extends  up  the 
arm,  and  may  reach  as  far  as  the  scapula.  Soon,  and  in  some  cases  without 
preceding  pain,  motor  troubles,  spasmodic  or  paralytic,  or  both,  appear.  The 
patient  notices  he  cannot  guide  the  pen,  it  digs  into  the  paper,  the  strokes 
are  irregular  and  go  too  far  up  or  too  low  down.  The  pen  is  grasped  too 
tightly  and  the  patient  cannot  let  go.  The  writing  "  resembles  that  done  in 
a  jolting  carriage."     (See  Fig.  66.)     The  cramp  is  usually  tonic,  not  clonic. 

Fig.  66. 


Handwriting  in  writers'  cramp. 

There  may  be  flexor  spasms  of  the  thumb,  forcing  it  into  the  palm.  Again 
there  may  be  flexor  or  extensor  spasm  of  the  index  finger,  or  of  it  and  the 
third  finger.  If  there  is  extensor  sjoasm  of  the  thumb  and  index  finger  the 
penholder  will  fall  from  the  hand.     If  the  flexor  and  extensor  carpiulnaris 


278  NERVOUS  DISEASES  AND  THEIR  TREATMENI. 

be  aiFected  the  pen  is  forced  strongly  against  and  digs  into  the  paper.  There 
may  be  spasm  of  the  pronators  and  supinators  of  the  forearm,  in  which  event 
the  pen  goes  hither  and  thither  over  the  paper,  and  the  markings  resemble 
rather  chicken-tracks  than  writing.  Rarely  there  may  be  an  accompanying 
spasm  of  the  shoulder  muscles.  Clonic  spasm  occurring  only  on  beginning 
to  write  and  affecting  the  thumb  and  index  finger  occurs  infrequently.  It 
should  be  possible  to  tell  from  the  handwriting  the  muscles  affected  in  the 
disease  and  whether  by  s]Dasm  or  palsy. 

Tremor  almost  never  occurs  alone.  It  is  usually  accompanied  by  tonic 
spasm.  At  the  beginning  it  occurs  only  when  Avriting  and  gives  the  hand- 
writing a  "  shaky  "  form.  Later  it  may  continue  while  the  patient  is  at  rest 
or  be  caused  by  any  movement,  and  then  is  apt  to  invade  the  left  hand  also. 
Ordinarily  the  tremor  is  confined  to  the  thumb  and  first  finger.  A  purely 
paralytic  form  of  the  disease  rarely  if  ever  occurs.  There  is  always  some 
spasm,  but  weakness  may  predominate.  There  is  fatigue  pain  in  the  affected 
muscles  and  some  difficulty  in  the  voluntary  contraction  of  them. 

It  is  rare  for  coarse  movements  to  be  affected,  and  fine  movements,  if  they 
differ  in  character  from  those  made  in  writing,  may  be  uninfluenced.  Some 
one  other  complicated  movement,  may  be  involved  as  in  a  patient  of  Gowers's 
who  could  do  anything  except  shave.  There  may  be  a  certain  amount  of 
weakness  in  particular  muscles  as  shown  by  Piore,  but  usually  the  grasp  of 
the  hand  is  good.     Slight  local  muscular  wasting  sometimes  occurs. 

There  may  be  no  change  in  the  electrical  reactions  of  either  nerves  or 
muscles.  In  long-standing  cases  there  may  be  increase  or  decrease  to  both 
the  faradic  and  galvanic  currents.  Eulenburg  found  qualitative  changes  in 
the  nerve  trunks. 

There  is  apt  to  be  a  general  condition  of  neurasthenia  or  mild  hysteria. 
Various  parsesthesise  are  complained  of.  Painful  points  in  the  course  of  the 
nerves  of  the  arm  are  common,  and  the  nerves  may  be  swollen.  Not  infre- 
quently there  are  tender  spots  in  the  spine,  especially  in  the  cervical  region. 
There  may  be  a  transitory  marble  pallor  of  the  fingers  from  vasomotor  con- 
striction. Stammering  is  an  occasional  complication.  If  the  patient  persists 
in  writing,  the  condition  gradually  becomes  worse,  until  finally  the  act  is  im- 
possible. At  the  beginning  it  is  often  possible  to  write  well  with  a  pencil. 
Patients  often  use  the  left  hand  in  writing.  In  such  cases  the  chances  are 
about  equal  that  it  wdll  escape. 

Pathology.  There  are  no  known  anatomical  changes  in  the  disease,  but  it 
is  highly  probable  that  if  we  could  use  the  same  methods  as  Hodge  used  in  his 
experimental  study  on  the  effects  of  fatigue  we  could  find  distinct,  though 
fine,  lesions  in  the  motor  brain  cortex,  or  in  it  and  the  cells  of  the  cervical 
enlargement  of  the  cord.  Three  theories  have  been  offered  to  explain  the 
disease.  First,  that  it  is  local  weakness  of  certain  muscles,  permitting  over- 
action  of  their  opponents ;  second,  that  it  is  reflex ;  and,  third,  that  it  is 
central — a  want  of  proper  balance  in  the  co-action  of  the  various  motor 
centres  concerned  in  the  action  of  writing.     The  last  is  the  most  satisfactory. 

Diagnosis  of  the  fully  developed  disease  is  easy.  The  beginning  stage 
may  be  mistaken  for  neuritis,  a  slowly  on-coming  hemiplegia,  or  even 
paralysis  agitans,  but  only  if  the  possibility  of  the  existence  of  writers' 
cramp  be  overlooked. 

Prognosis  in  a  bad  case,  or  one  of  long  standing,  is  never  very  good.  It 
is  better  in  those  cases  in  which  outside  elements — ill  health  and  worry — have 
a  large  causative  influence  than  in  those  due  solely  to  excessive  writing.  _  It 
is  better.in  cases  in  which  there  is  a  large  pain  element  than  in  those  which 
are  purely  motor.  Finally,  the  worst  case  may  recover,  while  one  apparently 
much  less  severe  may  persist. 


LOCAL  SPAS3LS.     OCCUPATION  SPASMS.  279 

Treatment.  The  best  treatment  is  avoidance  of  the  disease  by  adopting 
a  proper  method  of  writing.  The  patient  must  cease  absolutely  to  write  with 
his  right  hand.  No  mechanical  appliance  will  do  more  than  stave  off  the 
increase  of  symptoms  for  a  time.  There  is  no  reason  why  he  should  not  use 
the  left  hand  in  writing,  since,  if  it  is  attacked  he  is  no  worse  off  than 
before.  Galvanism  sometimes  does  good,  and  should  be  used,  but  faradism 
may  be  distinctly  harmful  to  the  too  irritable  muscles.  Massage  will  often 
relieve  the  pain,  and  has  a  good  effect  on  the  disease  itself.  Local  hand- 
gymnastics,  the  fingers  being  made  to  perform  movements  as  much  unlike 
writing  as  possible,  are  excellent.  Internal  medication  is  of  no  benefit,  except 
as  regards  the  general  health. 


OTHER  OCCUPATION  SPASMS. 

There  is  a  long  catalogue  of  occupations  which  may  produce  conditions 
exactly  parallel  in  etiology,  pathology,  prognosis,  and  treatment,  to  writers' 
cramp,  the  only  difierence  being  the  character  of  the  movements  affected. 

The  following  are  the  most  important : 

Seamstresses'  Cramp.  Any  occupation  requiring  constant  sewing  may 
lead  to  a  condition  of  rigid  flexion  of  the  fingers  used.  Similar  spasmodic 
conditions  occur  in  the  lower  extremities  in  ballet  dancers  and  operators  on 
the  sewing  machine. 

Spasm  of  the  tongue  has  been  met  with  in  players  on  the  clarionet. 

Burns  gives  a  long  list  of  other  occupations — drummers,  money  counters, 
masons,  compositors,  engravers,  cigarette  makers,  enamellers,  artificial-flower 
makers,  painters,  letter-sorters,  turners,  and  knitters.  Eichhorst  speaks  of 
the  case  of  a  girl  whose  daily  work  was  to  fasten  4000  needles  in  papers. 

Smiths'  Cramp,  or  hammer  palsy,  is  a  good  example  of  the  disease  as 
caused  by  coarse  and  simple  movements.  The  spasm  may  cause  the  hammer 
to  fall  from  the  hand,  or  there  may  be  a  loss  of  control,  causing  unexpected 
movements  of  the  arm.  In  one  case,  the  hand  holding  the  chisel  would  be 
unexpectedly  supinated.  I  saw,  quite  recently,  in  Dr.  Morris  J.  Lewis's  clinic, 
a  car  driver  whose  work  required  that  he  should  press  the  brake  handle 
with  the  palm  of  the  right  hand  continuously.  Some  months  ]Di'eviously  he 
noticed  slight  trouble  in  grasping  the  biV^e  with  the  fingers,  extension  of 
the  arm  occurring  with  every  attempt.  Finally,  the  spasm  and  pain  became 
so  great  that  he  was  unfit  for  work.  There  was  also  occasional  clonic  flexor 
spasm. 

Telegraphers'  Cramp.  This  occurs  only  in  operators  who  use  the  Morse 
machine,  in  which  there  is  repeated  flexion  and  extension  of  the  finger 
pressing  and  releasing  a  key  in  order  to  make  dots  and  dashes.  The  constant 
repetition  of  this  movement  many  thousands  of  times  daily  produces  a  spasm 
of  the  finger,  which  prevents  it  from  being  raised  quickly  enough  from  the 
key,  and  hence  dots  become  dashes.     Pain  may  accompany  the  spasm. 

Piano-players'  Cramp  occurs  more  frequently  in  women  than  in  men. 
It  may  be  either  spasmodic  or  neuralgic.  It  usually  begins  in  one  finger  of  the 
right  hand,  and  is  characterized  by  spasmodic  extension  of  the  finger,  which 
prevents  the  key  being  struck  at  the  right  time,  or  the  spasm  holds  the  finger 
fixed  upon  the  key.  There  may  be  pain  alone,  without  spasm,  so  severe  as 
to  compel  the  player  to  stop  playing,  and  occurring  in  the  hand  only  or  ex- 
tending up  the  entire  arm.  Players  on  the  organ,  the  zither,  or  the  harp  may 
be  similarly  affected.  In  violin  players  the  spasm  may  attack  either  the  hand 
holding  the  bow  or  the  one  controlling  the  strings. 


CHAPTER    IX. 
FUNCTIO:^AL  TREMORS. 

By  LANDON  carter  GRAY,  M.D. 

Definition.  Under  the  term  functional  tremor  are  embraced  those  various 
forms  of  tremulousness  which  are  not  of  tlie  type  of  disseminated  sclerosis 
or  paralysis  agitans. 

Clinical  History.  At  the  outset  of  this  subject  it  should  be  understood 
that  a  distinction  must  be  made  between  tremor  and  the  fine  muscular  move- 
ments which  are  seen  in  chorea  and  the  so-called'  convulsive  tics.  In  the 
latter  the  movements  are  either  fibrillary  or  extend  over  a  whole  muscle  or 
set  of  muscles,  and  they  consist  of  abrupt  or  more  or  less  abrupt  contrac- 
tions, succeeded  by  abrupt  or  more  or  less  abrupt  relaxations,  and  the  inter- 
vals between  each  muscular  contraction  are  distinctly  perceptible  or  pro- 
longed. In  the  former,  however,  the  movements  are  chiefly,  indeed  almost 
entirely,  fibrillary,  and  the  muscular  contractions  are  minute  in  range,  suc- 
ceed each  other  rapidly,  and  are  rhythmical  in  character.  They  may  be 
divided  into  four  great  classes,  accordingly  as  they  are  fine,  coarse,  intermit- 
tent, or  continuous.  Based  upon  the  dogmatic  teachings  of  Charcot,  the  belief 
was  entertained  for  many  years  that  the  tremor  of  paralysis  agitans  was  always 
continuous,  and  that  of  disseminated  sclerosis  always  of  the  so-called  inten- 
tional type,  i.  e.,  only  present  when  a  voluntary  movement  was  made  (see  also 
p.  27)  ;  and,  proceeding  upon  the  same  line  of  thought,  it  has  been  supposed 
that  the  same  distinction  would  be  found  in  the  tremors  that  were  not  due  to 
paralysis  agitans  or  disseminated  sclerosis.  Of  late  years,  however,  Charcot's 
dictum  has  been  regarded  with  more  and  mo^re  caution  by  neurologists,  until 
I  think  I  am  safe  in  stating  that  nowadays  it  is  generally  believed  that  the 
tremor  of  disseminated  sclerosis  is  mainly,  if  not  entirely,  of  the  intentional 
type  in  the  earlier  stages  ;  that  that  of  paralysis  agitans  is  mainly  of  the  con- 
tinuous form,  although  there  are  many  exceptions  to  this  rule  ;  whilst  in  the 
so-called  functional  tremors  no  absolute  rule  has  as  yet  been  established. 
Tremor  has  thus  fared  the  fate  of  other  symptoms  of  disease  in  having 
been  shown  to  be  unreliable  as  pathognomonic,  as  we  have  slowly  plodded 
our  way  to  recognition  of  the  wider  truth  that  disease  evidences  itself  by  a 
combination  of  symptoms  and  not  by  any  one  alone.  Tremor  may  afiect  all 
the  external  muscles  of  the  body  or  a  group  of  them,  either  in  one  limb  or 
in  a  segment  of  one  limb.  They  may  thei'efore  be  found  throughout  the 
head  and  neck,  in  the  eye  muscles  (nystagmus),  the  facial  muscles,  the  tongue, 
the  lips,  or  the  extremities.  Tremor  of  the  internal  muscles,  such  as  the 
diaphragm,  or  the  more  deeply  seated  of  the  trunk  muscles,  has  been  very 
scantily  studied,  and  we  know  scarcely  anything  about  it.  When  tremor  is 
of  the  intentional  type  it  will  be  evidenced  by  making  some  voluntary  move- 
ment, as  by  having  the  patient  approximate  a  glass  of  water  to  the  lips,  or 
write  the  name,  or  do  some  other  voluntary  act,  although  it  is  a  curious  fact 

1  For  these  convulsive  tics  I  have  suggested  the  name  of  Palmus. 


FUNCTIONAL  TREMORS. 


281 


that  this  intention  tremor  may  be  present  in  one  voluntary  act  and  absent 
in  another.  When  the  tremor  is  continuous,  it  will  be  present,  as  the  term 
implies,  when  the  patient  is  at  rest,  so  far  as  making  a  voluntary  act  is  con- 
cerned, although  it  should  not  be  forgotten  that  these  continuous  tremors 
will  be  exaggerated  by  emotion  or  by  mental  or  physical  effort.  The  rate  of 
tremors  has  been  determined  by  the  sphygmograph,  the  best  of  which  is  said 
by  Peterson  to  be  that  of  Edwards,  although  the  European  observers  have 
made  use  of  Marey's,  and  in  Peterson's  article  will  be  found  an  excellent 
resume  of  the  sphygmographic  studies  that  have  been  made.  According  to 
Peterson,  the  tremor  of  paralysis  agitans  varies  from  3.7  to  5.6  per  second, 
this  variation  being  often  observed  in  the  same  individual.  In  well-devel- 
oped multiple  sclerosis  the  latter  observer  found  a  rate  of  from  4.6  to  6.3 
per  second,  although  in  the  earlier  stages  it  may  run  as  high  as  7.9  to  8.1 
per  second.  Gowers,  however,  has  found  the  rate  in  paralysis  agitans  to  run 
between  4.8  and  7  per  second.  The  following  tables  will  show  the  variations 
in  the  different  tremors  by  different  observers  : 


Observer. 


Peterson 


Wolfenden  and  Williams 


Disease.  Rate  per  second. 

Basedow's  disease 8.7  to  12 

Hysterical  tremor 7  6  "      7.8 

Aicoholism 8.5  "    11.2 

Delirium  tremens 5.6  "      6.8 

Neurasthenia 7.4  or  more 

Multiple  sclerosis 4.6  to     6.3 

Lateral  sclerosis 6 

Paralysis  agitans 3.5  "      5.6 

L  Exophthalmic  goitre 8.7  "    12 

Basedow's  disease 10.8    to   11.5 

Hysteria 

Divers'  paralysis 

Paralysis  agitans  .        .        .        .        .        .      5  to   11 

Disseminated  sclerosis 5  "      8 

Lateral  sclerosis 5  "      5 

Exophthalmic  goitre 10.8  "    11.5 

(,  Multiple  sclerosis 5  8 

10 


Dana 


Neurasthenia 

Hereditary  tremor         .... 

Quinine 10 

Alcoholism 6.2 

Exophthalmic  goitre 8 

Epilepsy 10 

Paralysis  agitans 3 

Hysteria 5 

Senile  tremor 4 

Multiple  sclerosis 

Lateral  sclerosis 6 

Post-hemiplegic  sclerosis     .        .        .        .10 

[  Myelitis 5 

Alcoholism 8 

Exophthalmic  goitre 8 

Paralysis  agitans 5 

General  paresis 8 

Hysteria 5.5 

Senile  tremor 4 

Multiple  sclerosis  .        .  ...  4 

Lateral  sclerosis 

Charcot,  Dutil,  and  Marie        Exophthalmic  goitre 8 

C  General  paresis 10 

Gowers <  Paralysis  agitans 4 

(  Multiple  sclerosis 6 

Fere Epilepsy  .        • 7 

Horsley Lateral  sclerosis 8 

Charcot Multiple  sclerosis 7 


8      to     9 


Dutil 


to 

9 

" 

6.5 

" 

5.5 

to 

12 

" 

6 

to 

9 

" 

9.5 

" 

6 

" 

9.5 

" 

7.5 

" 

5.5 

'■ 

5.5 

to 

9.5 

" 

12 

" 

8.7 

" 

7 

to 

10 

to 

10 

The  data  for  this  table  have  been  gathered  by  different  sphygmographic 
instruments,  about  the  reliability  of  which  there  has  been  considerable  differ- 
ence of  ojiinion,  so  that  the  American  observers  have  discarded  entirely  the 
Marey  sphygmograph  which  was  employed  by  the  Europeans.  The  subject 
is  therefore  in  need  of  investigation  by  some  one  standard  instrument.     As 


282  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

far  as  they  go,  however,  these  observations  would  seem  to  show  that  the  rate 
of  tremor  of  paralysis  agitans  is  the  lowest  of  all,  although  even  this  dictum 
is  contradicted  by  Gowers ;  next  in  frequency  is  that  of  multiple  sclerosis, 
although  even  in  this  Charcot  found  a  rate  from  7  to  10  per  second;  whilst 
the  other  tremors,  although  varying  in  some  individual  cases,  as  a  rule  range 
higher.  Eegarding  the  table  still  more  critically  it  will  be  observed  that  the 
range  of  rate  in  the  same  disease  varies  according  to  the  different  observers, 
so  as  to  leave  us  in  very  considerable  doubt.  Thus,  in  paralysis  agitans,  the 
tremor  varied  from  that  observed  by  Charcot,  3  per  second,  to  that  observed 
by  Gowers,  7  ;  in  multiple  sclerosis  from  4  (Dutil)  to  10  (Charcot)  ;  in 
alcoholism  from  6.2  (Dana)  to  9  (Charcot  and  Dutil)  ;  and  in  exophthalmic 
goitre  from  8  (Charcot,  Dutil,  Marie)  to  11.5  (Wolfenden  and  Williams). 
We  cannot  therefore  base  any  diagnostic  certainty  upon  the  rate  of  tremor, 
and  the  sphygmographic  tracings  have  only  as  yet  been  scientific  curiosities. 
The  classification  of  tremors  may  be  made  as  follows  : 

Paralysis  agitans ; 

Disseminated  sclerosis  ; 

Tremor  from  lesion  of  the  brain,  spinal  cord,  or  peripheral  nerves ; 

Toxic  tremors ; 

Tremors  from  neurosis ; 

Emotional  tremor ; 

Febrile  tremor ; 

Senile  tremor ; 

Hereditary  tremor  ; 

Convulsive  tremor. 
Besides  these  there  are  certain  muscular  movements  which,  with  a  strange 
lack  of  precision,  are  often  included  under  the  head  of  tremor,  such  as  the 
intermittent  clonus  of  epilepsy,  the  fibrillary  contractions  of  muscular  atrophy, 
the  purring  tremor  or  purring  thrill,  the  shaky  movements  of  subsultus  ten- 
dinum,  and  vibratile  tremor  or  fremitus,  so  familiar  to  auscultators  when  an 
aneurism,  a  bronchial  rale,  a  pulmonary  cavity,  an  endocarditis,  or  some 
other  disturbance  of  the  thorax  or  abdomen  is  present. 

The  tremor  of  paralysis  agitans  and  disseminated  sclerosis  are  elsewhere 
treated,  and  need  not  detain  us  here.     (See  Chapters  X.  and  XXII.) 

Almost  any  lesion  of  the  brain,  spinal  cord,  or  peripheral  nerves  may  be 
accompanied  by  a  tremor,  and  this  may  be  present  only  in  the  parts  affected 
by  the  nervous  lesion,  or  may  extend  beyond  them  in  varying  degrees. 
Through  a  lamentable  confusion  of  thought,  under  this  heading  have  often 
been  included,  especially  by  the  French  writers,  hemichorea  and  hemiathe- 
tosis,  even  by  so  competent  a  writer  as  Demange,  as  late  as  1885  ;  and  this  is 
the  more  inexplicable  because  the  so-called  hemichorea  is  really  a  hemiathe- 
tosis  and  consists  of  gradual  worm-like  muscular  movements  with  long  in- 
tervals of  rest,  resembling  in  no  wise  the  minute,  quickly-succeeding,  partial 
fibrillary  activity  to  which  the  name  of  tremor  should  really  be  given. 

The  toxic  tremors  are  those  caused  by  arsenic,  mercury,  lead,  copper, 
and  alcohol.  Charcot,  shortly  before  his  death,  began  to  teach  very  posi- 
tively that  mercurial  tremor  was  always  hysterical,  and  he  based  his  conclu- 
sions upon  the  sudden  recoveries  and  the  frequent  presence  of  his  so-called 
hysterical  stigmata,  namely,  concentric  limitation  of  the  field  of  vision,  an 
emotional  condition,  and  seemingly  erratic  impairments  of  sensation.  Could 
we  bring  ourselves  to  believe  that  this  were  true  of  the  tremor  induced  by 
mercury,  the  correlated  conclusion  would  be  that  the  tremor  of  alcoholism, 
lead,  copper,  neurasthenia,  and  febrile  diseases  were  also  hysterical.  But 
when  we  remember  that  the  so-called  hysterical  stigmata  have  been  observed 
in  very  many  diseases  of  the  nervous  system  other  than  those  of  hysteria,  as 


FUNCTIONAL  TREMORS.  283 

has  been  shown  by  the  careful  observations  of  Oppenheim  and  Thompson,  it 
will  be  seen  how  unsupported  by  proof  this  conclusion  of  Charcot's  is,  whilst 
sudden  recoveries  under  proper  treatment  occur  in  a  thousand  non-hysterical 
diseases. 

The  tremors  that  are  observed  in  the  course  of  the  neuroses  are  not  of 
special  clinical  value,  except  historically.  What  is  generally  called  choreic 
tremor  is  really,  as  I  have  already  said,  not  a  tremor  at  all,  but  consists  of 
fine  fibrillary  movements  with  distinct  intervals,  or  in  the  more  violent  cases 
of  muscular  movements  involving  muscles  or  groups  of  muscles.  In  some 
very  rare  instances,  however,  a  chorea  will  be  accompanied  by  a  genuine 
tremor.  In  epilepsy  tremor  is  not  usual,  and  when  it  is  present  it  is  observed 
only  as  the  epilej)tic  attack  is  passing  off".  Hysterical  tremor  is  usually  of 
great  diagnostic  importance,  and  it  will  often  throw  light  upon  a  case  that  is 
otherwise  obscure.  I  have,  in  many  instances,  from  this  symptom  alone, 
made  a  tentative  diagnosis  of  hysteria,  which  the  fui-ther  progress  of  the  case 
has  confirmed.  In  convulsive  tic,  or  palmus,  as  I  have  called  it,  I  have  seen 
tremor  in  those  cases  which  were  accompanied  by  slight  mental  symptoms, 
but  the  disease  is  so  recently  a  subject  of  observation  that  I  am  not  able  to 
state  the  frequency  of  this  particular  symptom. 

Emotional  tremor  is  too  well  known  to  need  more  than  a  mere  mention, 
and  the  same  is  true  of  the  febrile  tremors. 

There  is  a  growing  inclination  at  the  present  day  among  neurologists  to 
consider  senile  tremor  as  a  variety  of  paralysis  agitans,  and  I  am  inclined  to 
agree  with  this  opinion,  the  more  especially  as  the  pathological  findings  which 
are  dealt  with  at  length  in  the  chapter  upon  paralysis  agitans  itself  lend  cre- 
dence to  this  view.  At  the  same  time  there  are  some  doubts  in  my  mind  as 
to  whether  there  may  not  be  a  clinical  distinction  between  senile  tremor  and 
paralysis  agitans,  especially  in  the  early  stages,  and  in  the  predominance  in 
the  former  of  tremor  of  the  jaws  and  head. 

There  is  a  form  of  tremor  which  is  hereditary,  beginning  in  young  adults, 
and  frequently  giving  rise  to  a  suspicion  of  disseminate  sclerosis,  and  in  later 
years  often  of  that  and  also  of  paralysis  agitans.  It  is  easily  distinguishable 
from  both  of  these  affections,  however,  by  the  fact  that  it  has  none  of  the 
classical  symptoms  of  either  of  these  two  diseases,  such  as  the  nystagmus, 
characteristic  speech,  attitude,  j)Osition  of  the  hands,  etc. 

Dr.  William  A.  Hammond,  in  his  text-book  on  diseases  of  the  nervous 
systein,  caills  attention  to  a  disease  characterized  by  a  j)aroxysmal  tremor  of 
short  duration,  which  had  previously  been  described  by  Tollmouche  and 
Parkinson.  The  attacks  are  usually  of  great  violence,  accompanied  by  loss 
of  consciousness  and  febrile  rise,  and  succeeded  by  a  feeling  of  great  fatigue, 
but  no  sleep  or  stupor.  The  prognosis  is  said  to  be  generally  favorable.  I 
have  never  seen  a  case  of  this  kind,  and  cannot  do  more,  therefore,  than 
speak  of  it  from  the  experience  of  others. 

Pathology.  The  f)athology  of  tremor,  in  the  true  sense  of  the  term,  is 
quite  unknown.  It  is  true  that  in  the  two  great  standard  types  of  disease, 
paralysis  agitans  and  disseminated  sclerosis,  in  which  tremor  is  the  salient 
symptom,  the  chief  pathological  lesion  would  seem  to  be  an  alteration  in  the 
connective  tissue  of  the  brain  and  cord.  That  this  cannot  be  the  real  cause 
of  the  tremor,  however,  has  been  demonstrated  by  those  several  cases  of  spinal 
cord  lesion  which  are  alluded  to  in  the  chapter  upon  paralysis  agitans,  and  in 
which  the  connective  tissue  of  other  portions  of  the  cords  was  found  to  be 
altered,  without  a  sign  of  tremor.  It  would  seem  to  be  most  reasonable  to 
assume  that  tremor  can  only  be  produced  by  direct  or  indirect  implication  of 
the  motor  tract.  These  motor  strands  have  a  long  textural  journey  to  pursue. 
They  start  above  in  the  clusters  of  motor  cells  in  the  motor  convolutions  of 


284  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  cerebrum,  and  at  this  station  they  are  connected  by  the  so-called  commis- 
sural fibres  with  many  other  areas  of  the  brain.  From  these  cells  they  go  on 
down  through  the  centrum  ovale  to  converge  into  the  internal  capsule,  thence 
passing  to  the  crura,  to  the  pons,  to  the  medulla  oblongata,  where  they  decus- 
sate, some  passing  down  through  the  lateral  pyramidal  columns  of  the  cord, 
others  through  the  anterior  columns  of  the  cord  or  the  columns  of  Tuerck, 
both  of  these  sets  of  fibres  making  their  way  to  the  cells  of  the  anterior 
columns  through  fibres  that  have  been  demarcated  of  late  years  by  the  re- 
searches of  Golgi,  Ramon  y  Cajal,  Lenhossek,  and  others ;  and  from  these 
cells  of  the  anterior  horns  passing  off  into  the  anterior  roots  of  the  motor 
structures  of  the  trunk,  head,  and  periphery.  It  is  easy  to  conceive  that  any 
direct  irritation  of  this  motor  tract — as  by  the  sclerotic  areas  of  disseminated 
sclerosis  in  the  cerebrum,  the  pigmentation  and  atrophy  of  the  cells  of  the 
anterior  cornua,  the  endarteritis  of  the  spinal  vessels,  and  the  increase  of 
connective  tissue  in  the  lateral  and  anterior  pyramidal  tracts  of  paralysis  agi- 
tans — may  well  impair  conduction  between  the  cortical  cells  above  and  the 
peripheral  structures  beneath,  so  that  the  nerve  current  flows  through  imper- 
fect media.  But  we  do  not  know  wherein  consists  the  molecular  disturbance 
of  this  motor  tract  producing  tremor,  and  those  other  disturbances  of  the 
same  motor  tract  causing  epilepsy,  chorea,  and  convulsive  tic ;  and  until 
we  do  know  this,  and  until  we  are  perfectly  cognizant  of  the  nature  of  these 
varying  molecular  conditions,  we  will  not  have  a  distinct  idea  of  the  genesis 
of  tremor,  or  how  it  is  produced  by  emotion,  heredity,  the  neuroses  and  toxic 
agents.  So  far  we  have  fallen  into  the  mistake  of  attaching  too  much  impor- 
tance to  those  pathological  findings  which  are  evidently  the  result  of  the 
primary  lesions  inducing  tremor,  when  in  reality  we  know  nothing  of  these 
primary  causes  themselves. 

Diagnosis.  A  diagnosis  of  the  nature  of  a  tremor  can  usually  be  made 
with  ease.  A  tremor  is  but  a  variety  of  involuntary  muscular  contraction. 
It  is  usually  of  four  grades.  First,  violent  muscular  movements  of  large 
range,  such  as  are  seen  in  the  so-called  convulsive  tremor ;  second,  the  violent 
convulsive  movements  of  a  large  range  alternating  with  fine  muscular  move- 
ments, constituting  a  true  tremor,  this  combination  being  seen  in  those  cases 
in  which  one  or  more  limbs  are  affected,  with  recognizable  organic  disease  of 
the  cerebrum,  as  is  evidenced  by  other  symptoms  of  paralysis,  contracture 
and  anaesthesia ;  third,  fine  tremor,  which  is  seen  only  when  voluntary  move- 
ments are  made,  and  which  is  known  as  the  intention  tremor ;  fourth,  the 
fine  movements  which  are  continuous,  observed  when  the  individual  is  at 
rest  or  making  some  movement.  Of  these  four  varieties  the  convulsive 
tremor  is  only  mentioned  here  for  the  sake  of  completeness,  as  it  may  be 
regarded  as  a  variety  of  epilepsy  Avithout  loss  of  consciousness,  or  at  all  events 
being  of  a  different  type  from  the  true  tremor.  The  second  variety  is,  as 
has  been  said,  always  indicative  of  some  gross  organic  lesion  in  the  cere- 
brum. Too  much  diagnostic  importance  should  not  be  attached  to  the 
tremor  being  present  on  voluntary  movement  or  continuous,  for,  as  has 
already  been  said,  whilst  it  is  true  that  the  tremor  of  disseminated  sclerosis 
is  usually  of  the  intention  type  in  the  early  stages,  and  that  of  paralysis 
agitans  is  generally  continuous,  there  are  yet  many  exceptions  to  these  two 
rules,  and  the  other  tremors  are  sometimes  continuous,  sometimes  intentional 
and  sometimes  continuous  or  passive  at  one  stage  of  the  disease,  or  vice  verm. 

When  tremor  is  due  to  disseminated  sclerosis  the  diagnosis  can  be  made  by 
the  fact  that  the  patient  is  usually  a  child  or  young  adult,  that  there  is 
nystagmus,  and  that  there  is  none  of  the  characteristic  gait,  attitude,  position 
of  the  hands  or  flushing  of  the  face  of  paralysis  agitans,  or  the  deliberate 
speech  of  that  disease. 


FUNCTIONAL  TREMORS. 


285 


Fig.  67. 


The  diagnosis  of  paralysis  agitans  can  be  made  by  the  fact  that  the  patient 
is  generally  at  or  beyond  middle  age,  and  that  there  is  a  deliberate,  slow, 
wise  speech,  that  the  body  is  bent  forward  and  held  stiffly,  which,  with  the 
slow,  shuffling  gait  and  the  bread-crumbling  position  of  the  hands  (Figure 
67),  constitutes  the  peculiar  attitude  ;  that  there  is  usually  a  dilatation  of  the 
facial  capillaries,  and  often  a  tendency  to 
go  backward  (retropulsion),  to  go  sidewise 
(lateropulsion),  or  to  walk  faster  and  faster 
(festination).  In  these  cases  of  paralysis 
agitans,  too,  it  will  sometimes  be  found 
that  the  patient  will  be  unable  to  main- 
tain the  centre  of  gravity  long,  which  may, 
in  the  slighter  cases,  be  shown  by  the  festi- 
nation, by  the  tendency  to  fall  forward  after 
walking  a  while,  or  to  fall  backward  in 
attempting  to  stand  erect. 

Hysterical  tremor  can  be  diagnosed  by 
the  emotional  or  traumatic  onset,  the  para- 
plegia, with  anaesthesia ;  the  monoplegia, 
with  zones  of  anaesthesia,  or  complete ;  either 
the  entire  absence  of  muscular  atrophy  or 
the  presence  of  hemianesthesia,  involving 
the  sense  of  sight,  smell,  taste,  the  upper 
and  lower  limbs,  or  the  concentric  limita- 
tion of  the  field  of  vision  (which  may  co- 
exist with  hemianaesthesia).  Great  stress 
has  been  laid  in  this  diagnosis  upon  the 
ovarian  tenderness,  but  this  I  have  found 
to  be  too  frequent  in  sensitive  women  to  be 
of  much  diagnostic  value.  It  must  never  be 
forgotten,  however,  that  hysteria  may  exist 
without  any  of  these  so-called  stigmata,  and 
then  the  diagnosis  may  become  a  matter  o± 
much  difficulty,  as  it  can  only  be  made 
through  careful  exclusion  by  one  who  is  at 
home  in  the  wide  realm  of  nervous  and 
mental  disease.  Indeed,  were  I  to  jvidge 
by  many  personal  experiences  of  my  own 
in  this  matter,  I  should  say  that  the  bulk  of 
hysterical  cases  in  America  were  not  accom- 
panied by  these  so-called  hysterical  stigmata. 
It  would  seem  probable  that  either  too  much 
stress  has  been  laid  upon  these  by  the  French 
writers,  or  that  the  Latin  race  is  more  prone 
to  these  symptoms  than  is  that  mixture  of 
races  which  has  gradually  become  fixed  upon  the  soil  of  North  America. 
Another,  though  occasional  diagnostic  factor  of  great  moment  which  has  not 
hitherto  been  alluded  to  by  writers,  is  the  bed-ridden  condition ;  by  which 
I  mean  to  say  that  a  patient  who  has  been  bed-ridden  through  a  number  of 
years,  without  appreciable  cause  that  can  be  determined  by  a  competent 
physician,  is,  in  the  vast  number  of  cases,  hysterical. 

The  diagnosis  of  the  toxic  tremors  can  be  made  only  by  means  of  exclusion 
and  the  knowledge  or  suspicion  of  the  toxic  agent  having  been  used.  Of 
late  years  so  many  precautions  have  been  adopted  in  protecting  artisans  from 
poisoning  by  lead  that  the  toxic  tremor  is  not  frequent,  and  very  few  cos- 


Photograph  of  a  case  of  paralysis  agi- 
tans, showing  the  attitude,  the  position 
of  the  hands,  and  the  fades. 


286  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

metics  are  now  sold  containing  it.  The  history  of  colic,  the  blue  line  upon 
the  gums,  occasionally  the  history  of  some  form  of  paralysis,  especially  that 
of  the  extensors  of  the  wrist,  or  mental  torpidity,  would  make  the  diagnosis 
easy.  The  tremor  of  mercury  can  readily  be  diagnosed  if  salivation  has  been 
present ;  but  in  many  cases  this  is  absent,  and  an  opinion  can  then  only  be 
formed  by  a  rigid  history.  The  tremor  of  arsenic  can  usually  only  be 
determined  positively  by  the  history,  although  in  two  cases  I  have  seen  it 
accompanied  by  paralysis  of  the  upper  and  lower  limbs.  The  diagnosis  of 
tremor  having  been  caused  by  copper  is  dependent  entirely  upon  the  history. 
That  tremor  is  due  to  tobacco  may  be  surmised  when  the  characteristic  heart 
is  observed,  although  usually  the  diagnosis  of  this  variety  will  also  be  based 
upon  the  history.  The  tremor  of  the  neuroses  can  readily  be  determined  by 
the  accompaniment  of  the  characteristic  symptoms  of  the  neurosis  itself. 

Prognosis.  The  prognosis  of  tremor  is  good  in  the  cases  which  are  due  to 
the  neuroses  and  toxsemia,  and  unfavorable  in  those  which  are  the  accom- 
paniments of  organic,  spinal,  or  cerebral  disease.  The  hereditary  form  is 
often  mcurable,  although  frequently  susceptible  of  great  amelioration. 

Treatment.  The  treatment  of  tremor  should  be  addressed  to  the  removal 
of  the  cause,  if  it  is  possible,  and  to  the  treatment  of  the  tremor  itself.  Lead, 
arsenic,  copper,  mercury  should  be  removed  from  the  system  in  the  well- 
known  ways,  which  need  not  be  detailed  here.  The  tremoi'  itself  can  be 
benefited  by  hyoscyamine,  hyoscine,  the  bromides,  oxide  of  zinc,  galvanism, 
faradism,  rest,  and  tonics.  Hyoscyamine,  in  doses  of  y^-g-  grain  once  or  twice 
daily,  is  an  excellent  remedy ;  but  the  objection  to  it  is  that  it  will  dry  the 
mouth  and  dilate  the  pupils  in  an  unpleasant  degree  in  many  people  if  long 
continued.  Hyoscine,  the  hydrobromate  or  hydrochlorate,  is  a  much  more 
pleasaut  remedy,  and  can  be  given  three  or  four  times  a  day  without  unpleas- 
ant efiect ;  but  it  is  not  always  so  efficacious  as  the  hyoscyamine.  It  is  often 
supf)Osed  that  these  two  drugs  are  identical  in  their  effects,  because  of  the 
chemical  similarity.  This  is  a  great  mistake,  however,  as  hyoscine  is  much 
more  efficacious  in  emotional  or  insane  excitement  than  hyoscyamine,  and 
has  none  of  the  depressing  effects  of  the  latter.  The  bromides  are  most  useflil 
in  the  treatment  of  tremor,  when  conjoined  with  hyoscine  and  hyoscyamine; 
the  dose  should  be  from  10  to  15  grains  two  or  three  times  a  day.  The  oxide 
of  zinc,  in  doses  of  1  to  3  grains  two  or  three  times  a  day,  will  often  have  an 
excellent  eftect,  especially  in  the  mercurial  tremors,  but  it  cannot  be  relied 
upon.  Galvanism  is  always  useful,  and  in  proper  cases  frequently  curative. 
It  should  be  applied  to  the  brain  and  the  spinal  cord  ;  to  the  former  a  dose 
of  1  to  2  milliamperes  in  sittings  of  two  to  three  minutes ;  to  the  latter  in 
doses  of  3  to  5  milliamperes  in  sittings  of  three  to  ten  minutes.  But  no  one 
should  apply  galvanism  in  these  cases  who  is  not  properly  equipped  with  a 
galvanic  apparatus,  accurate  rheostat  and  milliampere  meter,  and  a  proper 
outfit  of  electrodes.  The  old  habit  of  turning  on  so  many  cells  of  a  battery 
without  the  slightest  knowledge  of  the  amount  of  current  that  is  passing  is 
akin  to  the  old  method  of  dispensing  medicine  in  unmeasured  boluses. 
Faradism  is  a  much  simpler  form  of  electricity  to  apply,  and  may  be  used 
simply  by  holding  the  electrodes  in  the  hands  and  letting  a  very  gentle  cur- 
rent pass  for  five  or  ten  minutes,  or,  if  the  lower  limbs  are  affected,  applying 
the  large  electrode  to  the  sole  of  one  foot  and  holding  the  other  electrode  in 
the  palm  of  the  hand,  and  thus  taking  each  foot  and  arm  into  the  circuit  in 
turn.  Faradism  is  usually  not  efficacious  by  itself,  although  there  are  many 
exceptions  to  this  rule,  and  the  best  results  will  be  obtained  by  using  it  in 
alternation  with  galvanism.  Rest  is  always  useful  in  cases  of  tremor,  and  it 
should  ho,  proportioned  to  the  needs  of  the  case.  If  it  is  a  weakened  muscle 
that  is  tremulous  the  exercise  of  this   muscle  should  be  diminished,  and 


FUNCTIONAL  TREMORS.  287 

if  it  is  a  weakened  condition  of  the  whole  organism  that  is  at  fault  the 
expenditure  of  energy  by  the  whole  organism  should  be  correspondingly 
diminished.  The  particular  application  of  this  rule  will  vary  with  the  tact 
of  the  physician  and  the  circumstances  of  the  patient ;  but  in  every  case  it 
is  safe  to  say  that  in  choosing  between  too  much  or  too  little  rest  the  prefer- 
ence should  be  given  to  the  former.  In  all  cases  of  tremor  the  general  health 
should  be  brought  up  to  the  highest  pitch  possible ;  indeed,  in  some  slighter 
cases  of  neurasthenia  I  have  seen  tremor  disappear  in  a  few  weeks  Avhen  this 
alone  was  done ;  and  in  this  raising  of  the  standard  of  the  general  health 
tonics  are,  of  coui'se,  necessary.  Of  these  the  best  is  quinine  or  calisaya 
bark,  and  iron  should  be  conjoined  with  these  in  cases  of  anaemia. 


CHAPTER   X. 

PARALYSIS  AGITANS. 
By  LANDON  CAETER  GRAY,  M.D. 


Synonyms.     Shaking  palsy ;  Parkinson's  disease ;  Schiittelamung, 
Parkinson,  of  London,  first  described  paralysis  agitans  in  1817.    Although 
all  the  well-known  authors  have  made  this  disease  a  subject  of  consideration, 
nothing  essential  has  been  added  to  Parkinson's  description  of  it,  which  shows 
him  to  have  been  a  man  of  rare  intellectual  capacity. 

Symptoms.  The  onset  is  usually  gradual,  although  it  may  in  some 
cases  be  sudden.  It  occasionally  begins  in  the  lips,  though  most  fre- 
quently in  one  of  the  extremities.  One  case  of  my  own,  beginning  in  the 
lips,  continued  for  fifty  years.  A  gradually  extending  tremor  embraces  the 
muscles  of  the  head  and  neck,  the  extremities,  and  sometimes  the  tongue 
and  facial  muscles.  In  some  cases  this  is  unilateral,  but  it  generally  extends 
bilaterally.  In  pronounced  cases,  or  in  those  suffering  a  temporary  exacer- 
bation, the  tremor  is  so  coarse  that  it  almost  resembles  a  mild  localized  mus- 
cular convulsion,  although  in  ordinary  cases  it  is  simply  coarse,  without  those 
additional  movements  characterizing  a  convulsion.  A  peculiarity  of  the 
speech  consists  in  its  being  deliberate,  like  that  of  a  wise  man  carefully 
choosing  his  words,  and  the  attitude  assumes  a  character  indicative  of  this 
particular  disease.  The  head  and  neck  are  bent  slightly  forward,  and  the 
patient  holds  the  head  and  shoulders  stifily,  and  steps  with  a  short,  shuffling 
gait.  The  facies  is  also  peculiar,  and  very  difficult  of  description,  being  of  a 
singular  blank  immobility.  The  thumbs  and  fingers  assume  at  this  stage 
what  is  known  as  the  bread-crumbling  position — i.  e.,  the  thumb  and  fingers 
are  approximated  and  move  over  each  other,  as  if  in  the  act  of  crumbling 
bread.  So-called  propulsion  takes  place — that  is,  a  tendency  to  go  forward — 
and  when  once  the  patient  is  started  in  a  forward  direction  his  walk  becomes 
accelerated,  and  he  finds  it  almost  impossible  to  stop.  This  quite  often 
occurs,  but  in  rare  cases  the  tendency  is  to  retropulsion — going  backward. 
In  other  cases  a  still  rarer  movement  is  observed — that  of  a  sidewise  inclina- 
tion, so-called  lateropulsion.  A  slightly  red  color  of  the  face  is  shown  in  all 
marked  cases  of  paralysis  agitans,  seemingly  indicating  good  health,  but 
in  reality  due  to  vasomotor  paresis.  Great  stress  is  laid  by  Charcot  on  the 
fact  that  the  tremor  is  usually  only  manifested  when  voluntary  muscular 
movements  are  made,  he  claiming  this  as  a  valuable  diagnostic  sign ;  but 
too  much  importance  should  not  be  attached  to  its  pi-esence  or  absence, 
as  in  cases  that  have  not  reached  the  typical  stage  it  is  often  absent.  In 
some  cases  of  paralysis  agitans  involuntary  movements  are  observed.  Con- 
siderable study  has  been  devoted  to  the  sphygmographic  tracings  of  the 
tremor  in  the  attempt  to  derive  from  it  data  by  which  to  distinguish  it  from 
multiple  sclerosis.  (See  Chapter  on  Functional  Tremors.)  Charcot  found 
that  the  line  traced  by  the  tremulous  extremity  in  paralysis  agitans  is 
one  of  slight  tremulous,  continuous  waves  when  no  voluntary  movements 


PARALYSIS  AQITANS. 


289 


Fig.  68. 


are  made,  but  longer  and  somewhat  more  irregular  during  voluntary  effort. 
In  multiple  sclerosis,  however,  almost  a  straight  line  can  be  drawn  when 
no  voluntary  movements  are  made,  while  in  the  case  of  effort  the  line  is  in 
large,  coarse  curves,  much  more  so  than  at  any  time  in  paralysis  agitans. 
Contracture  and  rigidity  of  the  muscles  are  almost  always  to  be  observed, 
and  exceptionally  increase  of  the  tendon  reflexes.  Among  symptoms  occa- 
sionally found  are  increased  perspiration,  tachycardia,  a  feeling  of  increased 
heat  over  the  body  or  in  certain  areas, 
or  of  cold,  numbness,  prickling,  or  pain. 
Most  patients  afflicted  with  this  disease 
are  extremely  restless,  finding  great  dif- 
ficulty in  keeping  quiet,  and  even  in- 
sisting upon  being  allowed  to  walk 
about  when  they  are  almost  helpless. 
The  mental  faculties  are  usually  intact, 
and  I  have  even  known  cases  of  fifty 
years'  duration  in  which  no  impairment 
whatever  could  be  detected  in  the  mind. 
This  was  notably  shown  a  few  years  ago 
in  the  case  of  a  great  national  leader, 
who  though  helpless  in  body,  continuecl 
vigorous  in  mind  until  the  last.  How- 
ever, in  some  cases  there  is  marked  stu- 
pidity, and  in  others  peevishness  or 
slight  mental  dulness.  The  duration  of 
the  disease  is  entirely  indefinite,  and,  a 
perfect  cure  being  never  effected,  it 
continues  during  the  remainder  of  life. 
It  is  a  question  Avhether  it  tends  to 
shorten  the  patient's  life,  as  I  have 
known  cases  extending  over  thirty, 
forty,  and  in  two  cases  even  fifty  years, 
thus  bringing  the  patient  up  to  sixty, 
sixty-five  and  seventy,  a  fair  age  for 
even  a  healthy  person  to  live.  Ex- 
acerbations and  remissions  often  occur, 
sometimes  so  intense  as  to  cause  the 
patient  to  expect  death.  At  such  times 
the  patient  often  becomes  perfectly 
helpless,  and  at  times  comatose. 

Etiology.     Age  may  be  considered 
as  a  factor  of  importance,  as  most  cases 
occur  between  the  ages  of  forty  and 
sixty,  and  sometimes  u^)  to  seventy, 
affected  than  women. 

In  various  cases,  however,  the  cause  may  be : 

Cold  and  damp ; 

Emotions ; 

Heredity ; 

Trauma ; 

Strong  peripheral  irritation  ; 

Hemiplegia ; 

Gout ; 

Typhus. 
I  have  occasionally  obtained  a  history  of  cold  and  damp  as  prominent 

19 


Side  view  of  a  case  of  paralysis  agitans  show 
ing  forward  inclination  of  trunk.  Tendency  to 
propulsion.    (Dercum.) 

Men  are  somewhat  more  frequently 


290  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

factors,  but  this  has  not  often  occurred,  although  European  writers  claim  that 
they  are  frequently  the  exciting  causes  of  paralysis  agitans. 

Worry  and  anxiety  are  sometimes  distinct  causes,  and  fright  also  plays  a 
strong  part  in  the  cases  of  many.  A  patient  of  mine,  who  suffered  from 
paralysis  agitans  for  fifty  years,  gave  a  history  of  having  been  crossing  a  river 
on  a  ferry-boat,  and,  while  so  doing,  saw  a  child  leap  from  its  mother's  arms 
into  the  water.  It  was  swept  down  the  river  by  the  current  for  a  considerable 
distance,  being  buoyed  up  by  its  clothing,  and  was  finally  rescued  by  a  long- 
shoreman. On  returning  to  the  cabin  after  witnessing  this  scene,  my  patient 
found,  much  to  her  surjDrise,  that  her  upper  lip  was  "going,"  as  she  expressed 
it,  "like  a  rabbit's,"  and  in  this  way  the  malady  began. 

I  have  found  that  heredity  is  a  frequent  cause,  although  it  generally  re- 
quires close  and  patient  questioning  to  elicit  the  facts,  as  it  may  not  have 
manifested  itself  in  the  immediate  parents  of  the  patient,  although  different 
generations  of  the  family  may  have  been  irregularly  affected.  Emigrants 
from  the  north  of  Ireland  and  their  immediate  descendants,  as  well  as  many 
from  among  the  population  of  Scotland,  have  been  the  most  frequent  cases  in 
our  New  York  clinics. 

Trauma,  gout,  and  typhus  may  be  often  found  to  be  the  exciting  cause. 

Cases  of  paralysis  agitans  have  been  reported  by  Westphal  which  have 
followed  a  wound,  a  laceration,  or  burns  of  an  extremity. 

Hemiplegia  may  sometimes  precede  paralysis  agitans,  as  I  have  observed 
in  five  cases,  although  such  cases  should  not  be  confounded  with  those  in 
which  one  limb  or  one  side  of  the  body  becomes  tremulous. 

Prognosis.  The  prognosis  is  generally  good  so  far  as  the  probabilities  of 
life  are  concerned,  for  the  disease  seldom  has  a  fatal  or  sudden  termination, 
and  it  is  a  doubtful  question  as  to  whether  it  really  shortens  life.  In  most  cases 
the  prognosis  is  good  as  to  improvement  under  proper  treatment,  although 
writers  differ  very  much  as  to  this  point.  However,  cases  in  which  the 
tremor  is  confined  to  one  side  of  the  body,  or  to  one  extremity,  are  apt  to  be 
very  obstinate,  resisting  all  treatment,  and  in  these  cases  the  affected  limbs 
often  become  contractured  and  rigidly  paralyzed. 

Pathology.  Until  within  a  very  short  time  it  had  been  generally  supposed 
that  paralysis  agitans  was  a  functional  disease  of  the  nervous  system,  in  the 
sense  that  no  demonstrable  pathological  lesions  were  present.  It  is  true 
that  as  far  back  as  1872  Joffi-oy  had  claimed  that  in  three  cases  of  the 
malady  he  had  found  the  central  canal  of  the  cord  almost  obliterated  by  pig- 
mentation, but  this  was  also  observed  in  many  instances  in  which  no  clinical 
symptoms  of  paralysis  agitans  were  jDresent ;  and  it  was  shown,  too,  that  the 
slight  indurations  of  the  membranes,  hitherto  vaunted  as  pathognomonic 
lesions,  were  of  frequent  occurrence  in  the  aged.  But  the  observations  of 
Borgherini,  Ketscher,  Roller,  Schultze,  Saas,  Dana,  and  Redlich  have 
brought  this  question  to  the  fore  again  in  a  new  light,  for  they  have  demon- 
strated that  in  the  spinal  cord  and  medulla  oblongata  of  these  cases  there  are 
islets  of  sclerosis  which  very  evidently  have  their  origin  in  the  vessels.  The  con- 
dition is  therefore  designated  as  perivascular  sclerosis.  The  vessels  affected 
are  those  of  small  calibre.  Their  lumen  is  narrowed,  there  is  a  slight  prolif- 
eration of  the  intima,  the  layers  of  the  media  are  thickened,  and  are  somewhat 
nuclear,  hyaline,  and  concentrically  layered.  To  the  outside  of  these,  generally 
in  close  proximity,  sometimes  with  a  small  space  intervening,  there  is  a  region 
of  thick,  horny  tissue,  which  colors  readily  in  ammoniacal  carmine,  and 
answers  toj)Ographically  to  the  layers  of  the  adventitia  or  the  adventitial 
lymph  spaces.  Miliary  aneurisms  or  hemorrhages  from  this  cause  have  been 
observed.  From  this  point  there  is  a  thickening  of  the  neuroglia  extending 
into  the  surrounding  nervous  parenchyma,  in  places  surrounding  groups  of 


k 


PABAL  YSIS  A  GITANS.  291 

uerve  fibres,  in  otliers  only  individnal  nerve  strands.  Toward  the  periphery 
of  the  cord  these  apj)earances  diminish.  If  there  are  many  vessels  close 
together,  the  otherwise  separate  small  islets  of  sclerosis  may  become  confluent, 
and  there  is  formed  a  large  sclerotic  mass  of  tissue.  The  nerve  fibres  are  not 
affected  where  the  sclerosis  is  of  small  degree  and  especial  groups  of  nerves 
are  surrounded  ;  but  where  the  sclerosis  is  more  marked,  the  nerve  fibres  seem  to 
be  compressed,  so  that  the  medullary  layer  and  the  axis  cylinder  have  become 
diminished  in  size  or  have  disappeared  entirely.  The  large  vessels  may  also 
be  affected,  even  those  outside  the  spinal  cord,  as  the  posterior  fissural  artery, 
and  the  interfunicular  artery  esj)ecially,  in  the  coats  of  the  media.  These 
sclerotic  changes  are  seen  most  clearly  in  the  posterior  columns  of  the  cord, 
more  especially  in  the  middle  and  ventral  portions,  close  to  the  posterior  com- 
missure. But  the  lateral  columns  are  also  affected,  although  the  lesions  are 
not  limited  to  them ;  the  direct  cerebellar  column,  the  Gowers  column,  and 
the  lateral  tract  proper,  bordering  upon  the  gray  matter,  being  implicated  in 
a  diffiise  manner.  The  anterior  columns  are  but  very  slightly  involved,  and 
often  not  at  all.  The  vessels  of  the  gray  matter  are  often  thickened,  but 
there  is  no  implication  of  the  surrounding  tissue.  The  lumbar  cord  and  the 
cervical  enlargement  are  the  sites  of  the  greatest  implication,  but  the  lesions 
are  relatively  far  less  marked  in  the  upper  cervical  region  and  in  the  lower 
dorsal,  and  still  less  in  the  upper  and  middle  dorsal.  In  some  cases,  also,  there 
has  been  an  evident  implication  of  the  cortical  region  of  the  cord,  especially 
in  the  posterior  portions  of  the  lateral  columns.  Occasionally  in  this  latter 
region  there  are  streaks  of  tissue  histologically  similar  to  the  cortical  layer  of 
the  cord  extended  into  the  lateral  columns,  but  disappearing  around  the  nerve 
fibres ;  in  other  instances  there  was  a  slight  diflTuse  sclerosis,  with  increase  of  the 
septa  and  of  the  neuroglia,  apparently  not  of  vascular  origin,  and  in  one  case 
of  Redlich's  there  was  found  a  diffiise  sclerosis  of  the  perivascular  character 
which  has  been  described.  In  almost  all  cases  the  ganglion  cells  of  the  ante- 
rior horns  w^ere  markedly  pigmented,  sometimes  so  much  so  that  the  whole 
body  of  the  cell  was  filled  with  yellow  granules,  hiding  the  nucleus  and  leav- 
ing visible  only  a  small  portion  of  the  protoplasm,  although  this  excess  was 
unusual,  as  the  form  and  processes  of  the  cell  usually  remain.  A  high  degree 
of  pigmentation  is  also  present  in  the  cells  of  Clarke's  columns.  The  central 
canal  was  usually  obliterated  by  proliferated  ependymal  cells.  Amyloid 
bodies  were  found  in  large  numbers,  although  nowadays  there  is  good  reason 
to  believe  that  these  formations  are  not  to  be  regarded  as  pathological,  inas- 
much as  Redlich  has  shown  that  they  are  present  in  the  normal  brain  and 
cord,  often  in  large  numbers.  The  pia  of  the  cord  was  generally  thick- 
ened to  a  slight  degree,  and  excessively  pigmented.  The  anterior  and  pos- 
terior roots  were  normal,  although  their  vessels,  whilst  not  thickened,  have 
sometimes  been  found  widened.  The  nerve  fibres  of  Lissauer's  and  Clarke's 
columns  have  been  generally  found  intact.  In  one  case  of  Dubief 's  the  axis 
cylinders  had  a  varicose  shape,  and  he  found  the  main  site  of  the  lesions  in 
the  cervical  and  upper  dorsal  cord.  In  one  of  Borgherini's  cases  aneurismal 
enlargements  and  hemorrhages  were  observed,  and  he  also  found  the  posterior 
columns  affected,  but  to  a  slight  degree  relatively,  whilst  he  differed  from 
most  of  the  authors  in  observing  marked  alterations  in  the  gray  substance. 
Similar  alterations  have  been  found  in  the  medulla  oblongata  by  Ketscher 
and  Dana.  In  some  cases  similar  lesions  of  the  vessels  have  been  seen  in 
the  cerebrum,  but  not  the  sclerosis.  Borgherini,  Saas,  Ketscher,  and  Redlich 
have  also  described  alterations  in  the  peripheral  nerves  and  muscles,  consisting 
of  a  proliferation  of  the  connective  tissue  and  a  consequent  atrophy  of  the 
nerve  and  muscular  tissue,  with  thickening  of  the  vessels. 

The  question  has  arisen  as  to  whether  these  alterations  that  are  claimed  to 


292  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

be  characteristic  of  paralysis  agitans  are  not  really  due  to  senility.  About 
twenty  cases  have  been  examined  so  far,  and  in  all  of  these  the  appearances 
have  been  fairly  constant,  and  in  most  of  them  the  severity  of  the  patholog- 
ical lesions  have  borne  a  fair  ratio  to  the  clinical  phenomena.  But  it  is  a 
well-known  fact  that  obliteration  of  the  central  canal  of  the  cord  by  pro- 
liferation of  the  ependymal  cells,  pigmentation  of  the  ganglion  cells,  increase 
of  amyloid  bodies,  and  slight  thickening  of  the  membranes,  are  frequently 
found  in  old  age  in  cases  that  have  j^resented  no  signs  of  j)aralysis  agitans, 
as  has  been  shown  by  the  observations  of  Leyden,  Demange,  and  Redlich. 
The  opinions  of  the  neurological  pathologists  have  diifered  concerning  the 
meaning  of  the  alterations  in  the  vessels,  the  perivascular  sclerosis,  and  the 
increase  of  connective  tissue  running  in  from  the  peripheral  tissue  of  the 
cord.  Most  of  the  authors  are  inclined  to  regard  these  as  purely  senile. 
Ketscher,  in  particular,  made  a  number  of  observations  on  old  people,  and 
found  similar  alterations  of  the  vessels  to  those  which  have  been  described 
in  paralysis  agitans ;  but  the  intensity  of  the  lesions  was  less,  and  the  outer 
horny  layer  which  has  been  described  in  the  latter  affection  is  generally 
Avanting,  as  was  also  the  perivascular  sclerosis,  whilst  it  is  also  to  be  noted 
that  paralysis  agitans,  although  it  generally  occurs  in  individuals  toward 
fifty,  may  yet  occur  in  young  adults.  Demange  has  described  what  he  calls 
a  progressive  tabetic  constricture  of  vascular  origin  of  the  lateral  and 
posterior  columns,  clinically  characterized  by  marked  contractures  of  the 
limbs,  later  of  the  arms,  without  decided  paralysis  or  sensory  irritation, 
or  objective  sensory  defect,  increase  of  the  tendon  reflexes  at  first,  with 
loss  of  them  at  a  later  period.  These  cases  are,  according  to  this  author, 
those  of  chronic  myelitis,  caused  by  an  endo-  and  periarteritis,  and  standing 
in  a  general  relationship  to  general  atheroma.  Copin  has  described  altera- 
tions in  the  aged  of  a  somewhat  similar  nature,  attended  with  muscular 
enfeeblement,  but  without  the  contracture  described  by  Demange.  Gowers's 
senile  paraplegia  probably  belongs  to  the  same  class  of  cases.  Buzzard  has 
described  the  case  of  a  man  of  thirty-nine  who  had  had  syphilis,  then  symp- 
toms of  diplopia,  inability  to  walk  or  stand  without  assistance,  although  the 
legs  could  be  freely  moved  in  bed,  loss  of  patellar  reflex,  one-sided  optic 
nerve  atrophy,  marked  sensory  disturbances  in  the  lower  limbs,  and  immo- 
bility of  the  pupils,  in  whom  there  was  found  a  widespread  peri-  and  endo- 
arthritis,  with  connected  sclerosis  in  the  cervical  and  lumbar  cord,  especially 
in  the  posterior  columns,  and  to  a  much  slighter  degree  in  the  lateral  columns. 
Redlich  has  given  the  histories  of  several  cases  of  old  individuals  in  whom  there 
was  alteration  of  the  vessels,  with  perivascular  sclerosis  in  the  j^osterior  columns, 
particularly  in  the  ventral  portions  of  them,  both  the  lumbar  and  dorsal  cord 
being  especially  affected,  the  cervical  cord  to  a  less  degree,  and  in  some  a  shght 
ascending  degeneration  of  the  columns  of  Goll  being  present,  the  lateral  col- 
umns being  but  slightly  implicated.  From  all  this  it  is  evident  that  the 
character  of  the  lesion  in  paralysis  agitans  is  not  so  pathognomonic  as  is  its 
localization,  for  there  is  no  reason  why  the  same  lesions  present  in  the  cases  of 
Demange  and  Gowers  should  not  produce  the  symptoms  of  paralysis  agitans 
if  they  were  located  differently.  The  two  salient  symptoms  of  paralysis 
agitans  are  the  tremor  and  the  contracture.  Blocq  suggests  that  the  latter 
may  be  due  to  an  affection  of  the  muscles,  but  it  has  not  been  proven,  and 
we  must  therefore  assume  that  both  the  tremor  and  the  contracture  are  due 
to  the  spinal  lesion.  With  our  existing  knowledge  it  would  be  easy  to  sup- 
pose that  the  anatomical  location  of  the  lesion  in  the  lateral  or  anterior 
pyramidal  strands  would  be  sufficient  to  account  for  both  tremor  and  con- 
tracture ;  but,  unfortunately,  most  of  the  autopsies  have  shown  that  the  pos- 
terior columns  are  chiefly  affected.     It  would  seem,  therefore,  as  if  under 


PARALYSIS  AGITANS.  293 

certain  circumstances  the  implication  of  certain  fibres  in  these  posterior  col- 
umns was  to  be  held  accountable  for  the  clinical  symptoms.  Why  it  is, 
however,  that  in  the  cases  of  Demange,  Gowers,  and  Buzzard  the  implica- 
tion of  these  posterior  columns  did  not  j^roduce  the  symptoms  of  paralysis 
agitans  can  only  be  explained  by  the  supposition  that  in  these  cases  a  differ- 
ent set  of  fibres  was  affected.  In  the  cases  of  Demange  and  Redhch  there  was 
only  contracture,  and  no  tremor,  so  that  by  exclusion  it  would  seem  probable 
that  the  tremor  was  not  due  to  implication  of  the  posterior  column,  and  was 
probably  caused  by  affection  of  the  lateral  columns. 

Diagnosis.  The  diagnosis  of  paralysis  agitans  is  in  most  cases  an  easy  one. 
The  symjDtoms  are  so  characteristic  as  to  be  readily  recognized,  even  in  meet- 
ing a  patient  in  a  car  or  on  a  ferry-boat.  They  consist,  as  has  been  said,  of 
a  coarse  tremor,  peculiar  facies,  tendency  to  ruddy  hue  of  the  skin,  the  slow 
deliberating,  hesitating  speech,  the  peculiar  attitude,  the  bread-crumbling 
action  of  the  fingers,  and  the  age  between  forty  and  sixty.  Cases  in  which 
these  typical  symptoms  do  not  appear  are  difficult  of  diagnosis.  In  some 
patients  tremor  does  not  manifest  itself,  and  the  other  symjDtoms  must  then 
be  relied  upon  for  diagnosis.  Again,  some  patients  present  the  tremor,  but 
not  the  characteristic  facies,  color,  attitude,  or  speech,  and  if  this  happens  in 
a  patient  nearly  thirty  a  diagnosis  may  not  be  possible  without  sufficient  time 
to  closely  observe  the  progress  of  the  disease.  The  character  of  the  tromor 
was  formerly  thought  to  be  of  great  importance,  but  such  is  no  longer  the 
case.  I  believe  that  in  the  majority  of  cases  the  tremor  is  present  both  when 
the  patient  is  performing  voluntary  movements  or  is  at  rest ;  but  in  the 
early  stages  of  the  disease  there  are  many  cases  which  manifest  the  tremor 
only  upon  voluntary  movements,  or  in  which  at  such  times  it  is  much  exag- 
gerated. Much  stress  has  been  laid  upon  the  sphygmographic  tracings  ;  but 
these  are  open  to  objection,  because  in  many  cases  the  tremor  is  continuous 
and  fine,  whilst  in  others  it  is  very  coarse  and  not  continuous.  Paralysis 
agitans  should  be  differentiated  fi'om  the  following  diseases : 
Disseminated  sclerosis ; 
The  tremor  of  mercury,  lead  and  copper ; 
AlcohoHsm ; 
Chorea. 

Disseminated  sclerosis  presents  a  tremor  only  during  voluntary  movements 
— so-called  intention  tremor ;  the  patient  is  a  child  or  young  actult ;  there  is 
also  interrupted,  scanning  speech,  and  nystagmus ;  symptoms  of  focal  dis- 
turbance of  the  brain  may  appear,  and  the  characteristic  ruddy  complexion, 
facies,  slow  and  deliberate  speech,  bread-crumbling  position  of  the  fingers, 
and  attitude  of  paralysis  agitans  are  absent. 

In  lead-poisoning  other  symptoms  besides  tremor  will  be  manifested,  such 
as  the  wrist-drop  and  the  "lead-line"  uj^on  the  gums,  conjoined  with  the 
history  of  the  use  of  lead ;  while  the  tremor  of  mercury  and  copper,  as  well 
as  that  of  lead,  is  generally  fine.  The  history  of  copper  or  mercurial  poison- 
ing may  usually  be  obtained. 

Alcoholism  often  presents  a  fine  tremor  which  may  be  of  the  intention 
type,  esjDecially  after  a  debauch,  but  the  diagnosis  will  generally  be  made 
clear  by  the  history  and  appearance  of  the  patient.  In  chronic  alcoholism 
there  may  be  a  tremor,  but  this  need  only  be  observed  in  conjunction  with 
the  well-known  symptoms  and  the  history  of  the  case. 

Sydenham's  chorea  should  never  be  mistaken  for  paralysis  agitans,  as  in 
the  former  the  movements  are  of  the  quickly  beginning  and  ending  type, 
and  fi1)rillary  in  character,  or  in  the  athetoid  variety  they  are  more  gradual 
in  beginning  and  ending,  Avhile  the  patient  is  almost  always  a  child.  In  some 
cases  of  chronic  chorea,  where  proper  treatment  has  been  lacking,  or  frequent 


294  NERVOUS  DISEASES  AND  THEIR  TREAT2IENT. 

relapses  have  taken  place,  the  tremor  may  become  so  spasmodic  and  marked 
as  to  mislead  an  inexperienced  observer,  but  the  diagnosis  will  be  cleared  up 
by  the  history  and  the  character  of  the  symptoms  already  described.  Some 
writers  have  unfortunately  referred  to  the  jerky,  fibrillary  movements  of 
chorea  as  choreic  tremor. 

Treatment.  Definite  and  energetic  treatment  should  be  employed  in  cases 
of  paralysis  agitans.  Drugs,  however  much  vaunted  for  the  purpose,  are 
generally  useless  except  for  temporary  relief  The  expenditure  of  energy 
should  be  restricted.  As  much  as  possible,  all  fatigue  should  be  avoided,  and 
the  patient  should  either  be  put  to  bed  entirely  for  a  time,  or  kept  there  until 
noon  each  day,  retiring  very  early  at  night.  As  the  patient  improves  he  may 
be  allo'wed  to  rise  at  the  usual  time,  but  nothing  of  a  fatiguing  nature  should 
be  undertaken,  and  it  is  much  better  to  rest  too  much  than  too  little.  The 
physician  should  give  explicit  directions  as  to  just  how  many  hours  the 
patient  should  rest,  fixing  the  hours  of  rising  and  retiidng,  and  the  exact 
amount  of  exercise  to  be  j)ermitted.  This  is  of  the  highest  importance,  as 
general  princij)les  of  rest  are  of  no  use  at  all  to  the  inexjDerience  of  the  lay- 
man. Great  attention  should  be  paid  to  the  diet,  which  must  be  of  the  most 
nourishing  and  abundant  character.  Three  good  meals  should  be  taken  each 
day,  and  in  addition  to  this  it  is  advisable  for  the  j^atient  to  take  a  quart  of 
milk  during  the  twenty-four  hours ;  and  it  may  be  even  usefiil  to  give  beef 
tea,  using  a  pound  of  beef  made  into  beef  tea,  or  else  a  preparation  of  beef 
extract  or  of  the  peptonoids.  Stimulation  by  alcohol  should  always  be  resorted 
to,  and  it  may  be  either  in  the  form  of  two  or  three  ounces  of  whiskey  in  the 
twenty-tour  hours,  or  of  wine  or  ale,  an  equivalent  quantity  of  alcohol  being 
obtained  in  the  latter.  Xutrition  is  also  greatly  assisted  by  malt  extracts,  of 
which  only  fresh  and  reliable  preparations  should  be  prescribed.  The  solid 
malt  extracts  are  better  than  the  liquid,  as  the  precise  C[uantity  of  malt  can  be 
better  obtained  in  them,  but  in  case  the  liquid  form  be  more  agreeable  to  the 
patient,  it  may  be  used.  Tonics  are  alAvays  necessary,  and  the  best  of  these  is 
the  sulphate  of  quinine,  which  should  be  given  three  times  a  day,  in  doses  of  2 
or  3  grains,  an  hour  or  two  after  meals,  in  order  that  no  disturbance  of  diges- 
tion may  be  occasioned  by  it,  and  the  best  form  is  the  tablet  triturate.  It 
should  not  be  administered  in  solution  with  an  acid,  as  this  is  apt  to  act  un- 
favorably upon  digestion.  Besides  these  measures  of  rest,  alcoholic  stimulant, 
diet  and  tonics,  the  tremor  requires  remedies  to  be  applied  with  a  direct  view 
to  its  control.  The  best  agent  for  this  jiurpose  is  hyoscyamine,  the  crystallized 
form,  as  unpleasant  constitutional  efiects  are  ajDt  to  be  produced  by  the  uncrys- 
tallized  form.  One  y^^  grain  should  be  employed  once  or  twice  a  day,  and 
continued  for  weeks  or  months,  as  may  be  found  necessary.  Ten  grains  of  the 
bromide  of  potash  may  be  combined  with  the  hyoscyamine,  if  the  latter  does 
not  sufiiciently  control  the  tremor.  This  should  also  be  given  once  or  twice  a 
day,  usually  for  several  months  continuously.  Hyoscine  also  seems  to  be  quite 
useflil,  either  in  the  hydrochlorate  or  the  hydrobromate,  although  my  own 
experience  of  it  has  not  been  sufficient  to  enable  me  to  give  a  positive  opin- 
ion as  to  whether  it  ■svill  supplant  the  hyoscyamine,  which  would  be  desirable, 
as  it  possesses  none  of  the  objectionable  properties  of  the  latter  in  causing 
dryness  of  the  mouth  and  dilating  the  pupils,  and  it  can  be  given  much  more 
fi'equently.  The  treatment  thus  outlined,  consisting  of  rest,  diastase,  alco- 
holic stimulation,  and  muscular  sedatives  like  those  mentioned,  comprises  all 
that  is  needed  in  paralysis  agitans.  I  believe  that  observers  have  been  often 
misled  by  the  ruddy  color  of  the  face,  have  thus  refrained  fi'om  admin- 
istering stimulants,  and  have  given  the  sedatives  to  such  an  extent  that 
patients  have  been  unduly  depressed  ;  but  I  have  found  that  nourishing  and 
stimulative  treatment  alone  will  accomplish  more  than  the  exclusive  use  of 


PARALYSIS  AGITANS.  295 

the  sedatives.  Galvanism  is  a  nervous  stimulant  of  a  high  degree  of  useful- 
ness, and  should  almost  always  be  employed.  It  should  be  resorted  to  at 
least  three  times  a  week,  and  one  large  electrode  should  be  applied  to  the 
nape  of  the  neck,  while  a  smaller  one  is  placed  at  the  lower  dorsal  spine. 
Hot  water  should  be  used  to  moisten  both  the  electrode  and  the  skin.  From 
three  to  five  minutes  should  be  occupied  at  a  sitting,  and  a  current  of  three 
to  five  milliamperes  should  be  used,  and  this  may  be  increased  to  a  sitting  of 
five,  fifteen,  or  twenty  minutes,  and  to  a  cvirrent  of  ten  to  fifteen  milliamperes. 
I  can  positively  assert  that  with  this  treatment  most  cases  of  paralysis  agitans 
can  be  modified  so  that  the  patient's  life  may  be  made  comparatively  pleasant. 
If  eight  or  twelve  weeks  of  this  treatment  bring  relief,  the  hyoscyamine  and 
bromide  may  be  gradually  withdrawn,  the  galvanism  discontinued,  and  the 
rest,  the  diet,  the  diastase,  and  the  alcoholic  stimulant  will  be  found  to  be  all 
that  is  necessary.  The  same  means  can  be  employed  to  control  recurring 
exacerbations,  which  usually  take  place  in  the  course  of  a  few  weeks  or 
months.  I  tell  my  patients  frankly  that  a  complete  cure  cannot  be  ex- 
pected, and  that  these  relapses  must  therefore  be  looked  for  and  combated  by 
treatment,  so  that  no  alarm  need  be  felt  at  their  recurrence.  In  those  cases 
Avhich  occur  after  a  hemiplegia  affecting  only  one  limb  or  one  side,  there  is, 
unfortunately,  not  much  hope  of  improvement.  But  the  cases  of  paralysis 
agitans  w^hich  occur  after  hemiplegia  should  not  be  confounded  with  those  of 
sudden  onset  in  one  limb,  for  the  latter  are  usually  only  the  local  manifesta- 
tion of  a  general  paralysis  agitans  which  wall  yield  to  the  therapeutic  meas- 
ures that  have  been  laid  down. 


CHAPTER   XI. 

EPILEPSY. 

By  LANDON  carter  GRAY,  M.D. 

Synonyms.  Latin,  Morbus  sacer  seu  comitialis ;  French,  I'Epilepsie  ; 
German,  Fallsucht ;  Spanish,  Mai  caduco. 

Definition.  Epilepsy  is  derived  from  eTviXa/iSavu  meaning  "the  falling- 
sickness, "  as  a  loss  of  equilibrium  was  the  first  phenomenon  that  attracted 
attention.  But  since  that  time  the  term  has  been  applied  to  a  far  wider 
range  of  phenomena,  which  are  characterized  by  a  sudden  loss  of  conscious- 
ness, with  convulsions  affecting  muscles  in  varying  degree,  or  loss  of  con- 
sciousness without  muscular  implication,  or  muscular  convulsions  without  loss 
of  consciousness ;  and  it  is  also  given  to  conditions  of  alternating  conscious- 
ness, as  well  as  to  certain  mental  phenomena  that  are  supposed  by  some 
authors  to  be  the  equivalents  of  the  convulsive  or  comatose  symptoms. 

History.  The  disease  has  been  known  as  far  back  as  the  time  of  Hippo- 
crates, but  it  has  been  confounded  with  hysteria  and  other  nervous  affec- 
tions, as  in  the  case  of  Mahomet,  for  instance,  who  was  probably  afflicted 
with  what  is  known  now  as  hysteria  major,  whilst  the  oft-cited  case  of  Napo- 
leon the  Great  does  not  answer  at  all  to  the  description  of  what  we  nowa- 
days know  as  epilepsy  ;  indeed,  our  exact  knowledge  of  the  subject  has  been 
gained  largely  within  the  last  twenty  years,  synchronously  with  the  informa- 
tion we  have  obtained  concerning  the  anatomy  and  the  functions  of  the  nerv- 
ous system. 

Symptoms.  The  principal  clinical  forms  assumed  by  epilepsy,  or  rather 
epileptiform  affections,  ai'e  the  following : 

Grand  mal ;  major  epilepsy ; 

Petil  mal ;  minor  epilepsy  ; 

Convulsive  movements  without  loss  of  consciousness  , 

Vertigo ; 

Double  consciousness ; 

Hystero-epilepsy  ; 

Procursive  epilepsy. 

Laryngeal  epilepsy. 
When  we  speak  of  typical  cases  we  mean  those  that  are  the  most  numer- 
ous. In  this  sense  the  typical  attack  of  epilepsy  consists  of  a  sharp  cry,  an 
instantaneous  loss  of  consciousness  in  which  the  patients  falls  heavily,  the 
rapid  supervention  of  tonic  and  then  of  clonic  convulsions,  both  of  the 
latter  being  of  short  muscular  range  and  automatic  in  character  rather  than 
purposive,  these  phenomena  lasting  for  several  seconds  or  minutes,  when  the 
patient  becomes  quiet,  awakens  into  a  dazed  consciousness,  and  then  gradu- 
ally sinks  into  a  deep  sleep  lasting  one  hour  or  several.  This  is  known  as 
the  grand  mal.  But  the  deviations  from  this  type  are  innumerable.  The 
most  frequent  is  the  so-called  petit  mal.  This  consists  of  a  loss  of  conscious- 
ness so  slight  that  it  seems  often  like  mere  absent-mindedness.     The  eyes  may 


EPILEPSY.  297 

turn  upward  and  have  a  staring  appearance,  and  there  may  be  some  slight 
fibrillary  movements  of  the  facial  muscles,  and  I  believe,  as  is  claimed  by 
Hughlings-Jackson,  that  these  slight  muscular  movements  always  occur  in 
these  cases  ;  but  they  may  readily  be  overlooked,  a  fact  which  is  of  great 
medico-legal  importance  as  bearing  upon  the  nature  of  the  serious  maniacal 
attacks  which  may  follow,  and  during  which  assaults  or  murder  may  be  com- 
mitted. In  other  cases  there  may  be  only  convulsive  movements  of  the 
muscles,  as  in  one  patient  of  mine  who  could  never  undertake  to  carve  at  his 
dinner-table  because  of  the  tendency  that  his  arms  had  to  fly  a2:)art  and 
whirl  carving  knife  and  fork  in  eccentric  and  dangerous  orbits.  A  sensation 
of  vertigo  very  frequently  occurs  in  epileptic  individuals  in  the  intervals 
between  the  grand  and  j^etit  mal  attacks  ;  but,  so  far  as  may  exj)erience  goes, 
it  never  occurs  without  more  pronounced  evidences  of  epilepsy,  and  can 
therefore  be  readily  distinguished  from  true  attacks  of  vertigo,  which  are  so 
common  from  other  and  harmless  causes. 

The  conditions  of  double  consciousness  occur  after  the  attacks  of  grand  or 
petit  mal,  and  there  is  no  limit  to  their  variety.  I  believe  that  many  of  the 
cases  that  figure  in  the  newspapers  of  people  wandering  away  from  home 
and  coming  to  themselves  afterward  in  far-a-way  places  may  be  ascribed  to 
this  cause.  One  singular  instance  of  this  was  a  boy  who  came  to  my  clinic. 
He  would  leave  home  after  an  attack  of  grand  mal,  disappear  into  the  slums 
of  the  city,  engage  in  some  menial  occupation  far  below  his  usual  social  sta- 
tion, fill  it  without  arousing  the  slightest  suspicion  in  those  about  him,  and 
suddenly  return  to  his  normal  condition  of  consciousness  after  several  weeks, 
when  he  would  return  home  very  much  discouraged  and  amazed.  Of  these 
varieties  the  most  fr'equent  is  the  grand  mal,  and  next  the  petit  mal.  In  many 
of  these  attacks  there  are  certain  sensations  known  as  aune,  and  these  vary 
extremely  in  kind,  depending  probably  on  the  localization  of  the  lesion  in 
the  nervous  system.  The  color  of  the  face  in  these  attacks  is  very  variable, 
sometimes  pale,  sometimes  sufiused,  sometimes  cyanotic,  and  sometimes  there 
is  no  alteration  at  all.  The  statements  of  on-lookers  regarding  this  fact 
are  apt  to  be  unreliable,  as  the  latter  are  usually  too  much  disturbed  to  be 
accurate  observers,  whilst  the  physician  himself  seldom  sees  an  attack,  even 
if  he  be  the  resident  of  a  hospital,  for,  Avhile  I  have  probably  treated  thou- 
sands of  cases,  I  could  easily  count  on  my  fingers  all  those  that  I  have  ob- 
served during  the  attack  itself. 

Hystero-epilepsy  is  the  name  given  to  an  odd  combination  of  hysteria  and 
epilepsy,  and  the  descriptions  are  largely  due  to  the  writings  of  the  phy- 
sicians of  that  great  neurological  hotbed,  the  Salpetriere  of  Paris.  But  the 
cases  that  have  been  seen  in  England  and  this  country  are  of  a  far  less  sen- 
sational nature.  True  hystero-epilepsy  rarely  begins  with  a  cry  or  change  of 
facial  color,  but  generally  with  the  tonic  convulsions  of  true  epilepsy.  These 
are  followed  by  a  so-called  "  clownishness,"  which  is  characterized  by  all 
sorts  of  absurd  movements,  opisthotonos,  distended  abdomen,  cramps,  etc. 
Then  succeed  a  series  of  passionate  attitudes,  with  delirium.  It  has  been  in 
these  cases  especially  that  ovarian  compression  has  been  so  much  vaunted, 
but  I  have  not  found  it  of  much  use.  Hystero-epilepsy  differs,  however, 
radically  from  true  epilepsy  in  the  admixture  of  predominance  or  purposive 
or  seemingly  purposive  movements,  instead  of  a  tonic  muscular  movement 
of  shock-like  character  and  of  limited  muscular  range,  while  opisthotonos,  a 
symptom  rarely  or  never  seen  in  true  epilepsy,  is  occasionally  observed.  (See 
also  page  97.) 

Procursive  epilepsy  has  been  recently  described  by  Marie,  and  consists  of 
running  movements  forward,  but  otherwise  presenting  the  usual  phenomena. 
It  may  alternate  with  ordinary  epilepsy,  precede  it,  or  merge  into  it. 


298  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  so-called  laryngeal  vertigo  is  unquestionably  a  variety  of  epilepsy,  and 
the  term  vertigo  ought  to  be  discarded,  because  it  should  be  reserved  for  those 
subjective  sensations  of  dizziness  without  loss  of  equilibrium  which  are  not  usu- 
ally accompanied  or  followed  by  any  impairment  of  consciousness.  As  yet 
this  foi'm  has  only  been  described  in  adults.  It  consists  of  a  slight  loss  of  con- 
sciousness, occasionally  with  light  tonic  or  clonic  movements,  and  the  exciting 
cause  is  some  laryngeal,  tracheal,  or  bronchial  affection,  such  as  laryngeal 
tumors,  asthma,  etc.  Although  the  cases  so  far  reported  have  ceased  after  the 
cure  or  removal  of  the  seeming  cause,  the  histories  have  not  as  yet  extended 
over  sufficient  time  to  Ayarrant  us  in  stating  that  they  may  not  recur. 

In  some  cases  of  ejDilepsy  what  is  known  as  the  status  ejjilepticus  may  be 
observed,  consisting  of  frequently  recurring  attacks  of  convulsions  with  inter- 
vening unconsciousness,  both  lasting  for  hours  or  days.  This  may  be  observed 
in  almost  any  patient  from  whom  the  bromide  has  been  suddenly  withdrawn 
after  he  has  been  accustomed  for  a  long  time  to  large  doses  of  it. 

In  some  epileptics  the  disappearance  of  the  epilepsy  may  lead  to  the  super- 
vention of  certain  so-called  equivalents,  one  of  which  is  a  jDeculiar  dream-like 
state,  another  the  so-called  larvated  epilepsy  of  Falret,  consisting  of  an  out- 
break of  hysterical  insanity,  usually  of  the  maniacal  t^q^e,  or,  as  I  have 
occasionally  seen,  an  attack  of  violent  migraine,  great  irritability  of  temper 
or  enuresis.  Falret  claims  that  there  is  never  a.n\  petit  ma  I  preceding  these 
attacks,  but  Hughlings-Jackson  has  called  attention  to  the  fact,  which  I  have 
already  alluded  to,  that  petit  mal  may  be  very  readily  overlooked,  because  of 
its  short  duration  and  the  slightness  of  the  muscular  twitchings  of  the  face. 

Much  confusion  has  been  injected  into  the  subject  by  the  failure  to  recog- 
nize that  epilepsy  is  only  a  symptom,  just  as  is  fever  or  cough,  and  that  in 
every  case  the  question  of  diagnosis  is  resolved  into  the  further  one  of  what 
the  epilepsy  is  a  symptom  of.  From  this  point  of  view  we  may,  therefore, 
divide  all  epilepsies  into  those  that  are  due  to  recognizable  organic  disease  and 
tho.se  that  are  idiopathic. 

Idiopathic  epilepsy  can,  of  course,  only  be  diagnosed  when  the  different 
organic  lesions  have  been  excluded,  but  it  has  certain  features  which  are  of 
importance  from  a  therapeutic  and  diagnostic  standpoint,  and  prominent 
among  these  are  the  nocturnal  recurrence  of  some  attacks,  the  quasi-periodicity 
of  others,  the  association  with  migraine,  and  the  temporary  response,  usually 
in  a  favorable  way,  to  slight  changes  in  the  environment  or  the  treatment. 
I^octurual  epilepsy  should  always  be  suspected  in  an  individual  who  is  heredi- 
tarily predisposed  or  who  wakes  in  the  morning  exhausted  and  pale.  For 
some  thirteen  years  I  have  been  calling  attention  to  the  quasi-periodicity  of 
many  epilepsies,  manifested  sometimes  by  a  recurrence  of  the  attacks  at  cer- 
tain periods,  as  in  females  at  menstruation,  or  in  others  at  certain  times  of  the 
month  or  at  certain  intervals,  the  latter  sometimes  lasting  months  or  even  years. 
For  thirteen  years,  too,  I  have  been  lecturing  upon  the  conjunction  of  epi- 
lepsy with  migraine,  and  I  had  not  known  until  the  publication  of  Fere's 
book,  in  1890,  that  Tissot,  Parry,  and  Liveing  had  previously  observed  the 
same  fact.  In  these  cases  the  migraine  alternates  with  the  epilepsy,  the  former 
disajipearing  upon  the  supervention  of  the  latter,  and  vice  versa.  This  does 
not  imply  that  all  cases  of  migraine  are  subject  to  epilepsy,  but  only  that 
there  is  a  very  close  relationship  between  the  two  diseases  ;  and  I  may  further- 
more state  my  belief  that  almost  all  cases  of  migraine,  if  carefully  examined, 
will  be  found  at  some  period  to  have  had  a  loss  of  consciousness,  Avith  or  with- 
out convulsive  movements.  It  is  not  generally  known  that  epileptics  are 
readily  infhienced  by  slight  changes  in  the  environment  and  in  the  treatment, 
a  fact  which  explains  why  ej^ileptics  almost  always  do  well  upon  any  change 
of  treatment,  whether  this  be  medical  or  surgical — whether  it  consist  of  cut- 


EPILEPSY.  299 

ting  off  the  prepuce,  removing  the  clitoris,  extirpating  ovaries,  doing  opera- 
tions upon  the  male  or  female  genitalia,  using  the  hot  iron  or  moxa,  cutting 
the  eye  muscles,  or  even,  as  in  one  case  of  my  own,  in  etherizing  the  patient 
and  cutting  a  piece  of  skin  out  of  the  buttock.  Moreover,  these  epileptic 
attacks  are  very  prone  to  recur  in  variable  spells,  eveiy  day  or  every  alternate 
day  for  weeks  or  perhaps  months,  then  disappearing  for  a  variable  length  of 
time.  Most  epileptics,  as  I  have  pointed  out,  have  large  and  variable  pupils. 
Marie  and  Musso  have  contradicted  me  upon  this  point,  but  the  very  varia- 
bility of  the  pupils  renders  their  measurements  inconclusive.  Most  epileptics 
have  peculiar  facies,  which  it  is  impossible  to  describe  or  photograph,  but 
which  may  be  readily  detected  by  the  trained  eye.  This  facial  characteristic 
is,  of  course,  much  more  marked  in  those  who  have  been  for  a  long  time 
under  the  bromide  treatment,  and  to  it  will  be  superadded  a  peculiar  restless- 
ness, pallor,  acne,  coated  tongue,  and  the  peculiar  breath.  The  temper  of 
most  epileptics  is  extremely  irritable,  and  especially  is  this  the  case  in  children 
whose  malady  has  caused  their  parents  or  relatives  to  spoil  them. 

Etiology.     The  following  factors  bear  certain  relationships  to  epilepsy : 

Age; 

Sex ; 

Heredity ; 

Migraine ; 

Organic  brain,  spinal,  or  peripheral  lesions ; 

Traumata ; 

Lesions  or  impairment  of  functions  of  non-nervous  organs ; 

Hysteria ; 

Malnutrition. 
By  far  the  largest  proportion  of  cases  occur  under  nineteen  years  of  age, 
and  most  frequently  from  ten  to  nineteen.  After  this  the  greatest  number 
are  observed  from  ten  to  twenty-nine  ;  and  after  the  latter  age  there  is  a  rapid 
decrease  in  frequency,  until  the  cases  become  very  infrequent  after  fifty,  still 
more  so  after  sixty  years  of  age.  I  have  been  for  years  in  the  habit  of  show- 
ing by  the  histories  of  my  clinical  patients  that  many  cases  of  idiopathic 
epilepsy  will  begin  with  a  fit  in  early  infancy,  after  which  no  convulsions 
may  occur  for  a  year  or  for  years,  when  the  attacks  will  again  appear,  and  at 
this  or  some  later  period  the  case  will  become  well  marked. 

Females  are  rather  more  subject  to  epilepsy  than  males  ;  and  heredity  oc- 
curs in  about  one-third  of  the  cases.  It  is  undoubtedly  true  that  epilepsy 
may  be  caused  by  diseases  of  the  heart  and  of  the  kidneys,  by  impair- 
ment of  functions  of  the  gastro-intestinal  organs,  and  of  the  lungs ;  but  this 
is  rare,  and  the  so-called  genital  epilepsy  is  a  myth. 

The  association  of  hysteria  and  epilepsy  is  by  no  means  frequent. 
Profound  malnutrition  may  be  a  cause  of  epilepsy,  for  I  have  had  several 
cases  in  which  the  attacks  have  disappeared  for  ten,  eleven,  five,  seven,  or 
nine  years  after  the  restoration  of  the  general  health. 

Pathology.  Epilepsy  may  be  divided  pathologically  into  two  great  classes  : 
first,  that  which  may  be  referred  to  organic  disease,  and  second,  idiopathic 
epilepsy. 

Organic  epilepsy  may  be  caused  by  syphilis  of  the  nervous  system ;  dis- 
eases of  the  peripheral  nerves ;  meningitis,  either  cerebro-si^inal,  tubercular, 
or  suppurative ;  tumors  of  the  brain ;  abscesses  of  the  brain  ;  ear  disease  ; 
sclerosis  of  the  brain  and  cord  ;  the  cerebral  palsies  of  childhood  (due  to 
such  lesions  as  jDoren cephalitis,  hemorrhage  from  the  cerebral  arteries,  em- 
bolism or  thrombosis  of  the  cerebral  arteries  or  veins.) 

Very  little  is  known  of  the  pathology  of  the  idiopathic  form.  Neurolo- 
gists have  now  almost  entirely  discarded  the  old  theory  of  vasomotor  spasm 


300  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

producing  cerebral  anaemia  or  hypersemia,  for  no  logical  proof  of  it  has 
ever  been  produced.  Convulsions  may  be  induced  by  great  hemorrhage  or 
by  ligature  of  the  carotid  artery ;  but  the  profound  ischsemia  thus  result- 
ing has  never  been  proven  to  be  present  in  the  attacks  of  idopathic  epi- 
lepsy ;  whilst,  on  the  contrary,  there  is  much  to  show  that  no  marked  vascular 
alterations  take  place  in  the  cerebrum  of  epileptic  human  beings  and  ani- 
mals. Vulpian  has  found  that  no  hypersemia  or  ischsemia  appears  during 
an  attack  of  epilepsy  artificially  produced  in  guinea-pigs.  No  warrant 
exists  for  the  conclusion  drawn  by  some  authors  from  the  facial  circulation, 
it  being  by  no  means  an  index  to  the  cerebral  circulation,  as  it  often 
happens  that  in  a  profound  hypersemia  of  the  cerebral  meninges  the  face 
may  be  deadly  pale.  This  also  applies  to  deductions  that  might  be  drawn 
from  the  condition  of  the  circulation  of  the  retina.  A  sclerotic  condition 
of  the  brain  will  be  found  in  some  cases  of  idiopathic  epilepsy,  and  in 
some  the  pia  mater  will  be  the  seat  of  an  old  meningitis,  whilst  no  lesions 
are  discoverable  in  many  cases.  Much  discussion  of  the  probability  of 
sclerosis  of  the  cornu  ammonis  being  a  cause  of  epilepsy  has  taken  place ; 
but  this  is  by  no  means  a  constant  feature,  and  it  is  impossible  to  demon- 
strate whether  it  is  a  cause  or  an  effect.  Great  stress  has  been  laid  upon  a 
peculiar  variety  of  sclerosis  by  Barthez  and  Rilliet,  to  which  they  have 
given  the  name  of  tuberous  or  hypertrophic  sclerosis,  but  the  same  objec- 
tions which  have  been  brought  to  sclerosis  of  the  cornu  ammonis  also 
apply  to  this.  In  five  epileptic  brains  examined  by  Chaslin,  at  the  request 
of  Fere,  neurogliar  sclerosis  was  found  in  four.  The  convolutions  were 
small,  hard,  smooth,  or  slightly  roughened,  macroscopically  shrivelled.  No 
abnormalities  or  adhesions  of  the  pia  mater  were  observed.  A  great  irreg- 
ularity in  distribution  over  the  surface  of  the  cerebrum  prevailed,  large 
normal  portions  sometimes  extending  to  the  medulla  oblongata  or  the  cornu 
ammonis.  The  olivary  bodies  were  only  thus  affected  in  one  case.  A 
microscopical  examination  of  the  fundamental  lesion  shows  that  the  cere- 
bral tissue,  especially  the  gray  cortex,  had  been  invaded  by  a  number  of 
rough  fibrillse  of  uncertain  length.  The  author  says  :  "  In  the  normal  state 
the  first  layer  of  the  gray  cortex  contains  certain  so-called  spider  cells, 
whose  prolongations  are  scarcely  visible.  In  this  condition,  on  the  contrary, 
this  first  layer  is  formed  by  a  bundle  of  fibrils  arranged  nearly  parallel  to 
the  cerebrum,  and  it  can  be  distinctly  seen  to  originate  from  numerous  cells 
with  hypertrophied  prolongations.  In  the  preparation  which  I  am  viewing 
at  this  moment  there  is  a  place  where  this  transformation  invades  all  the 
layers,  but  leaves  intact  numerous  nerve  cells  and  vessels.  It  can  be  seen, 
moreover,  that  in  a  certain  space  these  fibrillse  form  in  the  depth  of  the 
cortex  a  network  of  nodal  points  in  which  lie  the  cells  of  the  neuroglia. 
Finally,  and  I  would  call  attention  particularly  to  this  fact,  this  first  layer 
is  studded  in  places  by  large  compact  bundles,  which  are  evidently  formed 
from  these  fibrillse.  I  would  observe,  in  passing,  that  the  vessels  which  re- 
main do  not  present  a  trace  of  inflammation,  there  being  simply,  in  certain 
points,  a  hyaline  transformation  of  the  capillary  wall."  There  is  a  question 
in  my  mind  whether  Chaslin  has  not  regarded  as  connective  tissue  what 
Cajal  has  recently  demonstrated  to  be  protoplasmic  prolongations  of  the 
nerve  cells  of  the  molecular  layer  of  the  cortex.  Chaslin  adopts  certain 
of  Ranvier's  views,  and  maintains  that  a  distinction  should  be  made  be- 
tween the  connective  tissue  of  mesodermic  origin  and  the  neuroglia,  which 
is  of  epithelial  or  ectodermic  origin ;  the  latter  embracing  Miiller's  fibres 
of  the  retina,  the  fibres  and  cells  of  the  neuroglia  in  the  spinal  cord,  and 
the  slightly  differentiated  prolongations  of  the  spider  cells  in  the  brain.  He 
describes,  for  the  first  time,  this  peculiar  neurogliar  sclerosis,  which  is,  he 


EPILEPSY.  301 

claims,  entii'ely  distinct  from  a  sclerosis  of  the  connective  or  mesodermic  tissue. 
The  peculiar  iibrillae  are  emanations  fr'om  the  neuroglia  cells,  indirect  proof 
of  the  same  assertion  being  found  in  the  non-adherence  of  the  pia  mater 
and  the  vesseLs.  These  filDrillffi  resist  the  successive  action  of  a  40  per  cent, 
solution  of  potassa  for  ten  minutes,  as  well  as  washing  with  water  and  con- 
centrated acetic  acid,  whilst  the  picrocarmine  color  remains  after  washing, 
and  formic  glycerin  is  an  efficient  preservative.  Treated  in  this  manner, 
the  connective  tissue  swells  and  decolorizes,  so  that  the  neuroglia  will  be 
intact  in  a  section  of  the  spinal  cord,  whilst  the  pia  mater  will  also  be  decolor- 
ized and  swollen.  Moreover,  after  the  action  of  alcohol  diluted  to  one- 
third,  all  other  forms  of  the  connective  tissue  are  decolorized,  but  these 
fibrillse  remain  colored  by  the  carmine  when  subjected  to  the  acetic  acid. 
This  pathological  distinction  of  Chaslin's  merits  attention  on  account  of  its 
definiteness.  Bevan  Lewis  has  observed  certain  striking  changes  in  the  cells 
of  the  second  layer  of  the  cortex,  and  in  some  cases  this  degeneration  has 
been  seen  to  affect  all  the  layers,  including  the  sjoider  cells. 

This  indefinite  knowledge  of  the  pathology  of  epilejjsy  is  no  more  exact 
than  that  of  the  modus  operandi.  The  older  writers  held  that  the  medulla 
oblongata  was  the  portion  of  the  nervous  system  most  concerned  in  the  symp- 
tomatology. Xothnagel  claimed  that  there-Avas  a  certain  area  in  the  floor  of 
the  fourth  ventricle  which  he  called  the  con^iilsive  centre,  and  that  ii'ritation  of 
this  caused  the  epileptic  conAiiLsions.  He  regarded  this  as  the  vasomotor  centre 
of  the  medulla  oblongata.  Wernicke  holds  that  the  location  of  this  area 
corresponds  with  the  lateral  motor  field  of  the  tegmentum  in  the  pons.  Com- 
plete section  of  this  region  did  not  produce  death  by  bleeding  nor  convul- 
sions, and  a  simple  section  will  suffice  as  an  irritant.  Violent  and  generalized 
convulsions  are  caused  by  the  near  approach  of  the  section  to  the  corpora 
quadrigemina,  and  a  simple  deep  section  will  cause  convulsion  of  the  lower 
extremities.  This  area  of  Xothnagel's  is  the  point  of  termination  of  the  so- 
called  long  nerv^e  strands  in  which  run  the  fibres  of  the  up2:)er  and  lower  ex- 
tremities, as  has  been  demonstrated  by  Osjannikow,  so  that  it  simply  adds 
another  fact  to  our  knowledge  of  the  various  focal  lesions  causing  epilejosy. 
Van  der  Kolk  had  an  airy  theory  to  the  effect  that  the  nuclei  of  origin  of 
the  hypoglossal  nerve  in  the  floor  of  the  fourth  ventricle  were  indurated  in 
proportion  to  the  amount  of  tongue-biting  which  was  manifested  in  the  con- 
vulsions, but  this  is  scarcely  worth  mentioning,  much  less  soberly  discussing. 
Fritsch  and  Hitzig  have  by  their  experiments  accumulated  facts  tending  to 
demonstrate  that  indirect  excitation  of  the  cortex  or  of  the  nerve  strands 
leading  to  the  peripheral  sti'uctures  is  causative  of  epilepsy  in  a  great  num- 
ber of  cases,  and,  in  the  light  of  these  discoveries,  Nothnagel's  observation 
has  only  demonstrated  a  similar  subsidiary  centre.  It  has  been  shown 
again  and  again  that  convulsive  attacks  of  clonic  or  tonic  nature  can  be  pro- 
duced by  mechanical  or  electrical  irritation,  and  that  the  same  effects  can  be 
caused  by  similar  irritation  of  the  nerve  strands  underlying  the  cortex.  Duret 
has  experimented  in  this  direction  also,  and  has  produced  the  most  wide- 
spread convulsions  by  irritation  of  the  cei'ebral  membranes,  particularly  the 
dura  mater.  It  should  not  be  forgotten,  however,  that  many  extra-cranial 
lesions  may  be  productive  of  epilepsy,  such  as  diseases  of  the  spinal  cord, 
alterations  in  the  blood,  such  as  are  to  be  found  in  malnutrition  and  albumi- 
nuria, disorders  of  the  peripheral  nervous  system,  as  Avell  as  of  many  of  the 
non-nervous  viscera,  and  by  various  febrile  conditions  and  toxic  agents,  so 
that  it  would  be  presumptuous  to  a.ssert  that  the  cortex  of  the  brain  is  alone 
affected  in  all  these  varying  conditions.  The  truth  probably  is  that  the  epi- 
leptic manifestations  are  due  to  a  peculiar  molecular  condition  of  the  motor 
tract  running  from  the  motor  convolutions  to  the  peripheral  structures  and 


302  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

muscles.  But  as  to  the  exact  uature  of  this  molecular  couditiou  we  are  in 
complete  ignorance,  as  we  are  also  ignorant  of  the  conditions  producing  any 
one  of  the  functional  nervous  diseases,  and  it  is  highly  probable  that  such  lack 
of  knowledge  will  prevail  until  in  the  far-oif  future  such  precise  appliances 
will  be  ours  that  we  will  be  enabled  to  see  the  molecular  play  in  the  living 
brain  and  spinal  cord,  or  until  our  methods  of  preparation  and  staining  are 
so  perfected  that  we  can  detect  such  minute  cellular  alterations  as  have  thus 
far  escaped  our  observation.  Many  metaphysical  theories  have  been  offered 
of  these  cellular  changes,  but  they  are  too  puerile  and  ridiculous  to  merit 
any  attention.  Whatever  this  altered  molecular  conditions  may  be,  there 
is  no  doubt  that  it  expresses  itself  in  epilepsy  through  the  motor  tract  run- 
ning from  the  motor  convolutions  to  the  muscles  of  the  periphery.  Muscles 
can  only  be  convulsed  by  direct  excitation  of  the  muscles  itself,  or  of  the 
motor  tract  leading  up  to  the  convolutions,  or  of  the  convolutions  them- 
selves. (See  in  this  connection  also  Chapters  XIV  and  XVI.)  But  some 
varieties  of  epilepsy  are  due  to  an  excitation  of  the  nervous  system  in  some 
part  that  extends  beyond  this  motor  tract,  as  is  manifested  by  such  symptoms 
as  word-deafness,  hemianopsia,  aphasia,  or  the  forward  movements  of  pro- 
pulsive epilepsy,  indicating  a  lesion  in  the  corresponding  centres  of  the  cor- 
tex, or  cerebellum,  or  the  nerve  strands  underlying  them ;  and  the  correct- 
ness of  this  view  has  been  demonstrated  by  autopsies ;  while  in  the  convul- 
sion arising  from  lesions  of  non-nervous  organs,  from  toxic  agents,  and  from 
diathetic  conditions,  in  direct  implication  of  this  motor  tract,  must  be  the 
cause.  Idiopathic  epilepsy,  like  migraine,  neuralgia,  chorea,  and  hysteria, 
is  therefore  a  neurosis,  and  it  is  a  matter  of  grave  doubt  whether  the  cellular 
and  sclerotic  changes  discovered  are  not  effects  rather  than  causes. 

Diagnosis.  The  fact  should  ever  be  borne  in  mind  that  epilepsy  is  a  symp- 
tom, and  the  object  should  be  to  discover  of  what  it  is  a  symptom.  Our 
chief  efforts  should  be  directed  to  ascertaining  whether  it  is  caused  by  any 
organic  disease,  such  as  lesions  of  the  brain,  spinal  cord,  or  peripheral  nerves  ; 
whether  it  is  related  to  nephritis,  malnutrition,  heart  disease,  marked  gastro- 
intestinal disturbances,  or  whether  it  accompanies  the  cerebral  palsies  of  child- 
hood. 

After  the  exclusion  of  all  these  organic  lesions  a  diagnosis  of  idiopathic 
epilepsy  may  be  made.  Tliis  should  not  be  difficult.  The  convulsions  are 
tonic  or  clonic,  with  loss  of  consciousness,  or  are  of  slight  force,  with  loss 
or  simply  impairment  of  consciousness,  and  need  only  be  differentiated  from 
simulation  and  hysteria.  Hysterics  do  not  fall  and  bruise  themselves,  or  bite 
the  tongue,  as  epileptics  do,  for  true  hysterical  attacks  have  not  the  same  loss 
of  consciousness.  Moreover,  the  movements  of  hysteria  are  of  a  volitional 
character  to  a  large  extent,  and  also  of  wider  range,  whilst  in  epilepsy  the 
muscular  movements  consist  only  of  simple  rigidity,  Avith  slight  tremor,  ex- 
tending only  over  a  short  period  of  time,  or  of  limited  flexions  and  exten- 
sions. However,  it  should  be  borne  in  mind  that  in  hystero-epilepsy,  true 
hysteria  and  true  epilepsy  may  be  conjoined. 

Epilepsy  is  rarely  simulated  in  this  country,  except  in  some  prisons,  where 
a  transfer  to  the  hospital  or  asylum  may  be  effected  by  a  patient  affiicted  with 
this  disease.  It  is  said  to  be  very  frequent  in  Europe  among  those  wishing  to 
escape  military  service.  Of  all  the  attempts  made  by  various  authors  to  dis- 
cover some  symptoms  of  ej^ilepsy  that  should  be  absolutely  pathognomonic, 
none  have  been  successful.  Marc  thought  that  the  convulsions  of  true  epi- 
lepsy would  not  be  increased  by  holding  asafa?tida  under  the  patient's  nose, 
but  this  has  been  controverted.  Voisin  placed  great  dependence  upon  the 
condition  of  the  pulse  before,  during,  and  after  an  attack ;  but  similar  vari- 
ations have  been  observed  in  other  conditions  than  epilepsy,  while  Fere  has 


EPILEPSY.  OQ3 

shown  that  they  are  absent  in  some  epileptics,  and  vary  considerably  in  others. 
There  exists  among  English  thieves  a  class  known  as  "  dummy  chuckers," 
whose  business  it  is  to  feign  convulsions  in  a  crowd,  attracting  the  attention 
and  sympathy  of  the  bystanders,  whilst  a  confederate  rifles"  their  pockets. 
One  of  these  men  was  for  some  time  an  inmate  of  our  American  prisons,  and 
I  have  frequently  had  him  simulate  a  convulsion  for  the  benefit  of  my  class, 
and  it  is  certainly  true  that  this  counterfeit  convulsion  is  extremely  like  the 
genuine,  and  difficult  to  detect,  except  by  repeated  and  close  observation, 
when  the  tendency  to  overdo  the  tonicity  or  clonicity  of  the  movements  and 
the  bleeding  of  the  tongue  (which  is  generally  cut  with  a  knife  beforehand) 
may  assist  in  the  detection. 

Prognosis.  It  is  still  an  undetermined  matter  as  to  what  constitutes  a  cure 
of  epilepsy.  Some  cases  may  continue  free  from  attack  for  a  period  of  ten, 
fifteen,  or  even  twenty  years,  and  an  infantile  convulsion  may  not  be  suc- 
ceeded by  further  attacks  for  many  years.  I  have  in  my  own  practice  known 
remissions  of  several  years — sometimes  six  or  seven.  The  life  of  a  patient 
may  sometimes  be  made  more  endurable,  and  even  pleasant  and  useful,  by 
modifying  the  violence  and  lessening  the  frequency  of  the  attacks.  Some 
cases,  however,  are  beyond  the  means  afforded  by  the  best  skill  of  the  med- 
ical profession.  Most  cases  of  grand  mal  may  be  improved,  but  a  cure  can 
only  be  effected  in  a  few  of  them.  The  only  way  in  which  it  can  be  ascer- 
tained what  degree  of  improvement  can  be  made  is  by  the  experimentation  of 
a  month  or  so  of  treatment.  The  j)atient's  relatives  should  always  be  in- 
formed that  the  treatment  must  be  faithfully  continued  for  years  to  even 
obtain  a  relief.  Petit  mal  is  very  rarely  affected  by  treatment,  and  my  expe- 
rience has  been  that  only  in  those  induced  by  malnutrition  and  formation  of 
ptomaines  from  acute  indigestion  does  improvement  occur.  E^Dilepsy  of 
peripheral  origin  may  be  expected  to  improve  under  treatment,  although  the 
cases  are  seldom  entirely  freed  from  a  convulsive  tendency.  Those  in  whom 
migraine  is  associated  may  usually  be  favorably  affected  by  treatment. 

Treatment.  As  epilepsy  is  of  many  varieties,  so  its  treatment  must  vary 
according  to  the  different  manifestations  of  the  disease.  An  operation  should 
be  done  upon  cases  caused  by  intra-cranial  lesions  if  our  present  knowledge 
of  localization  can  be  availed  of  as  a  guide.  But  before  operation  is  attempted 
the  nature  of  the  lesion  should  be  fully  determined.  It  would  be  folly  to 
operate  in  cases  of  single  or  double  hemiplegia  and  in  the  paraplegias  of  the 
so-called  palsies  of  childhood,  as  they  are  due  to  losses  of  cerebral  substance 
known  as  porencephalitis,  to  hemorrhage,  arterial  or  venous  thrombosis,  or 
sclerosis,  which  usually  proceeds  from  an  antei-ior  arterial  trouble.  An  oper- 
ation should  always  be  resorted  to  in  cases  of  well-defined  brain  tumor ;  also 
in  abscess,  if  it  can  be  localized  and  is  in  an  accessible  area.  The  scalp  should 
be  carefully  shaved  in  cases  of  cerebral  trauma,  and  a  minute  search  made 
for  the  cicatrix  or  depression,  and  trephining  should  be  performed  if  either 
is  found,  for  most  excellent  results  have  been  obtained  in  many  cases  by 
removal  of  slight  adhesions  of  the  membranes.  Under  proper  antiseptic 
precautions  trephining  is  a  harmless  procedure,  and  may  bring  to  light  con- 
ditions which  otherwise  might  remain  hidden.    (See  also  Chapter  XXXIII.) 

Mj'  friend.  Dr.  E.  G.  Mason,  has  kindly  collected  for  me  forty-four  cases 
of  epilepsy  that  have  been  operated  upon. 


304 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


No. 


Keported  by, 
or  operator. 


Date  of  trauma. 


C.  A.  Dundore     November  S,  1888 


J.  T.  Wilson 


J.  T.  Wilson 


F.  Salzer 


Kobert  Jones 

Guy  Hinsdale 

Guy  Hinsdale 
Whipple 

John  Snyder 

Stephen  Crane 
F.  T.  Hewston 


Not  given;  wound 
of  coronal  suture 
3^  an  inch  above 
temporal  bone. 


Not  given;  fracture 
left  frontal  bone 
near  junction 
with  parietal. 


1884:  left  side  of 
head. 


Nov.   28,   1870, 
struck  on  frontal 
bone  by  fragment 
of  shell. 


Date  not  given  ; 
trauma  over  left 
Rolandic  fissure. 


February  17,  1888, 
injury  to  left  tes- 
ticle. 

Not  given  ;  bean 
in  left  nostril. 

June,  1891,    over 
right   Kolandic 
fissure  J^   inch 
from  sagittal  su- 
ture. 

No  trauma;  uterus 
small,  anteflexed, 
and  very  small 
cervical  canal. 


No  trauma. 


1885  ;  injury  to  left 
occiput. 


No  trauma;  palmar 
contractions  and 
tight  prepuce. 


Interval 
between 
trauma 
and  ap- 
pearance 
of  fits. 


Character  of  fits. 


Interval 

between  and 
number  of 


Interval 

between 


Date  of 


appear- 

^^^^^P-^     andd°ateof'°P«'-^tion. 
operation.  ,. 

■^  operation. 


Marked  on  right  !  8  fits  before 


side  of  body. 


operation  ; 
intervals 
not  given. 


At  irregular 
intervals ; 
number  not 


Inime-      ; Right    hand    and    1  or  2  daily 
diately  ?  j  arm,   muscles  of  until  7th  d'y 
face  and  eyes.         after  injury, 
jwhen  ceas'd, 
I     and  had 
none  for  3 
■  years,  then 
at  irregular 
intervals. 
Fits  at  irre- 
gular inter- 
vals, very 
;    much  in- 
creas'dwhen 
'    drinking 
1    absinthe. 
:Not  given. 


1  week  + 

60  days 

Not  given 
4  days 


General 


General 


At  irregular 

and  frequent 

intervals. 

At  irregular 

intervals. 

Five  or  six 

weekly. 


Irregular 
intervals. 


Irregular 
intervals. 


1  month, 
13  days 


1st  oper. 
March  23, 

1889; 
2d  oper. 
July  20, 

1889. 
9  months 

after 

trauma ; 

dates  not 

given. 


15  monthsl  Not  given 
1st  oper.; 


4  years 


17  years 


More  than 
2  years 


8  months 

Not  given 
6  mos  + 


As  many  as     5  years -|- 
4  daily. 


Right    hand    and   At  irregular;  5  years 
arm  flexed;  right     intervals, 
leg  extended. 


2d  oper. 
4  months 
after  first. 


Oct.  29, 
1887 


Not  given 


Not  given 

Jan.  8, 
1892 


Aug.  1, 
1892 


March, 
1891 


Dec.  6, 
1891 


EPILEPSY. 


305 


Interval  be- 

Length of 

tween  and 

Result  as 

time  un- 
der obser- 
vation 
after  ope- 
ration. 

Kind  of 

Lesion  found. 

number  of 

stated  by 

Reference. 

Remarks. 

operation. 

fits  after 
operation. 

reporter. 

Trephine. 

13  fits  until 

5  mos.  + 
after  2d 

Col.  &  Clin. 

Time  of  observation  after 

second  opera- 

Rep., 1889. 

operation  insufiicient. 

tion  ;  4  after 

operation. 

vol.  x.  p.  281 

Trephine. 
Trephine. 

second  oper. 

Thick  cicatrix 

No  fits  for  3 

3  months 

Med.A  Surg. 

Autopsy  showed  cicatrix 

in  dura  which 

months,  when 

Rep.,  1888, 

and  bulging  of  dura,  ab- 

was not  dis- 

died during  a 

vol.  xlix. 

scess,   spicule  of   bone, 

turbed. 

severe  seizure. 

p.  737 

softened  brain  tissue. 
Temporary  recovery  (3 
months),  then  death.  \j 

Trephine. 

Ijoose  piece  of 
internal  table. 

First  fit  21days 
after,  then  at 

5  years 

Ibid.,  p.  738 

Cure  after  second  opera- 
tion. 

Trephine. 

Tense  cicatrix 
of  dura  re- 
moved. 

irregular  in- 
tervals tor  4 
months,  when 
had  2d  oper.  ; 
5  or  6  mild  fits 
during  next  3 
months,  then 
they  ceased. 

Trephine. 

Thickening 
and  adhesion 

Fits  8  days 

Wien.  Clin. 

No  improvement. 

after  opera- 

Woch., 1889, 

of  dura 

tion,  continu- 
ing at  irregu- 
lar intervals. 

vol.  ii. 
p.  91 

Trephine. 

Rough  projec- 
tion of  bone 
removed. 

Not  given. 

Not  given 

In  all  probability  dis- 
charged on  14th  day 
after  operation,  "and 
could  now  be  considered 
quite  cured."  Time  of 
observation  after  opera- 
tion insufiicient.    uOO 

Trephine. 

%  in.  spicule 

Not  given. 

"  Patient 

Not  given 

Liverpool 

Time  of  observation  after 

of  bone  re- 

made an  ex- 

Med. &  Chir. 

operation  Insufficient. 

moved. 

cellent  re- 
covery." 

Journ.,1889, 

vol.  ix.  p. 

451 

Removal  of 

Atrophy  of 

No  fits. 

Cured. 

3  months 

Am.  Journ. 

Time  of  observation  after 

left  testicle. 

glandular 
structure  of 

testicle. 

Med.  Sci., 

1889,  vol. 

xlvii   p.  587 

operation  insufficient. 

Removal  of 

Not  given. 

Cured. 

Ibid. 

Time  of  observation  after 

bean. 

operation  not  given. 

Trephine. 

Bone  thick ; 
dura  adherent. 

None. 

Recovery. 

1  month 

Lancet,1892, 
vol.  i.  p.  868 

Time  of  observation  after 
operation  insufficient. 

Cervical  canal 

"  Epilepsy 
cut  short  as 

No  defi- 

Physician 
and  Surg., 

Time  of  observation  after 

enlarged  and 

nite  date  ; 

operation  insufficient. 

straightened. 

if  by 
magic." 

came  un- 
der treat- 
mentiMay, 
1891 ;  pub- 
lished 
July,  1802 

1892,vol.xiv. 
p.  305 

Dilatation  of 

3  fits. 

Well. 

5  months 

Maryland 
Med.  Journ., 

Time  of  observation  after 

cervix  uteri. 

operation  insufficient. 

1893,  vol. 

xxviii.  p. 

529 

Trephine. 

No  fits. 

Recovery. 

10  months 

Trans.  Roy. 
Acad.  Med., 

Improvement,   though 
time  of  observation  was 

Ire.,  1891-2. 

insufficient  to  determine 

vol.  x.  p.  166 

amount  of  improvement. 

Palmar  facia 

,     Ifit. 

Patient  re- 
turned some 

:Edinb.  Med. 
Journ.,  1893, 

This  case  was  given  bro- 
mides in  addition  ;   im- 

forcibly 

stretched ;  pre- 

mos. after- 

vol. xxxix. 

provement.   Time  of  ob- 

puce "slit  up." 

ward  and 

reportefl 

himself 

quite  well  ; 

cured. 

p  20 

servation  insufficient. 

20 


306 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


No. 

Reported  by, 
or  operator. 

Date  of  trauma. 

Interval 
between 

trauma 
and  ap- 
pearance 

of  fits. 

Character  of  fits. 

Interval 
between  and 
number  of 
fits  before 
operation. 

Interval 
between 
appear- 
ance of  fits 
and  date  of 
operation 

Date  of 
operation. 

14 

C.  F.  Barber  ; 

1877  ;   depressed 

Imme- 

Vary from  1 
monthly  to 

8  years 

operation  by 

fracture  of  right 

diately 

Hammond 

frontal  bone. 

1  weekly. 

15 

C.  F.  Barber ; 

No  trauma ;   epi- 
lepsy since  child- 

Fits general ;  aura 
in  left  arm. 

1  to  20  in 

Not  given; 

operation  by 

24  hours. 

some  years 

F.  W.  Kockwell 

hood. 

16 

Thomas  Wells 

When  6  years  old 

10  years 

General 

Vary  from  1  Not  given 

Aug.  24, 

through 

depression  in  post. 

daily  to  1  in 

1885 

C.  F.  Barker 

sup.   corner  of 
right  parietal. 

two  weeks. 

17 

H.  0.  Dalton 

1876,  kick  by  mule 
in  left  frontal  re- 
gion. 

1  month 

General 

Irregular 
intervals. 

12  years 

1888 

18 

M.  A.  Starr  ; 

April,   1891,   frac- 

3 weeks 

Numbness  and 

Frequent 

20  months 

Nov.  9, 

operation  by 

ture  of  left  parie- 

tingling of  right 

intervals. 

1892 

McBurney 

tal  bone. 

hand,  shoulder, 
body,   and  leg  ; 
no   loss  of  con- 
sciousness. 

19 

Starr  and 

1882,  fracture  over 

1%  years 

Spasm   of  right 

As  many  as 

1%  years 

Jan.  30, 

McBurney 

left  coronal  su- 

after sec- 

hand ;  no  loss  of 

6  daily. 

1892, 

ture  ;  1890,  a  sec- 

ond fall, 

consciousness 

Apr.  1892, 

ond  fall  on  head. 

2d  oper. 

Jan   7, 

1893 

20 

Starr  and 

April,   1888,  frac- 

3 years 

Left  arm  and  hand, 

As  many  as 

1  year 

March, 

McBurney 

ture  about  middle 
of  coronal  suture, 
right  side. 

turning  head  to 
left,  then  became 
general. 

2  daily;  long- 
est interval 
was  9  weeks. 

1892 

21 

Starr  and 

April,  1888,  fell  on 

Not  given 

Spasm   right  foot 

As  many  as 

3  years 

Jan.  17, 

Weir. 

left  side  of  head 
near  vertex. 

and  leg,  turn  to 
right,    lose    con- 
sciousness and  fall 
in  a  general  fit. 

6  daily. 

1890 

22 

Starr  and 

1882,  fell  on  head. 

Imme- 

Twitching of  eyes 

Irregular 

Petit  mal 

Dec.  2, 

McBurney 

diately. 

and    head,    most 
on   right  side  ; 
general  convul- 
sions. 

intervals. 

until  two 
years  be- 
fore, after 

which 
grand  mal 

1892 

23 

Starr  and 

August,  1889,  frac- 

About 1 

At  first  general, 

Irregular 

2  years 

Dec.  19, 

Briddon 

ture   of  right 
temple. 

year 

but  later  muscles 
of  face  right  side, 
right  side  of  neck, 
right  arm  and 
hand. 

intervals. 

1892 

24 

Starr  and 

1887,  fall  on  ver- 

"Soon" 

General,  with 

Not  given. 

5  years 

June  10, 

McBurney 

tex,  right  side  an- 
terior to  Rolandic 
fissure. 

afterward 

gi-een  visual  aura. 

1892 

25 

Starr  and 

April,  1890,  struck 

3  mos,  + 

Tingling  movem'  nt 

Irregular 

11  months 

June,  1891 

McBurney 

on   left  side  of 
head  with  sand- 
bag. 

in  right  hand  and 
face  ;  face  drawn 
to  right,    mouth 
opened  and  closed; 
speech   lost ;    on 
two  occasions  lost 
consciousness. 

intervals. 

26 

Starr  and 
Poore 

Not  given  ;  fall  on 
right  side  of  head. 

3  months 

Spasms  of  left  arm. 

Irregular 
intervals ; 
frequently 
as  7  daily. 

Not  given 

Oct.  1889 

EPILEPSY. 


307 


Interval  be- 

Length of 

Kind  of 

Lesion  found. 

tween  and 
number  of 

Result  as 
stated  by 

time  un- 
der obser- 
vation 
after  ope- 
ration. 

Reference. 

Remarks. 

:<peration. 

fits  after 
operation. 

reporter. 

Trephine. 

1  weekly,vary- 

Not  given 

Brooklyn 
Med.  Journ., 

No  improvement. 

ing  to  1  in  two 

or  three 

1893,  vol.vii. 

weeks. 

p.  640 

Trephine  over 
centre  for  left 

Nothing  ab- 

Fits reappear- 
ed in  one  week 

Ibid. 

No  improvement. 

normal 

arm. 
Trephine. 

None. 

About  one 
year. 

Ibid. 

Was  under  bromides. 

Time  of  observat'n  after 

operation  insufficient. 

Trephine. 

Unusual 

amount  of 

fluid  escaped. 

2  fits  day  after 
operation,  1 
on  third  day. 

Successful. 

3  years 

Med.  Fort- 
nightly,1892 
vol.  i.  p.  75 

Cure. 

Trephine. 

Splinter  of 

2  slight  at- 

Recovery. 

4  months 

Brain  Surg., 

Time  of  observation  after 

bone  in  motor 

tacks  subse- 

Starr, p.  29 

operation  insufficient. 

area  ;  cyst  of 

quently. 

pia. 

Trephine  oven 

Dura  and  pia 

Fits  reappear- 

Recovery. 

Less  than 

Ibid.,  p.  31 

Time   of  observation  in- 

right arm 

adherent ;  2 

ed  in  3  months, 

3  months 

sufficient. 

centre ;  small 

cysts  ;  brain 

again  reap- 

after last 

pus  cavity  at 

appeared 

peared  in  4 

operation. 

site  of  opera- 

somewhat 

months;  2  fits 

Recovery. 

tion  evacu- 

atrophied. 

subsequently. 

ated  ; 

Scar  tissue  ; 

trephine. 

cyst. 

Trephine  over 

Ext.  table  frac- 

About one 

Recovery  ; 

Less  than 

Ibid.,  p.  35 

Time   of  observation   in- 

arm centre  on 

tured  ;  small 

month  after 

recurrence 

a  year;  fits 

sufficient. 

right  side. 

splinter  of 
bone  indent- 
ing dura;  dura 
thickened  ;  pia 
and  brain  yel- 
low and   oede- 
matous. 

operation 
there  was  re- 
currence. 

of  fits. 

frequent 
and  severe 

as  before 
operation. 

Trephine  over 
upper  third  of 

Small  white 
specks  resemb- 

Death fol- 
lowed opera- 

Ibid., p.  37 

Death. 

motor  area  for 

ling  miliary 

tion. 

right  side. 

tubercles  over 

pia  and  area 

for  leg. 

Trephine  over 

Subcortical 

2  attacks  of 

Recovery. 

4  mos. — 

Ibid.,  p.  38 

Time  of  observation  after 

area  for  right 

cyst. 

petit  mal  sub- 

operation insufficient. 

arm. 

sequently. 

Trephine  over 

Thickened 

2  in  the  two 

Recovery ; 

4  mos. — 

Ibid.,  p.  40 

No  real  improvement ; 

motor  area  for 

dura ;  brain- 

subsequent 

recurrence 

time  also  insufficient. 

face  and 

substance  re- 

months. 

of  fits. 

Broca's  con- 

placed by  con- 

volution. 

nective  tissue  ; 
pia  oedematous 

Trephine  over 

Depression  of 

5  in  subse- 

No result. 

4  mos.  + 

Ibid.,  p.  43 

No    improvement ;    time 

seat  of  frac- 

ext. table  ; 

quent  four 

also  insufficient. 

ture. 

dura,  pia,  and 
brain  normal. 

months ;  at 
last  visit  were 

as  frequent 
and  as  severe 
as  before  ope- 
ration . 

Trephine  over 

Nothing  ab- 

2 in  subse- 

Improve- 

6 mos.+ 

Ibid.,  p.  44 

Personal   observation 

arm  centre 

normal. 

quent  six 

ment  ; 

ceased  Dec.  1891,  but  it 

extending  to- 

months. 

relapse ; 

is    stated    that    fits  be- 

ward face  and 

death. 

came  more  frequent,  and 

motor  speech 

death  occurred  Novem- 

centres. 

ber,  1892. 

Evacuation  of 

Triangular  de- 

No spasms  for 

Recurrence 

Not  given 

Ibid.,  p.  46 

Author  says  in  all  prob- 

cyst;  did  not 

fect  in  bone 

one  year, when 

of  fits. 

ability    cyst    has    filled 

trephine. 

covered  with 
thick  connec- 
tive tissue  be- 
neath which  a 
cyst. 

they  returned 
as  before. 

again,     another    opera- 
tion contemplated.    In - 
provement ;  recurrenci'. 

308 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Interval 
between 

Interval 
between  and 

Interval 
between 

No. 

Eeported  by, 
or  operator. 

Date  of  trauma. 

trauma 
and  ap- 
pearance 

of  fits. 

Character  of  fits. 

number  of 
fits  before 
operation. 

appear- 
ance of  fits 
and  date  of 
operation. 

Date  of 
operation. 

27 

Starr  and 

1878,  fall:  exten- 

7 years 

General,  always 

Irregular 

7  years 

Oct.  18, 

H^artley. 

sive    fracture    of 

began  with  turn- 

intervals ; 

1892 

left  parietal  and 

ing  of  head  to 

as  many  as 

frontal  bones. 

right ;  had  an 
immediate  right 
hemiplegia  and 
motor  aphasia 
which  lasted  one 
year  after  acci- 
dent. 

5  daily,  but 
under  bro- 
mides usu- 
ally 1  in 
3  weeks. 

28 

Starr  and 

January,  1890,  fall 

"Soon" 

Always  at  night ; 

Frequent 

2  years 

Feb.  25, 

McBurney 

on  left  parietal 
region  ;   no  frac- 
ture. 

after 

closing  of  fingers 
and  thumb  of 
right  hand,  twit- 
ching; arm  flexed 
and  trembled  ; 
hand  brought  to 
face  by  shoulder 
movement ;  twit- 
ching right  side  of 
face;  head  slightly 
turned  to  right. 

intervals. 

1892 

29 

Starr  and 

Fell  several  years 

"Subse- 

General, begiuning 

Not  given. 

Not  given 

Not  given 

McBurney 

before ;  trephined 
one    year    previ- 
ously ;   nothing 
founds  ;  fits  con- 
tinued. 

quently" 

in  right  hand. 

30 

Starr  and 

1867,  fall;  scar  over 

14  years 

General,  epigastric 

2  or  3  w'kly; 

9  years 

March  8, 

McBurney 

left  parietal  bone. 

aura. 

at  times  as 

many  as  5 

daily. 

1890 

31 

Frank  and 

Sarcoma  of  middle 

Spasm  right  index 

Irregular 

1  year 

May  21, 

Church 

and  lower  thirds 
of  left  motor  area. 

finger,wrist,  hand 
and  arm  ;  general 
convulsion,  loss  of 
consciousness ; 
pain  right  hand  ; 
increasing  paral- 
ysis ;   leg  weak  ; 
some  aphasia. 

intervals. 

1889 

32 

Keen 

Nov.  1886,  fall  on 

6  months 

Left  fingers  anes- 

Irregular 

1  year 

April  18, 

right  side  of  head; 

thetic  after  in- 

intervals. 

1888 

depressed  fracture 

jury;  sudden  ver- 

over middle  %  of 

tigo  followed  by 

right  motor  area. 

temporary  paral- 
ysis of  left  hand. 

33 

Keen 

Not  given  ;  fall  on 

2  fits  in 

Flexion  of  right 

Frequent 



Oct,  29, 

left  side  of  head  ; 

11  years. 

hand,  spasm  of 

intervals. 

1890 

depressed  fracture 

then  be- 

arm, general  con- 

over arm  centre 

came 

vulsion. 

of  left  side. 

frequent. 

34 

Keen 

Not  given  ;    de- 
pressed fracture 
over  lower  parie- 
tal   convolutions 
(m  right  side. 

2  years 

General. 

14  years 

Nov.  21, 
1890 

35 

Diller 

Fall  at  6  months  ; 

3^  years 

Beginning  in  left 

73^  years 

Jan.  9, 

convulsions  and 

arm,  then  face. 

1891 

left  hemiplegias. 

then  leg ;  uncon- 
sciousness ;  hemi- 
plegia worse  in 
arm  ;   sensation 
diminished  in  arm 

36 

Lloyd  and 

1869,   struck    on 

5  3'ears 

Numbness  and 

Frequent 

14  years  ;June,  1888 

Deaver 

head. 

spasm  in  left 
hand  and  arm  ex- 
tending to  face 
(left  side) ;  paresis 
of  left  hand  and 
face  followed ; 
consciousness  oc- 
casionally lost  in 
an  attack. 

intervals. 

EPILEPSY. 


309 


Interval  be- 

Length of  1 

Kind  of 

Lesion  found. 

tween  and 
number  of 

Result  as 
stated  by 

time  un- 
der obser- 
vation 
after  ope- 
ration. 

Reference. 

Remarks. 

operation. 

fits  after 
operation. 

reporter. 

Trephine. 

Depression  op- 

1 fit  two 

Recovery  ; 

5  months 

Ibid.,  p.  47 

Improvement  ;    recur- 

posite lower 

months  sub- 

recurrence 

rence.   Time  of  observa- 

}4 of  Kolandic 

sequently. 

of  fits. 

tion  after  operation  in- 

fissure ;  skull 

sufficient. 

thickened  ; 

dura  adherent; 

pia  thickened 

and  clouded  ; 

brain  lough 

and  red  ;  large 

number  of 

capillaries;  pia 

closely  adher. 

Trephine  over 

Dura  adherent 

One  month;  in 

Recovery  ; 

1  year-|- 

Ibid.,  p.  49 

Dec.    20,   1892,    put    on 

middle  }/^  of 

to  bone  ;  small 

about  6  mos. 

return  of 

bromides,  and  in  March , 

Rolandic  fis- 

whitish plaque 

fits  changed  to 

attacks. 

1893,  cessation  of  obser- 

sure. 

of  connective 
tissue  on  pia  ; 
brain  normal. 

a  somnambu- 
listic charac- 
ter 

vation,    "entirely    free 
from  attacks."      Slight 
improvement.  Return  of 
fits ;   ceased  under  bro- 
mides. 

Trephine  over 

Fracture  of  ex- 

Not given. 

No  result. 

Not  given 

Ibid.,p   52 

No  improvement. 

seat  of  frac- 

ternal table  ; 

ture  ;  frontal 

brain,  pia,  and 

bone  anterior 

dura  normal. 

to  motor  re- 

gion. 

Trephine  over 

Fracture  of  ex- 

23 days  ;  as 

No  result. 

1  yr.  and  !  Ibid.,  p.  52 

No  improvement. 

site  of  scar. 

ternal  table ; 

frequent  as 

0  mos.     ; 

dura,  pia,  and 

before  opera- 

brain appear- 

tion. 

ed  normal. 

Trephine  over 
left  motor 

Thick  cicatri- 
cial mass  on 

Return  of  fits 
in  three 

Am.  Journ. 
Sci.,  July, 

Improvement.      Return 
of  fits  in  three  months. 

area,  middle 

cortex ;  sar- 

months. 

1890 

and  lower 

coma. 

thirds ;  brain 

excised  13^  in. 

in  circumfer- 

ence, i^  in. 

deep. 

Trephine  over 

Spicule  of  bone 

None  for  four 

Temporary 

4  months 

Ibid.,  Oct. 

Time  of  observation  after 

depressed  frac- 

projecting into 

months  after 

paralysis  of 

1888 

operation  insuflicient. 

ture. 

brain;  cyst ; 

chronic  men- 

ingo-encepha- 

litis. 

operation. 

hand  ;  no 

fits  for  four 

months. 

Trephine  ; 

Projecting 

None  for  eight 

Paralysis 

8  months 

.Ibid.,  Sept. 

Time  of  observation  after 

bone  and 

•pieces  of  bone; 

months. 

and  anaes- 

1891 

operation  insufficient. 

membranes 

brain  dis- 

thesia of 

about  depres- 

organized and 

hand  gradu- 

sion removed ; 

depressed. 

ally  passing 

hard  centre 

away. 

excised. 

Adhesion  be- 

Bone deficient; 

2  fits  in  subse- 

6 months 

Ibid. 

Time  of  observation  after 

tween  brain 

brain  adherent 

quent  two 

operation  insufficient. 

and  scalp  di- 

to scalp. 

weeks,  then 

vided. 

ceased. 

Trephine  over 

Fissure  in 

No  fits  after 

Recovery. 

43  days  ; 

Pittsb.  Med. 

Cyst  was  drained  ;  when 

motor  area  for 

bone,  cyst  con- 

operation. 

patient 

Rev.,  Nov. 

drain    was    removed    it 

arm,  right 

taining  3  oz. 

died  at  ex- 

1892 

filled  again.     Drain  re- 

side 

clear  fluid  un- 
der cortex. 

piration 
of  this 
period. 

placed  for  40  days,  when 
discharge  became  puru- 
lent, and  patient  died 
on  43d  day. 

Trephine  over 

Brain  normal. 

Convulsions 

Paralysis 

3  months 

Am.  Journ. 

Time  of  observation  after 

junction  of 

for  three 

and  anfes- 

Sci.,  Nov. 

operation  insufficient. 

middle  and 

weeks,  when 

thesia  in  left 

1888 

lower  thirds  of 

they  ceased. 

hand  perma- 

motor area ; 

nent. 

hand  centre 

excised. 

310 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Interval 
between 
trauma 
and  ap- 
pearance 
of  fits. 

Interval 

between  and 

Interval 
between 

No. 

Keported  by, 
or  operator. 

Date  of  trauma. 

Character  of  fits. 

number  of 
fits  before 
operation. 

ance  of  fits 
and  date  of 
operation. 

Date  of 
operation. 

37 

Knapp  and  Post 

1882,   struck  over 
right  temple. 

1  year  — 

Head  turned  to 
left,  then  convul- 
sions of  left  side 
of  face  and  neck  ; 
left  arm ;  some- 
times general  con- 
vulsions follow. 

4  or  5  daily. 

8  years 

May  1, 
1891 

38 

Knapp  and  Post  1885,   struck   on 

Severe 

General  ;    com- 

Nov. 1890 

head  ;   depressed 

and 

mence  by  turning 

fracture  over  left 

constant 

of  head  and  eyes 

second  frontal 

headache 

to  the  right. 

convolution. 

since  the 
trauma 

39 

E.  B.  Fisber  and 
J.  W.  Bryant 

1878,  slight  depres- 
sion of  skull  over 
hand  centre  of  left 
side. 

2  years 

Grcneral 

12  years 

May,  1892 

40 

E.D.Fisher  and 
Geo.  Woolsey 

Indefinite  history 
of  trauma. 

Commence  with 
sensory  aura  in 

. 

May,  1892 

fingers  of  left 

hand,  and  passing 

toward  face,  after 

which  loss  of  con- 

sciousness and 

general  convul- 

sions. 

41 

E.D.Fisher  and 

1887,   injury  to 

lyear 

Slight  at  first,  later 

7  attacks ; 

5  years 

Mar.  1892 

J.  E.  Kelly 

head  ;  depression 
of  parietal  bone 
behind  motor 
area  ;   side  not 
given. 

complete  seizures. 

1  monthly : 

slight  ones 

daily. 

42 

E.  D.  Fisher  and  Xot  given. 
J.  E.  Kelly 

Not  given 

Almost  continuous 
and  usually  lim- 
ited to  left  side. 

Not  given. 

Not  given 

June,  1892 

43 

E.  D.  Fisher  and  1878,  injury  to  head 
J.  E.  Kelly      ,  from  fall ;  depres- 

Not  given 

Very  frequent  ; 
general. 

Not  given. 

Not  given 

May,  1892 

sion  over  left  fron- 

tal bone  at  mar- 

gin of  hair. 

44 

Morrison 

No  trauma. 

At  first  slight,later 
severe;  beginning 

6  years 

Aug.  1891 

with  face  and 

head  turning  to 

right. 

Summary. 

Cured 2 

No  improvement      .                 "        ....  10 

Death  due  to  operation    .        .         • 3 

Improvement,  return  of  fits :  malignant  brain  disease 1 

Cases  in  which  there  was  a  cessation  of  fits  one  year  after  operation,  but  in 

which  bromides  were  used         .....         .....  2 

Temporary  improvement ;  time  of  observation,  however,  not  given  ...  3 
Cases  in  which  time  of  observation  after  operation  is  insufiScient  to  make  them 

of  value  in  statistical  tables 23 

Grand  total 44 


EPILEPSY, 


311 


Kind  of 
operation. 

Lesion  found. 

Interval  be- 
tween and 
number  of 
fits  after 
operation. 

Result  as 
stated  by 
reporter. 

Length  of 
time  un- 
der obser- 
vation 
after  ope- 
ration. 

Reference. 

Remarks, 

Trephine  over 
2d  frontal  con- 
volution, site 
of  scar. 

Dura  normal  ; 

pia  oedematous 
and  opaque  ; 
Brain  mark- 
edly bluish. 

Recurrence 
of  fits  as  be- 
fore. 

6  months 

Boston  Med. 

and  Surg. 

Journ.,  Jan. 

7,  1891 

No  improvement. 

Trephine. 
Trephine  over 

Bone  thicken- 
ed and  adher- 
ent to  dura, 
dura  adherent 
to  brain  ;  dura 
and  portion  of 

brain  sub- 
stance excised. 
No  fracture 
or  adhesions. 

Nothing  ab- 
normal. 

Continuanee 
of  convul- 
sions. 

Attacks  first 
increased  in 
frequency, 
then  de- 
creased, and 
finally  be- 
came as  be- 
fore opera- 
tion. 
Attacks  as 
frequent  as 
before,  but 
no  longer 
commenced 
on  left  side. 

4  months 

Ibid. 

Brain  Surg., 
Starr,  p.  62 

Ibid.,  p.  63 

No  improvement. 

No  improvement. 
Patient  intemperate ; 
insane. 

This  patient  showed  signs 
of  dementia.      Mental 
condition    did    not    im- 
prove   after    operation. 
No  improvement. 

seat  of  depres- 
sion. 

Trephine  over 

centre  for  left 
arm  ;  tumor 
opened  and 
then  united. 

Trephine. 

Inner  table 
pressing  on 
dura;  no  inter- 
nal fracture  ; 
dura  not 
opened. 

TTp  to  date 
slight  at- 
tacks of  diz- 
ziness ;  no 
seizures  ; 
Date  not 

Not  given 

Ibid.,  p.  63 

Temporary  impro  vem  int. 
Time  of  observat'n  at  lei- 
operation  not  given. 

Trephine  over 

Nothing  ab- 
normal; part  of 
hand  centre 

excised. 
Nothing  ab- 
normal. 

Dura  and 
brain  normal. 

Death  six 
hours  after 
operation. 

Mental  con- 
dition im- 
proved ;  at- 
tacks less 
frequent, 
but  later 
became  as 
before  ope- 
ration. 
No  result. 

Ibid.,  p.  64 
Ibid.,  p.  64 

Ibid.,  p.  57 

Death. 

right  motor 
area. 

Trephine  over 

Not  given 

Patient  demented  and  ad- 

site of  depres- 
sion. 

Trephine  over 

Fits  returned 
three  weeks 
after  opera- 
tion. 

dicted  to  masturbation. 
Temporary  improve- 
ment. 

No  improvement. 

junction  of 

temporal  ridge 

and  coronal 

suture. 

Note. — In  those  cases  classed  as  "  cured,"  observation  was  kept  up  for  more  than  three  years.  All  cases 
which  were  not  under  observation  for  at  least  one  year,  and  in  which  there  was  neither  death  nor  non- 
improvement,  have  been  classified  as  "cases  in  which  time  of  observation  after  operation  is  insufficient  to 
make  them  of  value  in  statistical  tables."  In  most  of  them,  however,  there  was  an  improvement,  usually 
temporary. 


312  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

From  this  summary  it  will  appear  that  there  were  only  two  cases  out  of 
the  forty-four  to  which  the  word  "  cured  "ican  accurately  be  ajDplied,  although, 
of  course,  this  conclusion  would  shock  many  of  the  narrators  whose  time  of 
observation  of  the  patient  after  the  operation  has  not  been  sufficient,  in  my 
opinion,  to  render  any  conclusion  warrantable. 

In  peripheral  irritation  a  valuable  adjunct  to  medication  is  the  removal  of 
the  irritant,  even  though  only  temporary  improvement  may  be  secured. 
Phimosis  or  an  adherent  prepuce  should  be  rectified,  and  an  irritable  clitoris 
should  either  be  treated  by  soothing  applications  or  by  a  careful  application 
of  a  60  per  cent,  solution  of  nitrate  of  silver.  Vaginitis  should  be  care- 
fully treated,  if  it  exists.  The  removal  of  the  insufficiency  of  ocular  mus- 
cles is,  in  my  opinion,  quite  useless,  but  marked  errors  of  refraction  should 
be  remedied.  If  so-called  laryngeal  vertigo  or  epilepsy  exists,  the  laryngeal 
tumor  giving  rise  to  it  should  be  removed.  As  the  difficulty  of  eradicating 
the  ej)ileptic  tendency  is  very  great,  surgical  measures  should  always  be  ac- 
companied by  medication. 

Children  afflicted  with  epilepsy  are  very  apt  to  be  spoiled,  and,  as  a  result 
of  injudicious  petting  and  indulgence,  they  often  become  almost  savage  in 
their  dispositions.  They  should  be  treated  with  the  utmost  firmness  and 
care,  either  by  a  trained  nurse  or  in  many  ways  which  the  good  sense  of  the 
physician  or  parents  may  suggest.  In  cases  of  this  kind  moral  treatment  is 
often  wonderful  in  its  effect  for  good. 

If  migraine  exists  in  conjunction  with  epilepsy  it  should  be  carefully 
treated.     (See  Chapter  XXXII.) 

If  a  periodicity  is  manifested,  careful  attention  should  be  paid  to  the 
treatment  at  such  periods.  The  patient  should  be  kept  especially  quiet,  in 
many  cases  it  being  advisable  to  put  them  to  bed  at  the  time  of  the  expected 
attack,  and  either  add  to  the  medication  or  increase  the  quantity  already 
being  administered.  A  dose  at  bedtime  may  be  all  that  is  necessary  in 
nocturnal  cases.  The  attacks  may  be  diverted  from  their  usual  time  of 
recurrence  in  some  of  these  cases,  so  that  an  attack  may  occur  in  the  day- 
time or  some  other  time  of  the  month.  In  such  cases  attention  should  be 
paid  to  the  periods,  and  the  treatment  kept  up  continuously. 

Without  doubt  the  most  valuable  means  of  treatment  at  our  disposal  are 
the  bromides.  They  should  be  given  in  large  doses,  unless  the  idiosyncrasy 
of  the  patient  prevents.  As  a  rule,  epileptic  patients  bear  the  bromides 
well,  but  in  some  instances  this  is  not  the  case,  as  in  some  exceptional  cir- 
cumstances the  disease  seems  to  be  aggravated  by  the  use  of  bromides ;  in 
some  an  ounce  may  be  administered  without  ill  effect,  and  in  others  a  dose 
of  10  grains  will  produce  a  collapse.  In  consideration  of  all  these  facts,  my 
plan  of  treatment  is  as  follows  :  The  bromide  is  administered  in  doses  of  10 
grains  each,  three  times  a  day,  unless  marked  periodicity  is  manifested,  in 
Avhich  case  it  is  given  in  proportionately  large  doses.  My  usual  prescription 
is  as  follows : 

R. — Potass,  brom ^ss. 

Aquse |iv.— M. 

S. — Teaspoonful  three  times  daily,  after  meals,  in  half-tumbler  of  water. 

After  about  a  week  of  treatment  by  the  smaller  dose  I  increase  the  dose 
to  15  grains  three  times  a  day,  unless  bromism  has  taken  place,  or  improve- 
ment is  manifest.  In  case  the  patient  bears  the  bromide  well,  but  does  not 
improve,  I  still  further  increase  the  dose  to  30  or  40  grains  daily.  If  brom- 
ism is  manifested,  but  no  improvement  in  the  epilepsy,  I  conjoin  5  grains  of 
the  bromide  of  sodium  with  the  bromide  of  potassium,  as  in  the  following 
prescription : 


EPILEPSY.  313 

R, — Potass,  brom .^ss. 

Sodse  brom .^ij. 

Aquse  . 5iA'.— M. 

S. — Teaspoonful  three  times  daily  in  half-tumbler  of  water. 

The  two  bromides  in  combination  will  often  have  an  increased  effect  upon 
the  disease  without  increasing  the  constitutional  effect  of  the  drug.  If  the 
patient  is  satisfactorily  brought  under  control  of  the  bromide,  this  dosage 
should  be  kept  up.  In  case  of  cease  of  improvement,  or  relapses  of  the  at- 
tacks, I  have  recourse  to  a  laxative,  a  brisk  cathartic,  a  change  of  scene,  or 
a  combination  of  belladonna,  borax,  or  hyoscyamine,  with  the  bromide  treat- 
ment already  given.  I  employ  these  latter  means  for  a  short  time  only, 
discontinuing  their  use  gradually.     I  use  the  following  prescriptions  : 

R.— Potass,  brom.  I  --  - 

Sodjeborat.    j ^^  ''^^• 

Aquae ^iv. — M. 

S. — Teaspoonful  t.  i.  d.,  after  meals,  in  half- tumbler  of  water. 

Or, 

R . — Potass,  brom.    1 

Sodse  borat.        \ aa     gss. 

Bellad.  ex.  fid.  ] 

Aquae ^iv. — M. 

S. — Teaspoonful  t.  i.  d.,  after  meals,  in  half-tumbler  of  water. 

Merck's  preparation  of  hyoscamine  should  be  used,  in  tablet  triturate  (gr. 
ToTT  night  and  morning,  alone).  Some  authors  consider  the  loss  of  uvular 
reflex  of  great  importance,  and  the  ability  to  tickle  the  throat  of  a  patient 
without  producing  nausea  is  accepted  as  a  symptom  that  sufficient  bromide 
has  been  given.  I  place  but  little  stress  upon  this,  however,  as  I  have  known 
cases  to  grow  worse  when  this  reflex  had  been  abolished ;  improvement  has 
taken  place  in  others  when  it  was  still  present,  and  in  others  still  the  bromide 
was  w^ell  borne  in  increasing  doses,  after  the  cessation  of  the  reflex.  As  the 
bromide  of  ammonium  has  not  proven  useful  in  my  hands  except  as  an  adju- 
vant, I  have  confined  my  application  of  the  bromides  to  those  of  potassium 
and  sodium.  Moderate  doses  of  Fowler's  solution  of  arsenic,  gtt.  ij.-iij.,  three 
times  a  day,  in  a  wine-glass  of  water,  will  usually  overcome  the  acne,  which 
is  at' times  considerable.  I  believe  that  cases  which  do  not  yield  to  the  bro- 
mide treatment  will  fail  to  improve  by  any  other,  except  that,  in  my  experi- 
ence, some  few  cases  w^ill  do  well  with  borax  when  the  bromide  has  failed. 
Gowers's  maximum-dose  treatment  in  alternation  with  the  treatment  just 
detailed  is  occasionally  very  useful.  This  consists  of  doses  of  two  or  three 
drachms  of  bromide  of  potassium  every  second  or  third  morning,  increasing 
the  dose  to  four  drachms  every  fourth  morning,  and  six  drachms  every  fifth 
morning,  these  doses  being  given  after  breakfast  in  a  tumblerful  of  water,  as 
epigastric  pain  and  vomiting  may  be  caused  if  they  are  not  w^ell  diluted.  He 
does  not  increase  the  dose  beyond  that  which  produces  transient  dulness  and 
lethargy.  A  great  variability  is  shown  in  the  susceptibility  of  patients  to 
the  doses,  some  being  unable  to  bear  more  than  four  drachms,  whilst  no 
unpleasant  symptoms  will  be  induced  in  others  by  the  administration  of  an 
ounce,  as  I  have  myself  observed.  A  period  of  six  or  seven  weeks  should  be 
covered  in  this  treatment,  reaching  the  maximum  dose  in  two  or  three  weeks, 
and  gradually  diminishing  the  doses  during  the  remainder  of  the  time,  after 
whicli  the  patient  may  be  left  without  treatment  for  several  weeks  or  mouths, 
although  I  have  never  seen  such  long  periods  of  freedom  from  attack  as  Dr. 
Gowers  claims. 


314  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Except  as  an  adjuvant,  belladonna  has  proven  of  little  efficacy  in  my  hands. 
One  or  two  minims  of  the  drug  should  be  given  three  times  a  day,  using  the 
fluid  extract,  and  carefully  noting  the  effects.  In  some  cases  borax  is  as  use- 
ful as  the  bromide  treatment,  though  this  is  not  usual.  This  treatment  should 
be  carefully  tried  in  all  cases  where  the  bromides  disagree  with  the  patient  or 
fail  in  effect.  The  dose  should  be  ten  to  twenty  grains  three  times  a  day,  in 
a  half-tumbler  of  water. 

The  salts  of  strontium,  the  lactate,  and  the  bromide,  in  the  same  dosage  as 
the  borax,  have  been  spoken  of  in  the  last  few  years  as  being  of  considerable 
efficacy  in  the  treatment  of  epilepsy.  I  only  mention  the  fact,  as  I  have 
myself  had  no  experience  with  them.  An  attack  which  is  preceded  by  an 
aura  may  sometimes  be  arrested  by  nitrite  of  amyl ;  but  as  this  warning  occurs 
very  seldom,  I  have  almost  abandoned  the  use  of  the  drug.  Preparations  of 
zinc,  which  were  much  in  favor  twenty  years  ago,  have  proven  of  little  value 
in  my  hands. 


CHAPTER   XII. 
GENERAL  DISEASES  OF  THE  BRAIX. 

ARRESTED  DEVELOPMENT,  MALFORMATIONS,  HYDRO- 
CEPHALUS. 


By  N.  E.  brill,  M.D. 

The  brain  is  a  frequent  seat  of  deviations  from  the  laws  of  normal  growth. 
These  deviations  may  present  either  an  arrest  of  the  development  of  the  brain 
or  of  some  of  its  anatomical  divisions,  or  an  overgrowth  of  the  brain  as  a  whole 
or  of  some  part  of  it.  The  defects  and  malformations  resulting  from  these  de- 
viations may  be  limited  in  area  or  may  be  generally  distributed  throughout 
the  entire  central  nervous  organ  ;  thus  a  foetus  may  present  an  entire  absence 
of  the  brain,  a  condition  to  which  the  term  anencephalia  is  applied,  or  only 
an  absence  of  the  cerebellum  or  of  the  corpus  callosum.  Again,  instead  of 
an  absence  of  this  organ  or  one  of  its  component  anatomical  divisions, 
there  may  be  present  an  anomalous  condition  of  the  growth  of  any  of  these, 
such  as  an  abnormal  smallness  of  the  brain  or  of  some  cerebral  lobe  and 
its  convolutions,  a  hypoplasia,  to  which  the  term  micrencephalia  and  mi- 
crogyria have  iaeen  respectively  given.  Again,  these  deviations  and  de- 
fects may  vary  in  degree  from  a  general  anencephalia  to  a  simple  convolu- 
tional  atypy. 

That  the  brain  should  be  so  frequently  the  seat  of  these  malformations  and 
abnormalities  is  not  to  be  wondered  at.  For  preponderating  as  it  does,  not 
only  in  mass,  but  in  rapidity  of  growth  during  embryonic  life,  it  is  the  organ 
most  exposed  to  the  shocks  of  those  traumatic  and  pathological  disturbances 
which  may  arise  during  the  early  months  of  intra-uterine  life.  The  disturb- 
ing influences  may  arise  from  within  or  without,  and  to  them  must  be  as- 
cribed the  causes  for  the  various  defects  in  growth  which  appear  at  the  birth 
of  the  foetus. 

Many  of  these  developmental  defects  are  inconsistent  with  continued  extra- 
uterine life.  In  these  cases  a  foetus  is  born  which  may  or  may  not  breathe. 
It  may  be  said,  as  a  general  rule,  that  when  the  developmental  defect  is  a 
gross  one  the  foetus  is  non-viable.  These  gross  defects  and  results  of  devel- 
opmental arrests  have  a  pathological  rather  than  a  physiological  interest. 

The  general  causes  of  cerebral  malformations  are  to  be  sought,  first,  in  a 
perversion  of  growth  of  the  ovum,  due  to  inhei'itance  or  to  an  original  defect 
in  either  of  the  parental  contributions  to  the  development  of  the  embryo  ; 
second,  in  a  pathological  disturbance  of  the  mesoblastic  or  epiblastic  layers  of 
the  embryo  ;  or,  third,  in  a  direct  disturbance  of  the  foetus  after  the  develop- 
ment of  the  neural  tube ; — the  last  factor  may  be  the  result  of  a  psychic 
disturbance  on  the  part  of  the  mother,  e.  </.,  a  shock  or  fright  (maternal  im- 
pressions), a  traumatic  or  other  disturbance  to  the  mother  operating  from 
without; — or,   fourth,  to  certain  diseases  of  the  foetus  which  may  develop 


316  ^^I:BVOUS  diseases  and  their  treatment. 

in  utero  or  after  birth.  ■  Of  course,  we  are  unable  to  determine  the  existence 
of  an  original  defect  in  the  developmental  units,  or  even  a  pathological  dis- 
turbance in  the  blastodermic  membranes.  We  must  infer,  however,  that 
such  conditions  must  have  existed  to  have  produced  the  malformations  and 
arrests  of  development,  which  are  so  frequently  found,  on  the  ground  that  no 
other  known  causes  may  be  reasonably  assumed.  In  fact,  certain  cerebral 
malformations  and  cerebral  developmental  arrests  are  so  constantly  occurring 
that  they  assume  a  fixed  and  definite  type.  Where  thLs  is  the  case,  it  may 
be  laid  down  as  a  general  rule  that  the  causes  producing  such  changes  are  to 
be  sought  among  the  fii'st  two  enumerated.  AYhen  an  atypical  malforma- 
tion occurs,  either  due  to  an  arrest  of  development  or  an  overgrowth  of  some 
cerebral  element,  the  cause  must  be  looked  for  either  in  a  disease  or  some 
pathological  condition  of  the  embryo  or  foetus,  or  in  a  disturbing  factor  which 
has  influenced  the  mother  and  has  been  indirectly  reflected  upon  the  foetus. 

The  character  and  the  degree  of  cerebral  malformation  depend  also  upon 
the  nature  of  the  disturbing  factor  and  upon  the  period  of  gestation  at  which 
the  latter  operates.  Thus,  such  an  influence  operating  before  or  during  the 
formation  of  the  neural  tube  will  be  attended  by  a  greater  amount  of  cere- 
bral developmental  arrest  than  at  a  period  when  the  hemispheric  vesicles 
have  afready  been  develoj)ed.  In  the  former  case  an  anencephalia  may  be 
produced  ;  in  the  latter,  some  other  forms  of  malformation  which  may  preserve 
some  portion  of  the  original  hemispheres.  Should  the  disturbing  influence 
be  an  original  defect  on  the  part  of  one  or  both  parents,  such  as  an  atypical 
formation  of  the  cerebral  convolutions,  a  microgyria,  or  a  micrencephalia, 
such  defects  may  be  transmitted  to  the  ofispring. 

Authors  generally  have  neglected  to  give  the  proper  weight  to  disturbing  psy- 
chical factors  in  producing  the  defects  of  which  this  chapter  treats.  These 
factors  are  not  infrequent  causes  of  the  production  of  cerebral  monstrosities. 
Fright,  fear,  or  a  persistence  of  conceptional  visual  impressions  on  the  part  of 
the  pregnant  mother  which  excite  any  of  these  emotions  in  her  are  occasion- 
ally attended  by  developmental  cerebral  defects  in  the  ofispring. 

The  literature  of  the  subject  abounds  in  cases  of  these  defects  ascribed  to 
this  cause.  Encephalocele,  microcephalia,  cyclopia,  and  other  malformations 
and  defects  have  all  been  reported  as  the  result  of  maternal  shock  upon  the 
foetus  in  utero. 

Any  deviation  from  the  fixed  type  of  a  normal  brain  is  a  malformation. 
When  this  term  is  applied  to  cerebral  pathology  it  includes  all  the  various 
forms  of  deviations,  to  wit :  cerebral  hj-perplasia,  cerebral  h\q3oplasia,  and 
cerebral  heteroplasia. 

Cerebral  hypoplasia  includes  the  following  pathological  conditions:  1. 
Anencephalia,  or  absence  of  the  brain.  This  condition  is  always  the  result 
of  an  arrested  development,  and  should  not  include  that  pathological  con- 
dition of  the  brain  due  to  a  hydrocephalus  internus,  in  which,  by  reason  of 
the  pressure  from  the  enormous  quantity  of  fluid  secreted  within  the  cerebral 
ventricles,  the  substance  of  the  brain  becomes  atrophic,  and  finally  coalesces 
with  the  cerebral  meninges,  so  that  it  is  difiicult  to  separate  them,  or  even  to 
determine  by  gross  examination  that  any  cerebral  cortex  is  left.  In  true  anen- 
cephalia there  is  almost  always  an  involvement  of  the  structui'es  of  the  meso- 
blast  formation,  the  bones  of  the  cranial  vault,  which  may  be  wholly  or  in 
part  wanting.  2.  Micrencephalia,  small  or  rudimentary  brain.  Under  this 
head  we  must  include  that  condition  of  atrophic  or  rudimentary  develop- 
ment of  the  cerebral  convolutions,  which  is  called  microgyria.  Micrenceph- 
alia and  microgyria  usually,  if  not  invariably,  accompany  each  other,  so 
that  a  micrencephalic  brain  usually  shows  an  atrophic  or  rudimentary 
development  of  the  convolutions.     3.  Absence,  or  original  rudimentary,  or 


GENERAL  DISEASES  OF  THE  BRAIN.  317 

atrophie  development  of  any  of  the  component  parts  of  the  brain,  such  as  the 
cerebelkim,  the  corpus  callosum,  a  cerebral  lobe. 

Anencephalia.  This  is  a  condition  which  is  usually  associated  with  a 
defective  development  of  the  meninges  and  cranial  vault.  Pathologists  dif- 
ferentiate between  two  degrees  of  this  condition,  total  anencephalia  and  par- 
tial anencephalia.  The  former  is  that  form  of  cerebral  malformation  in  which 
the  brain  is  totally  absent,  as  is  also  the  cranial  vault.  The  cavity  which  the 
brain  was  destined  to  fill  is  usually  occupied  by  a  mass  of  dark  vascular  mem- 
branous tissue.  Partial  anencephalia  is  a  condition  in  which  some  brain 
tissue  is  present,  and  some  definite  cerebral  substance  can  be  determined.  It 
may  or  may  not  be  associated  with  a  defective  cranium.  The  partial  anen- 
cephalies  are  alone  of  interest  to  the  neurologist,  for,  unlike  the  total,  some 
are  consistent  with  life  and  present  certain  definite  indications  of  their  exist- 
ence which  can  lead  one  to  form  a  diagnosis  of  the  condition  of  the  brain 
iutra-vitam.  While  total  anencephalia  is  due  to  a  complete  arrest  of  the  de- 
velopment of  the  hemispheres,  partial  anencephalia  is  the  result  of  merely  a 
defect  in  their  development.  The  former  is  produced  by  a  pathological  dis- 
turbance of  the  forebrain  of  the  embryo,  which  prevents  the  evolution  of  the 
hemispheres  ;  the  latter  presupposes  a  defect  of  certain  cells  in  the  forebrain, 
wdiich  preclude  their  complete  evolution.  Thus  partial  anencephalia  may 
vary  in  degree  and  extent.  There  may  be  an  almost  complete  absence  of 
both  hemispheres,  an  entire  absence  of  one  hemisphere,  or  a  defect  in  one  or 
both  hemispheres.  The  last  defect  may  be  a  loss  of  brain  substance,  leaving 
a  cavity,  sometimes  communicating  with  the  ventricles  within  the  hemis- 
pheres and  sometimes  with  the  subarachnoidean  space.  This  last  condition 
was  first  described  by  Heschl  in  1859,  and  was  called  by  hiva  porencepjhalia. 
(See  also  Chapter  XVII.) 

Investigators  have  recently  been  devoting  their  attention  to  the  etiology  of 
anencephalia.  It  is  the  opinion  of  many  that  intra-uterine  disturbances  are 
the  most  important  factors  in  its  production.  There  can  be  no  doubt  that 
irrespective  of  heredity  and  primary  defects  in  the  ovum,  both  of  which  are 
determining  factors  in  the  production  of  anencephalia,  pathological  condi- 
tions of  the  amnion  are  the  most  prolific  cause  for  this  cerebral  defect.  Long 
ago  Dareste^  and  Geoffroy-St.  Hilaire  called  attention  to  the  fact  that  a  small 
amnion  exercised  an  injurious  influence  on  the  growth  of  the  embryo.  In 
fact^  the  latter  regards  arrest  of  development  as  the  result  solely  of  mechan- 
ical causes.- 

Adhesion  of  the  amnion  to  the  head  end  of  the  embryo  must  exercise  a 
causative  factor  in  the  production  of  anencephalia.  The  anencephalia  will 
be  complete  or  partial  according  to  the  time  of  embryonic  development  that 
this  adhesion  takes  place  and  according  to  the  condition  of  adhesion.  Should 
the  adhesion  take  place  before  the  cerebral  vesicles  are  formed,  the  constric- 
tion at  the  cephalic  end  and  the  pathological  changes  which  the  cells  there 
undergo  will  prevent  the  evolution  of  the  hemispheric  vesicles,  and  a  total 
anencephalia  will  be  produced.  Should  the  adhesion  be  small  in  extent  and 
involve  but  a  limited  area  partial  anencephalia  will  ensue.  It  seems  to  me 
that  this  is  the  only  explanation  of  the  development  of  that  form  of  partial 
anencephalia  in  which  one  hemisphere  is  developed  while  the  other  is  absent. 

Almost  all  who  have  been  investigating  teratological  phenomena  have  come 
to  the  conclusion  that  an  abnormal  constriction  of  the  amnion  at  the  head 
end  of  the  embryo  gives  rise  to  the  forms  of  arrested  development  shown  in 
anencephalia,  exencephalia,  cyclopia,  and  arhinencephalia.    It  would  appear 

1  Dareste  :  Recherches  sur  la  production  artificielle  des  monstruosities,  Paris,  1877. 

2  Geoflfroy-St.   Hilaire :  Hist.  gen.  et  partic.  des  anomalies  de  Torganisation  chez  rhomme  et  les 
animaux.    Paris,  1832-1837. 


318  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

to  me  that  an  excessive  amount  of  amniotic  fluid  could  likewise  exercise  a 
restrictive  influence  and  determine  the  development  of  cerebral  malforma- 
tions. 

Pressure  exercised  on  the  foetus  in  utero  by  pathological  conditions  on  the 
part  of  the  mother  may  give  rise  to  adhesions  between  the  amnion  and  neural 
tube,  and  serve  as  indirect  causes  for  these  conditions. 

Attention  has  recently  been  paid  to  the  artificial  production  of  malforma- 
tions. Thus  L.  Gerlacli,  Fol,  AVarynsky,  Richter,  and  Eoux  have  instituted 
experiments  on  the  ova  of  chickens  and  fi'ogs  with  such  disturbing  factors  as 
variations  of  temperature,  injuries  to  the  ovum,  changes  in  the  position  of 
the  ovum,  removal  of  parts  of  the  o^iim,  etc.,  and  have  produced  monstrosi- 
ties as  a  result.  These  experiments  serve  to  prove  that  a  normal  cerebral 
development  recj^uires  a  normal  ovum  perfectly  adapted  to  its  environments, 
one  which  receives  no  shock  or  trauma,  and  whose  evolution  proceeds  without 
any  pathological  conditions  arising  in  its  integral  units. 

The  question  of  discriminating  between  the  pathological  features  of  partial 
anencephalia  and  porencephalia  has  not  yet  been  settled.  It  is  certain  that 
every  porencephalia  is  a  partial  anencephalia  in  a  general  sense,  and  as  such 
should  be  described  in  connection  with  the  latter  develoj^mental  defect.  Irre- 
spective of  the  causes  enumerated,  partial  anencephalia  may  be  the  result  of 
certain  pathological  factors  produced  by  morbid  changes  occurring  in  the 
brain  of  the  foetus  toward  the  end  of  uterine  life,  and  in  the  brain  of  the  child 
immediately  or  soon  after  birth.  These  morbid  changes  may  be  the  result 
of  a  thrombosis  or  embolism  of  some  cerebral  vessel,  resulting  in  the  forma- 
tion of  a  focal  softening,  and  subsec^uent  disintegration  of  the  softened  area, 
with  serous  transudation  into  the  cavity  produced  by  the  softening.  Cere- 
bral hemorrhage  may  likewise  give  rise  to  the  same  result.  Encephalitis  is 
also  a  cause  for  these  defects  and  hiatuses.  Traumatism,  either  instrumental 
or  otherwise,  during  parturition  must  not  be  overlooked  as  a  cause  for  this 
condition. 

One  of  the  most  ft'equent  and  important  factoi-s  in  the  production  of  par- 
tial anencephalia  is  a  disease  of  the  ejoendyma  of  the  ventricles,  an  ependy- 
mitis,  which  results  in  the  formation  of  subejDendymal  morbid  changes  and 
the  transudation  of  large  quantities  of  fluid  into  the  ventricular  ca^^ties  of 
the  brain. 

Eaidy  obliteration  of  cerebral  vessels,  either  from  disease  of  the  cerebral 
vessels  of  the  foetus  or  fi-om  a  fault  in  the  development  of  the  vascular  system 
of  the  embryo,  may  also  be  a  cause  of  anencephalia. 

Encephalitis  is  regarded  by  most  authors  as  a  potent  factor  in  the  produc- 
tion of  cerebral  defects  like  porencephalia.  In  fact,  some  are  inclined  to 
believe  that  the  vast  majority  of  cases  showing  partial  anencephalia  or  poren- 
cephalia are  the  sole  results  of  this  pathological  condition. 

These  causes  may  operate  on  the  foetal  brain  as  well  as  on  the  brain  of  the 
newborn,  in  the  former  case  producing  a  congenital  porencephaHa,  and  in 
the  latter  a  so-called  acquired  porencephalia. 

Syphilis  on  the  part  of  the  parent  and  its  transmission  to  the  foetus,  pro- 
ducing changes  in  the  foetal  cerebral  vessels  favoring  the  production  of  throm- 
botic and  necrotic  changes  in  the  brain,  must  not  be  overlooked  as  an  impor- 
tant factor  in  the  production  of  partial  anencephalia  and  porenceiDhalia. 

It  is  thus  apparent  that  a  more  rational  classification  of  anencephalia 
would  be  into  true  anencephalia  and  spurious  anencephalia  ;  the  former 
being  confined  to  the  cerebral  defects,  due  to  changes  inherent  in  the  ovum 
and  embryo,  the  result  of  hereditary  or  transmitted  influences ;  the  latter, 
to  all  pathological  causes  arising  from  within  or  without  the  foetus.  Under 
the  former  classification,  of  total  and  partial,  the  partial  anencephalies  are 


GENERAL  DISEASES  OF  THE  BRAIN.  319 

bound  to  become  confounded  with  those  defects  due  to  pathological  causes, 
which  ought  not  to  be  considered  as  originial  defects  in  development.  Thus, 
a  defect  due  to  a  thrombosis,  to  a  hemorrhage,  to  an  encephalitis,  or  to  an 
ependymitis  should  not  be  called  an  anencephalia ;  for,  before  the  patho- 
logical process  giving  rise  to  this  defect  was  established,  the  cerebrum  may 
have  been  perfectly  normal.  The  resulting  defect  is  in  such  cases,  therefore, 
not  an  arrest  of  development,  but  a  destructive  change  in  an  already 
developed  brain. 

Porencephalia.  Inasmuch  as  the  signs  of  partial  anencephalia  and 
porencephalia  have  much  in  common,  the  latter  will  be  described  here,  but 
it  should  be  remembei'ed  that,  notwithstanding  the  fact  that  pathologists 
differ  as  to  what  shall  constitute  a  porencephalia,  when  it  is  spoken  of  in 
this  chapter  it  is  meant  to  signify  a  loss  or  defect  of  brain  substance,  due  to 
pathological  causes  arising  in  the  foetal  brain,  and  which  shows  signs  of  its 
presence  from  birth  ;  hence,  a  congenital  defect  in  the  brain.  Many  path- 
ologists regard  the  absence  of  a  hemisphere  as  a  porencephalia.  Others 
regard  the  defects  due  to  hemorrhage,  or  thrombosis,  or  to  hydrocephalus 
internus,  whether  produced  before  birth  or  during  the  first  two  years  of 
infantile  life,  as  a  porencephalia.  We  insist,  however,  that  such  an  accep- 
tation of  the  term  is  unscientific  and  unphilosophical ;  its  use  should  be 
restricted  to  congenital  pathological  defects  only. 

Since  Heschl'  first  described  the  pathology  of  this  form  of  cerebral  mal- 
formations much  attention  has  been  paid  to  the  subject.  Kundrat,^  in  an 
able  monograph  in  which  he  called  general  attention  to  Heschl's  case,  collated 
a  number  of  his  own,  giving  minute  details  of  all  the  pathological  findings 
in  each  case.  This  monograph  has  been  the  basis  of  most  all  subsequent 
contributions  to  the  subject. 

Heschl,  who  suggested  the  term,  confined  it  to  those  cases  of  defects  in  the 
cerebrum  which  presented  an  absence  of  cortical  and  subcortical  cerebral 
tissue,  either  communicating  with  the  arachnoidal  space  or  shut  ofi*  from  it, 
the  loss  of  tissue  extending  down  more  or  less  deeply  into  the  cerebrum,  even 
as  far  as  the  endyma  of  the  ventricles,  and  sometimes  communicating  with 
an  opening  into  the  ventricular  cavities.  Thus,  there  resulted  a  j)ore  or 
funnel-shaped  depression  in  the  cerebrum,  hence  the  name. 

The  defect  is  confined  to  the  convexity  of  the  hemispheres  or  to  the  Island 
of  Reil.  The  mesal  surface  of  the  hemispheres  is  never  involved,  and  no 
case,  to  my  knowledge,  has  as  yet  been  reported  in  which  that  surface  has 
been  implicated. 

In  porencephalia  there  is  usually  associated  a  developmental  defect  in 
the  hemisphere  which  contains  the  lesion.  This  hemisphere  is  usually 
smaller,  its  convolutions  and  fissures  atypical.  This  relation  of  convolutions 
and  fissures  exists  in  most  cases.  In  exceedingly  few  cases  can  no  disturbance 
of  the  cerebral  convolutional  architecture  be  determined.  In  congenital 
porencephalia  there  is  usually  a  radiating  distribution  of  the  convolutions 
and  fissures  about  the  defect.  In  fact,  Kundrat  believes  that  such  a  relation 
of  convolution  and  fissure  to  the  defect  is  the  charactesistic  feature  which 
differentiates  a  congenital  porencephalia  from  one  which  has  developed  after 
birth.  In  no  case  of  porencephalia  are  the  primary  fissures  absent.  They 
may  be  involved  in  the  defect,  but  some  portion  of  them  remains.  This 
would  go  to  prove  that  the  pathological  developmental  defect  producing  the 
porencephalia  must  occur  after  the  fifth  month  of  gestation.  The  primary 
fissures  are  not  infrequently  changed  in  their  direction,  a  result  which  may 
be  directly  due  to  the  progress  of  the  associated  developmental  defect ;   but 

1  Heschl :  Prager  Vierteljahresschr.,  1859  and  1868.       -  Kundrat :  Die  Porencephalic,  Graz,  1882. 


320  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

their  presence  has  been  established  in  every  well-investigated  case.  The 
secondary  fissures  are  frequently  absent. 

When  the  porencephalia  is  intra-cerebral  the  convolutions  over  the  lesion 
are  smaller  and  less  rounded  than  normal.  They  sink  slightly  below  the  level, 
of  the  surrounding  gyri,  leaving  a  depression  on  the  surface.  Should  the 
porencephalia  communicate  with  the  subarachnoidean  space,  the  gyri  imme- 
diately adjacent  to  the  defect  present  anomalous  conditions.  Since  they  are 
usually  implicated  in  the  pathological  process  producing  the  porencephalia, 
histological  changes  can  frequently  be  determined  in  them  ;  thus,  a  diminution 
of  the  neuroglia  and  atrophy  of  the  nerve  fibrillse  are  not  infrequent.  The 
gyri  themselves  end  with  rounded  edges,  which  sink  into  the  cavity  of  the 
defect,  and  becoming  gradually  thinner,  merge  with  the  subcortical  substance. 
In  some  cases,  owing  to  the  loss  of  sub-cortical  tissue,  and  the  further  develop- 
ment of  the  cortex,  the  latter  grows  over  the  defect  and  leaves  only  a  sinuous 
track — a  linear  opening  or  slit — on  the  cerebral  surface,  which,  if  not  closely 
examined,  appears  merely  to  be  an  unusually  wide  sulcus. 

The  relation  of  the  cerebral  meninges  to  the  porencephalia  is  important, 
and  is  considered  by  Kundrat  to  be  characteristic.  He  considers  it  a  differ- 
ential mark  between  a  true  ( congenital)  and  spurious  (acquired)  porenceph- 
alia. In  the  former  case  the  pia,  where  the  defect  is  covered  by  cortex 
and  does  not  communicate  with  the  subarachnoidean  space,,  follows  closely 
the  depression  of  the  hemisphere,  which  is  arched  over  by  the  tense  arach- 
noid. In  those  cases  where  the  defect  communicates  wdth  the  sub-arach- 
noid space,  the  pia  dips  down  into  the  cavity  for  some  distance,  whereas 
the  arachnoid  ends  abruptly  at  or  near  the  margins.  When  the  cavity  com- 
municates with  the  ventricle  the  pia  ends  almost  at  the  ependymal  lining  of 
the  ventricle,  the  ependyma  being  itself  thickened.  In  the  acquired  cases 
the  pia  does  not  follow  the  depression,  but  ends  abruptly  at  the  margin  of 
the  depression.  Sometimes  the  cavity  in  these  cases  is  filled  by  a  vascular 
connective-tissue  formation  which  imitates  in  appearance  a  thickened  pia, 
but  which  seems  to  have  no  connection  with  it. 

In  all  cases  where  the  defect  communicates  with  the  ventricle  the  latter  is 
found  to  be  dilated,  its  endymal  covering  thickened,  and  its  surface  to 
have  a  granular  appearance.  In  fact,  dilatation  of  the  lateral  ventricle  is 
one  of  the  most  constant  accompaniments  of  porencephalia,  and  is  sometimes 
found  in  cases  when  the  defect  does  not  communicate  with  the  ventricle. 

The  seat  of  the  porencephalia  varies,  its  region  of  selection  being  the  con- 
vexity of  the  parietal  lobe.  In  ninety-six  cases  examined  by  Audry'  it  was 
fovmd  in  both  hemispheres  in  32  cases,  in  the  left  hemisphere  in  38  cases,  in 
the  right  hemisphere  in  26  cases. 

The  lobes  involved  in  the  single  defect  showed  the  following :  Parietal 
lobe,  17  cases ;  frontal  lobe,  7  cases ;  temporal  lobe,  4  cases  ;  occipital  lobe, 
8  cases. 

In  the  cases  examined  by  Kundrat  the  temporal  lobe  was  found  to  be  more 
frequently  the  site  of  the  defect  than  the  frontal  lobe,  and  the  parietal  to  be 
most  fr-equently  of  all  aflTected. 

Corresponding  with  the  gross  changes,  microscoj^ical  examination  shows  an 
atrophy  and  disintegration  of  the  tracts  connected  with  the  defective  area. 
When  the  area  involved  is  in  the  motor  region  of  the  cortex  the  pyramidal 
tract  is  rudimentary,  and  when  traced  through  the  internal  capsule,  pes, 
pons,  and  medulla,  shows  a  marked  contrast  in  size  to  its  opposite  fellow, 
(See  Fig.  69.)  In  these  cases  the  isthmus  cerebri  is  asymmetrical,  the 
afiected  pyramid  in  the  medulla  being  either  not  at  all  elevated  or  even  not 

1  Revue  de  Med.,  1888,  viii.  6,  pp.  462-467,  583. 


GENERAL  DISEASES  OF  THE  BRAIN. 


321 


recognizable  as  a  distinct  formation  ;  in  some  cases — those  in  which  the  entire 
motor  area  of  the  cortex  is  destroyed — the  pyramidal  tract  is  entirely  absent. 
The  association  fibres  of  the  cortex  cerebri  show  the  same  atrophic  and  rudimen- 
tary development.  It  is  owing  partly  to  these  associated  changes  in  the  subcor- 
tical connecting  strands  and  partly  to  the  original  loss  of  the  cerebral  substance 
in  the  pathological  defect  that  the  affected  hemisphere  is  smaller  than  the 
non-affected  one.  Asymmetry  between  the  two  hemispheres  is  more  marked  in 
the  congenital  cases.  In  these  cases,  too,  the  basal  ganglia  on  the  affected 
side  participate  in  the  defective  development,  the  thalamus  especially  being 
smaller  than  normal,  as  is  also  the  lenticular  nucleus. 


Fig.  69. 


Large  porencephalic  defect  in  the  left  insula.    View  of  the  brain  from  the  base. 
Secondary  degeneration  of  the  left  crus  and  pons.    (After  Kundrat). 

The  septum  lucidum  is  often  absent,  and  especially  so  in  those  cases  where 
there  is  a  dilatation  of  the  lateral  ventricle. 

The  cerebellum,  in  a  few  cases,  has  been  found  to  be  smaller  than  normal, 
and  also  asymmetrical,  the  asymmetry  being  confined  to  the  lobe  on  the  same 
side  as  the  defect  in  the  cerebrum. 

The  cranium  itself  stands  usually  in  direct  relationshijD  with  the  lesion.  In 
most  cases  there  is  a  marked  asymmetry.  In  some  cases  where  the  poren- 
cephalia involves  a  large  area  of  the  cerebrum  there  may  be  no  cranial 
asymmetry,  whereas,  on  the  other  hand,  slight  porencephalic  defects  are 
attended  by  a  degree  of  cranial  asymmetry  beyond  proportion  to  the  cerebral 
defect.     Where  the  cranial  asymmetry  does  not  correspond  with  the  cerebral 

21 


322  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

defect,  the  porencephalia,  it  may  be  assumed,  occurred  late  iu  foetal  life  or 
after  birth.  In  the  congenital  cases  there  seems  to  be  a  direct  relationshij)  be- 
tween the  degree  of  cranial  asymmetry  and  the  extent  of  the  cerebral  lesion. 

The  character  of  the  asymmetry  of  the  skull  varies.  In  some  cases  the  in- 
volved portion  is  distended — giving  the  appearance  of  a  hydrocephalic  head 
— while  in  others  it  is  microcephalic.  The  latter  cases  are  more  numerous 
by  far  than  the  former.     The  face  very  often  participates  in  the  asymmetry. 

Symptoms.  The  symptoms  of  partial  anencephalia  and  porencephalia  are 
much  alike. 

Total  anencephaha  is  a  condition  which  does  not  permit  of  life. 

The  character  of  the  symptoms  varies  according  to  the  seat  of  the  lesion. 
The  most  common  signs  are  idiocy  or  imbecility,  hemiplegia,  mutism,  mal- 
formation, and  contractures  of  the  extremities.  In  some  cases  associated  with 
these  signs  is  strabismus. 

A  child  who  from  birth  shows  a  hemiplegia,  with  or  without  contractures 
of  the  paralyzed  side,  who,  as  childhood  advances,  shows  no  evidence  of  re- 
cording impressions  and  makes  no  progress  in  intelligence,  who  does  not 
acquire  the  use  of  speech,  who  has  a  cranial  deformity,  who  shows  a  perver- 
sion of  the  emotions,  who  dribbles  saliva,  and  cannot  learn  the  use  of  a  vessel 
to  hold  its  excreta,  presents  the  usual  picture  of  a  congenital  porencephalia. 

If  the  child  should  be  born  without  any  apj)arent  symptoms  of  this  nature, 
and  if  within  the  first  two  years  of  infant  life  it  develops  symptoms  similar 
to  the  above,  especially  if  a  history  of  traumatism  can  be  adduced,  or  of 
hereditary  syphilis,  such  a  child  may  be  said  to  have  acquired  porencephalia. 

The  most  constant  of  all  the  symptoms  is  paralysis.  It  is  present  iu  the 
congenital  as  well  as  in  the  acquired  forms,  and  is  a  necessary  result  of  the 
destructive  process  in  the  brain.  Rarely  are  all  the  extremities  the  seat  of 
paralysis.  The  usual  form  is  a  hemiplegia  contralateralis,  which,  if  secondary 
degeneration  involve  the  pyramidal  tract,  is  accompanied  by  contracture  of 
the  paralyzed  limbs.  Contracture  may  also  be  the  result  of  a  defectively 
developed  pyramidal  tract. 

Independent  of  the  paralysis,  there  is  often  present  a  malformation  of  the 
extremities,  sometimes  in  the  paralyzed,  sometimes  in  the  unparalyzed  limbs, 
and  not  infrequently  in  both.  This  is  present  in  some  form  in  almost  all  of 
the  congenital  cases  of  porencephalia,  and  is  rare  in  the  post-natal  form. 

Mutism,  or  inability  to  express  articulate  speech,  is  not  infrequent  in  the 
congenital  form.  It  is  rare  in  cases  of  acquired  porencephalia.  The  defect 
in  the  acquisition  of  speech  may  be  absolute,  nothing  but  inarticulate  cries 
being  expressed  at  times  of  emotional  excitement ;  or  speech  may  be  imper- 
fectly developed,  so  that  the  child  may  be  able  to  express  itself  in  a  special 
w^ay  to  those  who  are  accustomed  to  be  about  it.  It  may  learn  the  use  of 
some  words  and  phrases.  Inability  to  speak  in  these  cases  stands  in  direct 
relationship  to  the  psychical  disturbance,  so  that  where  the  idiocy  is  extreme 
speech  is  entirely  wanting. 

Deafness  is  sometimes  present,  and  is  usually  found  in  those  cases  where 
the  lesion  affects  the  temporal  lobe.  When  associated  with  mutism  it  serves 
as  an  additional  factor  in  the  production  of  absolute  loss  of  the  power  of 
acquiring  articulate  speech. 

Blindness  exists  only  in  a  few  cases,  and  is  found  where  the  porencephalia 
involves  a  great  area  of  the  cerebral  hemispheres.  It  may  be  the  result  of 
the  cerebral  lesion  or  of  an  associated  rudimentary  development  of  the  optic 
tracts. 

Strabismus  and  insufficiency  of  the  ocular  muscles  are  not  infrequent 
accompaniments  of  this  affection. 

Idiocy  is  generally  present  in  the  congenital  cases,  and  depends  for  its 


GENERAL  DISEASES  OF  THE  BRAIN.  323 

existence  on  the  defect  in  development  of  the  brain  which  is  associated  with 
the  original  lesion.  It  is  extremely  rare  in  the  acquired  cases,  the  latter  pro- 
ducing a  lesser  psychical  disturbance,  manifesting  itself  in  an  imbecility.  The 
larger  the  defect  the  more  pronounced  will  be  the  mental  disturbance,  and 
this  is  especially  so  in  those  cases  in  which  the  porencephalia  is  produced 
during  foetal  life.  Every  degree  of  imbecility  and  idiocy  may  be  presented 
in  the  variovis  cases.  Thus  an  absolute  absence  of  all  mental  life  may  be 
present  in  some  of  the  congenital  cases,  the  afflicted  individual  showing  no 
emotions,  uttering  inarticulate  cries,  passing  his  urine  and  feces  without 
knowledge  of  the  act,  registering  no  impressions,  not  even  acquiring  the 
instinct  of  preservation,  apparently  only  the  automatic  nervous  functions 
being  in  operation. 

Not  infrequently  associated  with  this  condition  is  epilepsy.  Convulsions 
and  epileptiform  attacks  increase  the  mental  hebetude  and  add  horror  to  the 
lives  of  these  poor  unfoi'tunates.     (See  also  Chapter  XVII.) 

MiCRENCEPHALiA  AND  MICROCEPHALIA.  In  the  Same  manner  that 
there  may  be  an  absence  of  development  of  the  entire  brain  or  of  any  of  its 
component  parts,  an  arrested  or  a  defective  development  of  the  brain  or  any 
part  of  it  may  occur.  Thus  the  brain  entirely,  or  one  of  its  hemispheres  or 
lobes,  may  present  a  greater  or  less  diminution  in  size. 

The  term  micrencephalic  is  given  to  that  brain  which  does  not  approach 
in  weight  the  lowest  standard  of  weight  in  man,  as  Avell  as  to  a  brain  which 
is  much  diminished  in  size  in  some  or  all  of  its  component  parts.  When  the 
brain  vault  is  similarly  diminished  in  an  individual  that  person  is  said  to 
have  a  microcephalic  cranium.  The  two  conditions  are  usually  associated. 
The  diminution  in  size  of  the  brain  depends  not  only  on  a  defective  develop- 
ment of  the  cortical  and  subcortical  elements,  but  also  on  a  general  arrest  of 
development  of  the  cerebral  vesicles  after  the  fifth  month  of  gestation.  This 
arrest,  though  generally  distributed  in  area  over  the  hemispheres,  only  par- 
tially affects  the  neural  elements.  As  a  result,  mostly  all  of  the  gross 
anatomical  elements  of  the  cerebrum  may  present  themselves  merely  dimin- 
ished in  size,  and  the  micrencephalia  may  represent  a  miniature  brain  with 
small  gyri  and  shallow  sulci ;  or  the  brain  may  be  fully  developed  in  certain 
parts  and  defectively  so  in  others,  giving  an  appearance  of  a  partial  atrophy 
of  the  brain  limited  to  certain  lobes.  The  distinction  between  an  atrophy  of 
the  brain  and  the  results  of  arrested  cerebral  development  should,  in  this 
connection,  be  always  borne  in  mind ;  for  micrencephalia  may  be  the  result 
of  either  cause,  or  both  combined.  The  retrogressive  changes  occurring  in 
a  cerebrum  not  yet  fully  developed,  due  to  some  pathological  process,  and 
resulting  in  an  atrophy  of  the  affected  portion  of  the  brain,  may  itself  be  the 
essential  factor  in  the  production  of  an  arrest  of  development  in  other  parts 
of  the  same  cerebrum.  It  thus  becomes  apparent  that  while  both  defects 
may  be  productive  of  micrencephalia,  this  condition  may  be  the  result  of 
either  cause  independently. 

Micrencephalia  is  but  a  form  of  2:)artial  anencephalia,  and  is  dependent  for 
its  production  on  similar  or  analogous  causes  to  those  which  produce  the  latter. 
A  true  micrencephalia  is  always  the  result  of  an  arrested  development,  which 
may  affect  the  entire  cerebrum  or  some  part  thereof,  and  which  is  due  to 
either  an  original  defect  in  the  epiblast  of  the  ovum  or  to  some  acquired 
pathological  process  in  the  foetal  brain. 

There  is  a  form  of  micrencephalia  which  is  the  result  of  mechanical  causes. 
This  form  is  associated  with  a  premature  synostosis  of  the  cranial  bones.  The 
effect  of  this  deviation  from  normal  cranial  growth  is  to  produce  a  hindrance 
to  the  antero-posterior  or  to  the  lateral  growth  of  the  cranium,  or  to  both. 
The  cranium  remains  contracted  and  small,  the  hemispheres  beneath  have  no 


324  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

room  to  exj^and  in  their  groAvth,  aucl  a  small  or  micreucephalic  brain  is  the 
result.  This  condition  can  only  result  when  all  the  sutures  of  the  cranium 
are  involved  in  this  pathological  condition.  If  only  some  of  the  cranial  bones 
be  affected,  and  prematni'e  junction  of  only  some  of  the  sutures  results,  a 
compensatory  expansion  and  growth  of  the  other  unaffected  bones  takes  place, 
and  the  skull  and  brain  become  developed  in  length  or  breadth,  as  the  case 
maybe,  beyond  the  normal,  producing  a  markedly  dolicocephalic  or  brachy- 
cephalic  skull. 

Virchow^  classifies  the  following  cranial  abnormaKties  dependent  upon 
general  or  partial  synostosis  of  the  cranial  sutures  : 

A.  Simple  microcephalia  may  be  produced  by  general  premature  synostosis 

of  all  the  cranial  sutures. 

B.  Dolicocephalic — long  heads. 

a.  Su2:)erior  middle  synostosis. 

a.  Simple  dolicocephali  (synostosis  of  sagittal  suture). 
|3.  Sphenocephali,  wedge  heads  (synostosis  of  the  sagittal  suture 
and  compensatory  growth  in  the  region  of  the  large  fontanelle). 
h.  Inferior  lateral  synostosis. 

a.  Leptocephali,  small  heads  (synostosis  of  the  frontal  and  sphe- 
noid.) 
|8.  Klinocephali,  saddle   heads    (synostosis  of  the  j)arietal   and 
sphenoid  or  temporal  bones). 
c.  Foetal  synostosis  of  the  halves  of  the  frontal. 

a.  Trigonocephali,  forehead  small  and  cuneiform ;    head,  when 
viewed  from  above,  j)resents  a  triangular  shape. 

C.  Brachycephali,  short  heads. 

a.  Posterior  synostosis. 

a.  Pachycephali,  thick  heads  (synostosis  of  parietal  and  occipital). 
)3.  OxycejDhali,  pointed  head  (synostosis  of  the  parietal  with  the 
occipital  and  temporal  and  compensatory  growths  of  the  ante- 
rior fontanelle  region). 
h.  Superior,  anterior,  and  lateral  synostosis. 

a.  Platycephali,  flat  heads  (extensive  synostosis  of  frontal  and 

parietal). 
Q    Trochocephali,  round  heads  (partial  synostosis  of  frontal  and 

parietal  in  the  middle  half  of  the  coronal  suture.) 
y.   Plagiocephali,  oblique  heads  (one-sided  synostosis  of  the  fron- 
tal and  parietal), 
c.  Inferior  middle  synostosis. 

a.  Simple  brachycephali  (early  synostosis  of  sphenoid  and  cranial 
base). 
The  micrencephalia  produced  by  premature  synostosis  of  the  cranial 
bones  presents  usually  a  brain  generally  diminished  in  size — a  miniature  brain 
in  which  all  the  elements  are  small,  the  primary  convolutions  and  sulci 
as  a  usual  thing  typical  in  form  and  direction,  but  interrupted,  smaller,  and 
less  deep  than  normal.  In  these  cases  the  convolutions  appear  to  be  flattened 
by  the  early  pressure  exerted  upon  the  growing  hemispheres,  and  the  sec- 
ondary gyri  are  less  distinctly  marked  or  absent. 

The  cranial  capacity  of  microcephalic  heads  varies  according  to  the  age 
of  the  subject.  Carl  Vogt,  who  examined  carefully  this  measure  in  33 
crania,  of  which  25  per  cent,  were  those  of  females,  gave  the  following 
average :  The  youngest  cranium  examined  was  one  of  a  child  who  died 
after  birth,  the  oldest  one  belonging  to  a  person  who  lived  44  years.     The 

1  Virchow  :  Ges.  Abhandl.,  Frankfurt,  a.  M.,  1856,  p.  901. 


GENERAL  DISEASES  OF  THE  BRAIN.  325 

average  capacity  of  these  crania  in  children  between  the  ages  of  five  and 
fifteen  years  was  382  c.cm.,  in  microcephalic  adults  441  c.cm.  In  other  words, 
the  former  represented  about  the  normal  cranial  capacity  of  a  child  of  six 
months  of  age,  the  latter  that  of  a  two  to  two-and-a-half-y ear-old  child. 

These  crania  show  a  reduction  in  size  in  all  measurements.  The  mini- 
mum standard  of  the  circumference  of  a  normal  cranium  is  placed  at  about 
43  cm.  Crania  whose  circumference  is  smaller  than  this  are  considered  as 
microcephalic. 

The  weight  of  micrencephalic  brains  varies  to  an  almost  extreme  degree. 
A  brain  which  is  below  the  standard  of  the  minimum  weight  in  man,  960 
grms.,  or  880  grms.  in  woman,  may  be  said  to  be  a  micrencephalic  brain. 
There  is  a  wide  latitude  in  weight,  though,  in  micrencephalia.  Thus  Sander*^ 
describes  the  brain  of  a  micrencephalic  infant  of  five  months  of  age,  which 
weighed  in  the  fresh  state  only  170  grms.,  and  Jensen^  a  girl  of  eight  years, 
whose  brain  weighed,  in  the  same  condition,  924  grms.  More  important, 
however,  than  the  absolute  weight  is  the  relative  weight  between  the  brain 
and  general  body.  This  should  bear  the  ratio  of  14  per  cent,  at  birth,  and 
only  of  2.37  per  cent,  in  adult  life  (Vierordt). 

Let  it  be  understood  clearly  that  only  some  of  the  cases  of  micrencephalia 
can  be  referred  to  cranial  causes  for  their  production.  These  cases  are  siii 
generis,  and  ought  not  to  be  considered  as  due  to  arrested  development  of  the 
brain.  The  brain  exposed  to  pressure  develops  in  all  its  parts,  but  slowly 
and  incompletely.  It  is  not  an  arrest  of  development,  but  rather  an  imper- 
fect development.  The  large  number  of  cases  of  micrencephalia,  however, 
are  the  results  of  a  true  arrest  of  cerebral  development,  arising  either  from 
intrinsic  disturbances  in  the  ovum  or  from  acquired  pathological  changes 
due  to  local  cerebral  or  extrinsic  maternal  influences. 

It  is  now  generally  conceded  that  the  most  frequent  cause  of  micren- 
cephaly is  an  early  foetal  hydrocej^halus  internus.  When  we  come  to  speak 
of  this  condition  we  will  find  that  the  endyma  of  the  cerebral  ventricles  is 
the  chief  factor  in  its  development.  Hans  Virchow^  affirms  that  this  mal- 
formation of  the  brain  does  not  lie  in  the  cranium,  but  in  the  brain  itself, 
and  is  the  result  of  a  chronic  lepto-meningitis,  which  in  addition  to  estab- 
lishing a  hydrocephalus  is  productive  of  an  aplasia  of  those  portions  of  the 
cerebrum  which  are  associated  with  the  diseased  pia. 

The  appearances  of  defective  or  arrested  development  outside  of  the 
diminished  size  of  the  cerebrum  are  apparent  at  the  first  sight  of  a  micren- 
cephalic brain.  These  are  referable  to  the  gyri  and  sulci,  to  the  corpus 
callosum  and  to  special  lobes. 

The  gyri  and  sulci  not  only  deviate  in  size  from  the  normal,  but  the  pri- 
mary convolutions  and  fissures  may  not  be  distinguishable  at  all  or  only 
with  difficulty.  Much  attention  has  been  given  to  the  occurrence  in  these 
brains  of  a  type  of  gyral  and  fissural  development  referable  to  those  occur- 
ing  in  the  anthropoid  apes  and  which  have  been  called  ape-like  fissures.  • 

Ape-like  Fissures.  On  the  lateral  convexity  of  the  occipital  lobe  of  all 
anthropoid  apes,  separating  it  distinctly  from  the  parietal,  running  almost 
directly  perpendicular  to  the  Sylvian  fossa,  is  a  fissure.  This  is  the  oper- 
cular fissure  of  the  apes.  It  is  called  opercular  because  its  posterior  or 
caudad  lip  overlaps  its  anterior  or  encephalad  lip  by  a  thin  wall  of  cerebral 
tissue  like  a  cover.  When  the  lips  forming  this  fissure  are  separated,  gyri 
concealed  by  the  overlapping  tissue  are  brought  to  view.     These  gyri  are 

1  Sander,  Julius :  Archiv.  fur  Psychiatrie,  Bd.  i.  p.  299. 

2  Jensen,  Julius  :  Archiv.  f.  Psychiatrie,  Bd.  x.  p.  950, 

3  Virchow  Hans :  Ein  Fall  von  aiigeborene  Hydrocephalus  internus.  Zugleich  ein  Beitrag  zur 
Microcephalenfrage.    Aus  Festschrift  v.  A.  v.  KOUiker.    1886.    Leipzig. 


326  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

transition  gyri  between  the  parietal  and  occipital  lobes.  Gratiolet',  who 
called  attention  to  this  subject,  showed  that  in  most  apes  some  of  these  gyri 
descended  into  the  depths  of  the  opercular  fissure  (fissura  perpendicularis), 
and  are  normally  concealed  by  it  and  are  only  visible  when  the  fissure  is 
opened.  In  these  transition  gyri  Gratiolet  undertook  to  differentiate  the 
various  anthropoid  apes'  brain. 

In  some  microcephalic  brains  this  opercular  or  external  perjje^idicular  occi- 
pital fissure  is  present.  Its  usual  site  is  the  situation  of  the  sulcus  occipitalis 
transversus,  from  which  it  proceeds  directly  downward  and  forward  and 
distinctly  divides  the  parietal  from  the  occipital  lobe.  In  its  depths  are  to 
be  found  the  transition  gyri  which  are  given  such  an  important  position  by 
both  Gratiolet  and  Bischoff'.^  The  transition  gyri  in  the  anthropoid  apes  are 
two  in  number.  Gratiolet  taught  that  upon  the  character  of  these  gyri, 
whether  they  were  visible  or  concealed,  he  could  establish  a  basis  for  the  class- 
ification of  anthropoid  brains.  He  believed  that  the  brain  of  the  orang- 
outang was  to  be  differentiated  from  that  of  the  chimpanzee  by  the  absence 
in  the  latter  of  the  first  transition  gyrus  and  by  the  concealment  of  the 
second  by  the  opercular  fissure. 

Some  microcephalic  brains  have  been  described,  in  which  in  addition  to 
the  presence  of  the  opercular  fissure  some  form  of  transition  gyrus  has  been 
preserved,  either  unconcealed  on  the  surface  or  only  brought  to  view  when 
the  opercular  fissure  has  been  separated.     (See  Fig.  70.) 


Gtr, 
.0 


Brain  ot  an  imbecile  showing  ape-lilre  formation  of  the  occipital  lobe.  (After  William  Sander.) 
O.  Opercular  fissure.    C.  Central  fissure.    G.  tr.  Transition  gyrus.    S.  Fossa  Sylvii. 

The  explanation  of  the  presence  of  this  fissure  is  an  interesting  one.  It  is 
well  known  that  the  external  perpendicular  occipital  fissure  is  always  present 
in  the  foetal  brain  at  the  seventh  month.  In  the  course  of  the  eighth  month 
of  foetal  life  it  disappears. 

A  brain  of  an  insane  patient  has  been  described  by  W.  Sander,  m  which, 
among  other  anomalies,  a  convolutional  arrest  of  development  of  the  occi- 
pital lobe  occurred,  and  in  which  the  opercular  fissure  and  these  transition 
gyri  were  present,  as  was  also  another  ape-like  fissure  parallel  to  the  former 

1  Gratiole't :  Memoire  sur  les  Plis  cerebreaux  de  I'Homme  etdes  Primates,  Paris,  1854. 

2  Bischofif:    Abliandl.  der.  K.  Bayer.  Acad.  d.  Wissenschaft,  ii.  c.  xi.  Bd.  n.  ,  ,.„,  ^„  p^vim.! 

3  W.  Sander :  Ueber  eine  affenartigeBildung  des  Hinterhauptslappen  eines  menschhchen  Gehirus. 
Archiv.  f.  Psychiatric,  Bd.  v.  p.  842. 


GENERAL  DISEASES  OF  THE  BRAIN.  327 

and  also  in  the  occipital  lobe.  This  latter  fissure,  however,  has  no  analogue 
in  the  fcetal  brain.     (See  Fig.  70.) 

Another  ape-like  formation  of  cerebral  fissures  is  sometimes  found  in  mi- 
crencephalic  brains  in  the  Sylvian.  In  the  normal  brain  the  Sylvian  fissure  is 
composed  of  three  legs,  forming  a  figure  like  the  letter  Y.  The  part  of  the 
hemisphere  bounding  its  anterior  edge  is  the  orbital  surface  of  the  third 
frontal  convolution,  its  posterior,  the  apex  of  the  temporal  lobe.  Between 
the  two  descends  the  operculum' — not  to  be  confounded  with  the  opercular 
fissure  of  the  ajDc's  occipital  lobe — pressing  the  two  legs  apart,  but  not  de- 
scending far  enough  to  convert  the  Y  into  a  V.  In  the  anthropoid  apes 
this  part  of  the  cerebrum  apparently  descends  further  and  causes  the  Sylvian 
fissure  to  assume  the  latter  shape.  This  V-shaped  condition  of  the  Sylvian 
is  sometimes  found  in  micreucephalia.  The  apparent  descent  of  the  opercu- 
lum is  not  the  only  factor  in  the  production  of  the  V-shaped  fissure  of  Syl- 
vius. The  evolution  of  speech  in  man  has  been  attended  by  an  increase  in 
the  development  of  the  lower  frontal  convolution,  adding,  as  it  were,  to  the 
formation  of  the  third  leg  of  the  Y  from  the  original  V-shape,  as  found  in 
the  anthropoid  apes.  A  comparison  of  the  human  with  the  simian  brains 
will  establish  this  proposition.  In  the  latter  the  frontal  lobe  in  its  lower  part 
is  flat  and  relatively  small,  in  the  former  well  rounded,  and  in  part  in  ajjpo- 
sition  with  the  anterior  extremity  of  the  temporal  lobe,  so  that  it  forms  a 
lower  stem  to  the  V,  converting  it  into  a  Y. 

Even  in  some  cases  where  the  ape-like  formation  of  the  fissure  of  Sylvius 
is  present,  the  Island  of  Reil  may  be  uncovered.  As  a  usual  rule,  it  is  cov- 
ered by  the  operculum. 

On  the  mesal  surface  of  the  cerebrum  is  sometimes  found  in  micreucephalia 
another  anthropoid  ape-like  formation  of  fissures  and  gyri.  This  is  observ- 
able in  the  formation  of  those  on  the  mesal  face  of  the  occij)ital  lobe.  In 
man  the  internal  perpendicular  occipital  fissure  joins  directly  the  calcarine 
fissure,  forming  the  wedge-shape  lobe,  the  cuneus.  This  junction  is  charac- 
teristic of  the  human  brain.  In  the  anthropoid  bi'ains  the  internal  perpen- 
dicular fissure,  while  it  appi'oaches  the  calcarine,  does  not  join  it,  so  that  a 
space  is  left  between  the  terminal  extremities  of  these  tAVO  fissures,  forming 
a  gyrus  which  has  been  called  by  the  Germans,  die  Zivickelwindung.  This 
gyrus  connects  the  hippocampal  gyrus  with  the  cuneus,  lying  between  the 
former  and  the  gyrus  fornicatus,  and  is  found  in  all  the  brains  of  the  anthro- 
poid apes.  Its  presence  in  some  cases  of  micrencephaly  has  been  noted  by 
several  writers,  including  Bischoff  and  Vogt^. 

While  the  above  so-called  aj^e-like  fissures  and  gyri  occur  only  occasionally 
in  micreucephalia,  they  have  likewise  been  found  in  idiots  who  were  not 
microcephalic,  as  well  as  in  some  negro  brains.  Their  appearance  in  micreu- 
cephalia probably  led  Carl  Vogt'^  to  the  hypothesis  that  micrencephalia  was 
an  atavistic  phenomenon,  and  that  the  idiots  possessing  these  brains  repre- 
sented a  return  to  the  ape  state  of  man,  or  to  that  original  state  before  the 
races  of  apes  and  man  were  divided.  Important  as  their  presence  is,  it 
should  be  remembered  that  all  the  fissural  anomalies  described  do  not  occur 
together  in  the  same  brain,  and  that  they  sometimes  appear  in  appai'ently 
normal  brains.  In  fact,  Meynert*  described  the  brain  of  a  well-educated 
engineer,  who,  during  life,  presented  no  mental  change,  in  which  the  oper- 
cular fissure  was  found  exceedingly  w^ell  developed. 

1  Operculum  or  opercular  lobule,  so  called  because  it  covers  the  cortex  of  the  Island  of  Reil. 
-  Carl  Vogt :    Arch,  fiir  Anthropologie,  Bd.  ii.,  Braunschweig,  1867. 

3  Vogt,  Carl:  Ueber  die  Microcephalia  oder  Afl'eumeuschen,  Archives  fiir  Anthropologie,  Bd.  ii. 
Braunschwig,  1867,  p.  276. 
<  Theodor  Mejaiert  :    Arch,  fiir  Psychiatric,  Bd.  vii.  p.  281. 


328  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Their  presence,  however,  must  be  regarded  as  the  expression  of  a  partial 
arrest  of  cerebral  development. 

Almost  as  important  as  the  presence  of  the  so-called  ape-like  fissures  and 
gyri  are  the  abnormal  types  of  other  fissures  and  gyri  discoverable  in  many 
micrencephalic  brains.  As  a  usual  thing,  in  these  cases,  the  hemispheres 
are  greatly  asymmetrical  both  in  size  and  shape,  and  the  fissures  and  gyri, 
while  aberrant  in  each,  yet  difier  from  each  other.  It  is  even  sometimes 
difficult,  by  reason  of  the  absence  of  the  divisional  fissures,  to  define  the  cere- 
bral lobes.  The  fissures  that  are  usually  aberrant  are  the  central,  the  pre-  and 
post-central,  the  interparietal,  and  the  occipital.  These  may  be  reduplica- 
ted or  interrupted  by  so-called  bridging  convolutions.  These  convolutions 
either  represent  a  redundant  duplicature  of  fixed  convolutions  or  are  the 
result  of  an  aberrant  fissural  development. 

The  course  and  direction  of  these  fissures  may  also  deviate  from  the  nor- 
mal type.  Thus  the  central  fissure  may  cross  the  post-central  gyrus  and 
connect  with  the  interparietal.  The  internal  perpendicular  occipital  may 
divide  the  hippocampal  gyrus  into  two  gyri.  The  calcarine  has  been  de- 
scribed as  being  continuous  with  the  hippocampal. 

The  formation  of  atypical  convohitions  and  gyri  is  the  expression  of  an 
inherent  primordia-1  defect  in  the  epiblastic  development  of  the  neural  tube. 
This  defect  occurs  ah  initio  and  cannot  be  ascribed  to  any  defect  in  the  brain 
coverings  or  cranial  vault. 

That  Virchow's  belief,  that  the  formation  of  normal  fissures  and  gyri  is  the 
result  of  the  mechanical  pressure  of  the  enveloping  tissues  of  the  brain  upon 
a  more  rapidly  growing  cortex  is  not  the  explanation  of  this  phenomenon,  is 
proven  by  the  fact  that  brains  which  do  not  completely  fill  the  cranial  cavity 
and  cerebra,  that  have  defective  or  partially  absent  crania,  show  the  same  ten- 
dency to  the  formation  of  gyri  as  those  wdiose  envelopes  are  completed.  If 
pressure  were  the  cause,  the  latter  cases  should  present  no  convolutions.  Such, 
however,  is  not  the  case.  The  explanation  of  convolutional  formation  must 
be  sought  somewhere  else.  Jelgersma^  denies  the  connection  or  relation  of 
cranial  growth  and  the  development  of  convolutions.  He  believes  that  the 
formation  of  gyri  and  sulci  is  simply  the  result  of  the  tendency  of  the  cere- 
bral mantle  to  extend  its  surface  of  growth  against  the  restraining  factor,  of 
a  mutual  relation  between  brain  space  and  the  development  of  the  tracts 
within  the  cerebrum. 

That  the  development  of  the  central  connections  of  the  cortex  and  the 
correlated  parts  is  an  important  factor  j9er  se,  independent  of  space,  is  proven 
by  the  tendency  in  the  higher  vertebrates  to  show  a  convolutional  arrange- 
ment of  the  intercalar  gray  masses,  hke  the  olive  and  the  nucleus  of  the 
trapezium.  This  convolutional  tendency  certainly  cannot  be  ascribed  to  pres- 
sure arising  from  the  meninges  or  cranial  vault.  The  cerebellum  itself  is 
also  nothing  but  an  intercalar  station  between  cortex  and  periphery,  and  is  rich 
in  convolutions.  It  appears  to  me  that  the  development  of  neural  tracts 
is  alone  the  important  element  in  producing  a  convolutional  arrangement  of 
the  gray  matter.  Where  such  tracts  develop  early  in  the  cerebrum  there 
will  be  found  an  early  appearance  of  the  convolutions.  This  is  exemplified 
by  the  early  development  of  the  external  perpendicular  occipital  fissure  and 
the  central,  representing  as  they  do  the  areas  of  visual  and  motor  functions, 
both  important  functions  in  the  preservation  of  the  species.  It  must  be  re- 
membered that  the  formation  of  the  cerebral  gray  is  much  more  rapid  than 
that  of  the  subcortical  white  tracts ;  that,  also,  the  connections  between  the 
two  are  early  formed,  but  that  these  connections  and  tracts  act  as  a  pulling 

1  G.  Jelgersma:  Uberden  Baudes  Saugethiergehirns,  Morphologisches  Jahrbuch,  Bd.  xv.  p.  83, 1889. 


GENERAL  DISEASES  OF  THE  BRAIN. 


329 


force  upon  a  covering  (cortex),  which  grows  more  rapidly  than  the  connect- 
ing tracts  themselves.  This  seems  to  me  to  be  more  than  a  probable  explana- 
tion of  the  formation  of  the  involution  of  gray  cortex.  It  coincides  with 
the  facts  of  embryological  development ;  it  explains  the  tendency  to  the  in- 
volution of  such  bodies  as  the  olivary  nuclei  and  cerebellum,  and  hkewise 
disregards  the  presence  or  absence  of  external  pressure,  which  we  have  shown 
cannot  have  any  influence  in  producing  a  fixed  convolutional  type.  The  re- 
lation of  cortex  to  periphery  is  always  fixed,  and  connecting  strands  do  not 
deviate  in  their  course  through  the  cerebral  axis.  The  pyramid  tract  always 
seeks  its  cortical  connection  through  fixed  and  definite  areas,  and  attaches 
itself,  if  I  may  use  that  expression,  to  a  fixed  cortical  area.  This  is  also  true 
of  the  cerebellar  connecting  tracts  and  of  other  intra-cerebral  connections. 
Hence  do  we  normally  find  fixed  depressions  in  the  cortex,  the  primary  fis- 
sures and  convolutions  depending  upon  the  formation  of  these  fissures.  These 
primary  fissures  and  convolutions  are  present  in  brains  which  themselves 
deviate  irom  the  normal  in  other  respects ;  for  instance,  in  cases  of  acrania 
and  in  cases  of  cranial  asymmetry.  If  Virchow's  explanation  of  the  formation 
of  the  fissures  and  convolutions  were  correct,  then  every  cranial  asymmetry 
and  deformity  would  have  to  be  accompanied  by  an  aberrant  fissural  develop- 
ment.    This,  however,  is  not  the  case. 

Fig.  71. 

Sulc.centr. 
Aon.  ^5jj 

R.&yr.Sornic.    \  Lamierm.     /  "    /  Bulc.call.marg. 

'  '       ■       I  Abn.    Prsecun. 


Sulc.oec. trans. 


Abn-\ 


Fiss.calc. 


Col  ant  foin 


Sp.luc. 


^'■(>P^-  \      Schn. 
Com.ant.    Gyr.unc 
L.  perf.ant. 


G.hipp. 


^Pulv.  Thai. 


''Sulc.occ.temp.inf 


Mesal  face  of  the  micrencephalic  brain  of  Hofmann,  showing  absence  of  corpus  callosum,  radia- 
tory  disposition  of  the  sulci  and  gyri,  and  separation  of  the  internal  occipital  and  calcarine  fissures. 
(Case  of  Onufrowicz.) 

Absence  of  the  Corpus  Callosum.  Other  fissural  anomalies  depending  upon 
the  absence  of  the  corpus  callosum  deserve  mention.  The  corpus  callosum 
is  not  infrequently  found  absent  in  micrencephalia.  Cases  of  the  absence  of 
this  commissure  in  other  brains  not  micrencephalic  have  also  occurred. 

Onufrowicz,^  who  exhausted  the  literature  on  this  subject,  and  who  ex- 
amined the  brain  of  the  micrencephalic,  Hofmann,  mentioned  in  the  title  in 
the  foot-note  below,  comes  to  the  following  conclusions  :  The  common  char- 
acteristics of  all  brains  in  which  complete  absence  of  the  callosum  was  found 
AT  ere : 


1  Das  balkenlose  microcephalengehirn  Hofmann.    Archiv  f.  Psychiatric,  xviii.  p.  305. 


330  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

1.  Absence  of  the  lyra. 

2.  Probable  absence  of  the  gyrus  fornicatus. 

3.  Absence  of  the  sulcus  calloso-margmalis,  excepting  its  dorsad  ascend- 
ing branch. 

4.  Fornices  and  septum  lucidum  are  not  joined  in  their  middle. 

5.  Dilatation  of  the  ventricles,  at  least  the  posterior  horns. 

6.  Nervi  Lancisi  for  the  most  part  present. 

7.  Absence  of  the  tapetum  callosi  has  never  been  demonstrated. 

The  corpus  callosum  may  be  rudimentarily  developed  or  may  be  entirely 
absent.  In  the  former  cases  it  is  very  thin  and  short,  with  rudimentary  con- 
nections with  the  frontal  and  occipital  lobes.  Its  absence  must  be  regarded 
as  an  arrest  of  development  at  a  stage  before  the  great  commissural  connec- 
tions between  the  two  foetal  hemispheres  take  place. 

When  it  is  absent  it  is  naturally  accompanied  by  fissural  and  gyral  abnor- 
malities, as  well  as  by  absence  of  other  anatomically  related  parts.  Thus  in 
most  of  the  cases  there  is  absence  of  the  anterior  commissure  and  a  rudimen- 
tary condition  of  the  middle  commissure.  The  fornix  is  also  rudimentary. 
The  fissures  on  the  mesal  face  of  the  hemispheres  assume  a  radial  distribu- 
tion at  right  angles  to  the  centre  of  revolution  of  the  cerebrum.  The  inter- 
nal perpendicular  occipital  is  no  longer  perpendicular,  but  horizontal,  and 
does  not  join  the  calcarine.  The  calcarine  is  continued  forward  and  joins  the 
hippocampal.     (See  Fig.  71.) 

The  ventricles  are  not  infrequently  dilated,  and  sometimes  the  posterior 
horn  of  the  lateral  ventricle  is  entirely  absent  or  obliterated. 

The  occurrence  of  defective  development  of  the  corpus  callosum  has  been 
explained  by  Richter^  as  being  due  to  mechanical  causes  arising  from  an  asso- 
ciated defect  in  cranial  development  in  some  cases.  The  usual  angle  formed 
by  the  petrous  portions  of  the  two  temporal  bones,  being  about  120°,  becomes 
enlarged  in  diseased  crania,  especially  in  those  of  idiots,  to  more  than  150°  ; 
the  tentorium  attached  to  them,  on  a  consequent  diminution  in  the  cranial 
base,  sinks  down  further,  dragging  the  falx  with  it,  so  that  the  latter  opposes 
by  its  presence  an  obstacle  to  the  junction  of  the  commissural  fibres  of  the 
foetal  brain,  Avhich  are  sent  out  from  each  hemisphere,  and  which  by  their 
junction  form  the  callosum.  The  sinking  of  the  falx  by  being  dragged 
down  by  the  tentorium,  which  cannot  develop,  owing  to  the  defective  devel- 
opment of  the  cranial  base,  and  the  further  development  of  the  cerebral 
hemispheres  of  the  foetus,  cause  the  callosum  to  grow  against  the  falx  and  to 
be  arrested  at  that  obstacle  to  its  growth. 

Cases  of  absence  of  the  callosum  without  micrencephalia  are  as  numerous 
as  cases  occurring  with  it.  Thus  cases  have  been  recorded  in  which  during 
life  no  symptoms  of  any  cerebral  defect  were  manifested,  the  defect  having 
only  been  discovered  on  autopsy. 

Other  parts  of  the  brain  in  micrencephalia  show  an  associated  retardation 
in  growth  and  development.  The  crura  are  asymmetrical  and  smaller  than 
normal,  the  pons  not  infrequently  flat,  and  in  one  case,  which  I  have  read, 
though  I  have  been  unable  to  find  the  reference  since,  so  defective  that  the 
trapezium  was  exposed.  Its  defect  in  most  cases  depends  upon  the  amount 
of  arrest  which  the  cerebellum  has  suffered.  The  medulla  shows  a  similar 
involvement.  The  pyramids  are  small,  sometimes  even  rudimentary.  The 
asymmetry  of  the  medulla  in  some  cases  is  exceedingly  well  marked.  All 
these  defects  depend  for  their  presence  upon  the  nature,  the  seat,  and  the 
extent  of  the  cerebral  developmental  arrest,  so  that  they  vary  in  the  different 
cases. 

1  Richter  :  Virchow's  Archiv,  1886,  Bd.  106. 


GENERAL  DISEASES  OF  THE  BRAIN. 


331 


Giacomini  describes  a  case  of  a  micrencephalic  in  whose  brain  was  found 
a  complete  junction  of  both  crura  in  the  mesal  line,  forming  apparently  one 
crus.     (See  Fig.  72.) 


Fig.  72. 


Micrencephalic  brain,  showing  deformity  and  junction  of  the  crura.    Or.  Orbital  sulcus. 
K.  Pons.     T.  Apex  of  temporal  lobe.    (Alter  Giacomini.i) 

Microgyria.  Associated  with  micrencej^halia  and  with  porencephalia  is 
another  abnormality  of  fissures  and  convolutions  to  which  the  term  micro- 
gyria has  been  applied.  It  is  characterized  by  the  development  of  almost 
innumerable  secondary  and  tertiary  fissures,  dividing  the  affected  lobes  into 
minute  lobules  and  gyri.    The  gyri  are  very  small,  numerous,  and  thin.     (See 

Fig.  73. 


Brain  of  micrencephalic  cretin,  showing  an  external  parieto-occipital  fissure  at  P.  0.  and 
microgyria  of  temporal  lobe.    Insula  is  uncovered.    (After  Giacomini.-) 

Fig.  73.)  In  some  cases  their  smallness  and  thinness  give  the  gyri  the  ap- 
pearance of  a  mere  membranous  expansion.  The  degree  of  microgyria 
varies  in  the  most  of  cases.     In  some  l)ut  a  lobule  of  the  l)rain  may  be  the 

1  C.  Giacomini :  I  cervelli  dei  microcefali,  1890. 

2  C.  Giacomini :  I  cervelli  dei  microcefali,  1890,  p  50. 


332  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

seat  of  this  peculiar  malformation,  in  others  an  entire  lobe,  and  in  still  others 
one  hemisphere,  or  even  both  in  part.  This  condition  is  also  present  in  cases 
of  absence  of  special  lobes  of  the  cerebrum,  being  distributed  over  the  re- 
maining lobes  of  the  affected  hemisphere.  (See  Fig.  74).  It  was  at  one 
time  considered  that  this  condition  of  the  crebral  convolutions  was  the  result 
of  an  encephalitic  process,  with  subsequent  contraction  and  shrinkage  of  the 
affected  parts,  but  microscopical  examination  of  the  cortex  of  microgyral 

Fig.  74. 


Microgyria  and  arrested  development  of  the  occipital  lobe  in  a  deaf  mute.  a.  Right  hemisphere. 
5.  Left  hemisphere,  c.  Left  defective  occipital  lobe  with  microgyria.  d.lMembranous  cyst  in  region 
of  the  parietal  lobe.    (After  Zieglee.) 

brains  has  failed  to  demonstrate  any  evidences  of  a  pathological  lesion. 
Chiari^  examined  carefully  the  cortex  of  one  of  his  cases  and  could  find  no 
morbid  processes  in  the  cortex  or  subcortical  fields,  at  least  none  which  could 
be  adduced  as  due  to  a  chronic  encephalitis. 

A  peculiar  feature  of  the  cortex  in  microgyria  has  been  demonstrated  by 
Binswanger'^,  who  found  no  giant  cells  in  the  affected  cortex  of  the  motor 
region,  and  that  the  pyramid  type  of  cells  was  simply  approached.  In  other 
words,  there  was  but  a  rudimentary  development  of  the  pyramidal  layer  of 
cells.  This  is  a  good  indication  that  the  condition  of  microgyria  is  dej)end- 
ent  upon  a  defective  or  arrested  development  of  the  cortex,  and  not  a  local 
pathological  process.  Anton^  corroborates  to  a  great  extent  the  demonstra- 
tion of  Binswanger.  In  his  cases  the  cellular  elements  of  the  cortex  were 
not  only  rudimentary,  but  were  much  diminished  in  number.  Recently  the 
examination  of  two  more  cases  was  made  by  Otto*,  who  found  in  the  cortex 
of  the  smallest  of  the  convolutions  a  defective  development  of  the  cells, 
especially  the  pyramidal  cells,  and  an  entire  absence  of  the  giant  or  large 
pyramids.  But  in  addition  to  this  he  describes  two  zones,  light  gray  in 
color,  beneath  the  cortex  and  interspersed  in  the  subcortical  layer.  The 
extent  of  these  varied.  On  examination  they  proved  to  be  rudimentary 
ganglion  cells. 

1  Chiari :  Jahrbuch  fiir  Kinderheilkunde,  N.  F.,  xiv. 

2  Vircvhow's  Archiv,  1.S82,  Bd.  87. 

3  Anton  :   Zeitschrift  iiir  Heilkuude,  1886,  Bd.  vii. 

*  E.  Otto  :  Casuistische  Beitriige  zur  Kentniss  der  Mickrogyrie,  Archiv  fiir  Psychiatric,  Bd.  xxiii. 


GENERAL  DISEASES  OF  THE  BRAIX.  333 

Corresponding  Avith  the  rudimentary  character  of  the  pyramidal  celLs  of 
the  cortex  is  to  be  found  a  smallness  in  these  cases  of  the  pyramidal  tract, 
and  the  pyramid  in  the  medulla  oblongata.  Heschl',  who  first  described 
microgyria,  concluded  that  its  cause  was  due  to  an  arrested  deyelopment  in 
the  subcortical  region,  and  that  by  reason  of  the  continuous  growth  of  the 
cortex,  it  being  restricted  in  expansion  by  the  arrest  below,  necessarily 
curled  itself  into  numerous  diyisions  or  gyri. 

No  exhaustiye  study  of  the  microscoi^ical  features  of  the  cortex  in  micren- 
cephaly has  as  yet  been  made.  Thus  far  there  has  been  oliseryed  a  de- 
crease in  the  neuroglia  and  a  defectiye  or  imperfect  deyelopment  of  the  cor- 
tical cells.  Sachs''  examined  the  brain  of  a  child  with  arrested  cerebral 
deyelopment  and  found  marked  changes  in  the  structure  of  the  small  and 
large  pyramid  cells.  Almost  all  of  these  were  defectiye.  Some  were  with- 
out nucleus  and  nucleolus  ;  in  others  these  were  present,  but  surrounded  by  a 
"  detritus-like  mass."  In  his  case  there  were  no  indications  of  a  preyious 
encephalitic  process,  nor  could  he  demonstrate  any  morbid  changes  in  the 
neuroglia.  The  changes  in  the  cells  described  by  Sachs  seem  to  be  analo- 
gous to  those  occurring  in  microgyria  described  by  Chiari,  Binswanger,  An- 
ton, and  Otto. 

Absence  of  Special  Lobes.  Associated  with  micrencephalia  and  microgyria 
are  cases  of  cerebral  malformation  in  Avhich  partial  and  complete  absence 
of  sj^ecial  lobes  of  the  cerebrum  occur.  The  lobe  most  frequently  absent  is 
the  frontal,  next  in  frequency  is  the  occipital.  Ziegler'  describes  a  case  of 
this  form  of  cerebral  hypoplasia  in  a  deaf  mute  in  whom  the  left  occij)ital 
lobe  was  entirely  absent,  the  parietal  defectively  developed,  and  its  convolu- 
tions showing  a  typical  microgyria.     (See  Fig.  74.) 

It  is  extremely  difficult  to  assign  a  reason  for  these  cases  of  malformation. 
Why  an  arrested  development  should  be  limited  to  a  few  lobules  or  to  an 
entire  lobe  without  any  discoverable  pathological  condition  in  the  hemis- 
pheres seems  to  be  inexplicable,  excepting  on  the  ground  of  some  local 
cause.  In  some  of  these  cases  thickening  of  the  pia,  indicating  a  former  in- 
flammatory process  in  that  membrane,  has  been  described. 

Another  malformation  occurring  at  times  with  micrencephalia  is  junction 
of  the  two  cerebral  hemispheres.  Cases  of  the  same  anomalous  develop- 
ment also  occur  independently.  The  junction  is  not  usually  complete, 
the  longitudinal  fissure  being  present  in  part,  so  that  the  cerebrum  gives 
moi'e  the  appearance  of  two  hemispheres  connected  by  bridges  of  cerebral 
tissue  which  cross  the  fissure  interrupting  it.  The  connection  may  occur 
also  at  the  base  as  well  as  upon  the  dorsal  surface.     (See  Fig.  76.) 

The  somatic  accompaniments  of  micrencephalia  are  referable  to  arrests  of 
development  in  other  parts  of  the  body. 

From  birth  a  micrencephalic  child  is  easily  recognized  by  the  small  size 
of  the  head  and  the  relatively  large  face.  This  difference  is  more  apparent 
as  the  child  increases  in  age,  for  while  the  head  seems  to  stand  still  in  devel- 
opment, the  face  grows  steadily,  emphasizing  the  original  difference. 

Very  frequently  there  is  an  absence  of  the  intermaxillary  bone,  giving 
rise  to  harelip.  Cleft  palate  is  sometimes  an  accompaniment.  The  nose  is 
broad  and  appears  to  sink  into  the  face,  giving  a  peculiar  expression.  The 
skull  in  its  entirety  shows  usually  a  prognathism  which  is  well  marked 
Avhenever  it  occurs.     (See  Fig.  75). 

The  extremities  are  the  seat   of  malformations,    such    as   shortening   of 

1  Heschl ;    Ueber  die  vordere  quere  Schlafenwindung  des  menschlichen  Grosshirns,  Wien,  1878. 
-  B.  Sachs.    On  Arrested  Cerebral  Development,  with  Special  Reference  to  its  Cortical  Pathology. 
Journal  of  Nervous  and  Mental  Diseases.  1887,  vol.  xiv.  p.  541. 
8  Ernst  Ziegler  :    Lehrbuch  der  Speciellen  Pathologic,  7  Auflage,  Jeuu,  1892,  p.  324. 


S34 


J^EBVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  limbs,  defective  or  absent  toes.  One  limb  may  be  fully  developed  and 
the  other  be  atrophic.  Club-foot  and  contraction  of  tendons  are  not  infre- 
quent. 

The  general  causes  mentioned  in  the  beginning  of  this  chapter  have  their 
influence  in  the  production  of  micrencephalia. 


Fig.  75. 


FiCx.  76. 


Fig.  75.    Photograph  of  micrencephalic  child,  one  day  old  (Wille,  Archiv.filr  PsycMatrie,  vol.  x). 

Fig.  76.  Brain  of  the  same,  showing  simplicity  in  convolutions  and  fissures.  Dorsal  view.  The 
hemispheres  are  asymmetrical  and  are  united  in  the  process  of  development,  the  longitudinal  fissure 
being  interrupted. 

Heredity,  alcoholism,  and  syj^hilis  in  the  parents  are  important  factors  for 
its  development.  ^Maternal  impressions,  fright  on  the  part  of  the  pregnant 
mother,  are  no  less  influential  causative  features  in  the  production  of  this  de- 
velopmental arrest. 

The  hypothesis  of  Carl  Vogt,  that  those  cases  of  micrencephalia  with  ape- 
like formation  of  fissures  and  convolutions  were  simply  cases  of  atavism,  can 
have  no  claim  to  our  recognition.  The  researches  of  Aeby,^  Bischoff",^  San- 
der,^ Mierjajewsky,^  Virchow,^  and  others  have  given  this  theory  its  quietus. 
The  generally  accepted  opinion  of  all  now  regards  micrencephalia  as  a  result 
of  a  cerebral  developmental  arrest  which  is  occasioned  by  special  causes  vary- 
ing with  each  case.  The  special  causes  may  be  a  hydrocephalus  internus,  a 
narrowing,  obliteration,  or  defective  development  of  the  carotid  artery,  a  de- 
fective cranial  development,  local  pathological  processes,  such  as  an  ependy- 
mitis,  or  a  traumatism  occurring  in  utero.  Porencephalia  and  micrencephalia 
are  not  infrequently  associated  and  are  etiologically  mutually  dependent  in 
some  cases. 

Persons  afflicted  with  micrencephalia  rarely  reach  adult  life.  A  few  cases 
have  been  reported  of  micrencephalic  idiots  Avho  have  reached  an  age  of 
forty  years.  As  a  usual  thing  some  intercurrent  affection  ends  their  careers 
early.  In  fact,  micrencephalies  have  little  power  of  resisting  disease,  and  suc- 
cumb to  pulmonary  and  infectious  affections  in  infancy  and  childhood. 

The  hfe  history  of  some  of  these  sufferers  is  the  same  as  that  of  all  idiots. 


1  Aeby:  Archiv.  fiir  Anthropologie.  vi  and  vii.,  1874;  Ueber  des  Verhaltniss  der  Mikrocephalie 
zum  Atavismus,  Stuttgart,  1878  :  Virchow's  Archiv,  Bd.  77. 

-  V  Bischoif.  loc   cit.  3  Sander,  loc.  cit. 

■i  MierjajeAvsky  :  Ueber  einen  Fall  von  Mikrocephalie,  Verhandlungen  der  Berliner  Gesellschaft  fiir 
Anthropologie,  "etc.,  Zeitschrift  fiir  Ethnologic,  Berlin.  Bd.  iv.,  1872. 

5  Rud.  Virchow,  Menschen  und  AflFenschadel,  Bd.  iv.  Heft  96,  der  gemeinwissenschaftlichen  Vor- 
trage.  Berlin,  1870,  p.  31. 


GENERAL  DISEASES  OF  THE  BBAIN.  335 

In  them  there  is  an  absokite  lack  of  all  mental  co-ordination.  The  idiocy  is 
extreme,  and  all  the  higher  mental  functions  are  absent.  They  give  no  sign 
of  receiving  or  registering  any  mental  impressions.  Others  show  a  less  high 
degree  of  idiocy,  and  give  indications  of  defective  mentality,  with  few  signs 
of  any  ideational  life.  Some  of  them  can  be  taught  simple  mechanical  pur- 
suits. 

The  motor  innervation  is  seriously  affected  in  most  cases.  This  defective 
innervation  may  vary  from  a  slight  paresis  to  an  absolute  paralysis.  Some 
are  unable  to  perform  any  voluntary  motion  whatever,  others  are  able  to 
walk  and  even  run.  The  most  frequent  condition  of  defective  motor  inner- 
vation is  a  paretic  condition  of  the  extremities  of  such  a  nature  that  while 
such  patients  may,  when  recumbent,  move  their  limbs  to  some  extent,  they 
are,  when  erect,  helpless  and  unable  to  walk.  (See  chapter  on  Cerebral  Pal- 
sies of  Childhood.) 

Convulsions  more  or  less  general  are  occasionally  observed.  They  are 
usually  general  in  character.  True  epilepsy  associated  with  micrencephalia 
is  not  a  frequent  manifestation. 

Treatment.  The  treatment  of  these  conditions  is  practically  the  treatment 
given  to  idiots  and  imbeciles.  It  is  the  subject  of  anxious  consideration 
to  the  parents  of  these  unfortunates.  The  family  physician  is  usually 
brought  into  the  council,  and  thus  much  depends  upon  his  decision  in  this 
matter ;  every  physician,  be  he  neurologist  or  general  practitioner,  should 
be  acquainted  with  the  essential  principles  underlying  the  treatment  of  the 
results  of  these  defective  states. 

Before  the  lack  of  mental  development  becomes  apparent  the  physician 
may  be  called  upon  to  treat  the  child  for  the  paralysis  which  is  so  often  the 
most  pronounced  feature  in  these  cases.  This  is  to  be  treated  by  the  same 
means  as  are  paralyses  from  cerebral  disease  in  the  adult,  the  consideration 
of  which  will  be  found  in  Chapter  XV,  and,  further,  in  the  chapter  on  "  The 
Cerebral  Palsies  of  Childhood."  The  contractures  which  so  often  invade  the 
paralyzed  limbs  are  especially  troublesome  conditions  to  remedy.  Systematic 
exercise  of  muscular  groups,  both  actively  and  passively,  should  be  put  in 
practice  early.  To  assist  in  this,  electricity,  massage,  calisthenics,  and  light 
gymnastic  exercise  should  be  brought  into  requisition.  These  means  should 
not  be  neglected,  as  they  are  the  most  important  in  producing  a  somewhat 
useful  limb.  Especially  are  they  serviceable  in  spastic  conditions  of  the 
extremities.  Physical  exercise  and  gymnastic  work  must  always  be  made 
commensurate  with  the  physical  power  and  strength  of  the  patient.  They 
should  never  be  permitted  to  be  carried  to  the  point  of  fatigue.  There  is  no 
doubt  that  in  some  of  these  cases — in  those  whose  mental  weakness  is  not  of 
a  high  grade — that  the  potential  of  mental  development  is  increased  by  these 
means. 

Still  more  important  should  be  the  consideration  given  to  developing  a 
useful  hand.  On  such  a  result  much  of  the  patient's  future  contentment 
depends.  In  this  connection  it  should  be  remarked  that  it  is  useless  to 
attempt  remedial  measures  late.  The  earlier  they  are  put  into  execution  the 
greater  will  be  the  chance  of  success.  Such  a  result  will  fail  in  those  cases 
in  which  the  mental  weakness  is  of  a  high  degree.  When  it  is  impossible  to 
arouse  or  excite  attention  on  the  part  of  the  subject  it  is  useless  to  continue 
treatment  in  this  direction.  This  is  almost  invariably  impossible  in  idiots 
exhibiting  a  high  degree  of  mental  defect.  If  the  faculty  of  attention  can 
be  excited  or  developed  there  will  be  promise  of  a  great  degree  of  success  in 
developing  other  mental  faculties  and  the  physical  powei's.  The  elder 
Seguin,  to  whom  we  are  certainly  indebted  for  an  exhaustive  investigation 


336  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

and  consideration  of  this  subject/  certainly  deserves  credit  for  his  "vvork  in 
this  field.  He  oj^ened  up  a  new  career  for  these  unfortunates.  A  perusal  of 
his  articles  and  a  careftil  study  of  them  are  absolutely  essential  to  all  who 
undertake  the  care  of  the  weak-minded. 

A  constant  supervision  as  to  the  best  hvgenic  surroundings  should  be  exer- 
cised by  the  physician,  whether  the  child  be  treated  at  home  or,  preferably, 
in  an  institution  for  -^veak-minded  children.  Fresh  air  and  wholesome  and 
proper  food  are  essentials.  Soft  and  fluid  food  should  be  given  to  those  who 
cannot  be  taught  to  masticate,  and  to  those  who  swallow  with  difiiculty, 
owing  to  a  defective  development  of  or  paresis  of  the  muscles  of  deglutition. 

Dyscrasise  should  be  corrected  by  the  proper  remedial  agents.  Hereditary 
syphilis,  and  the  so-called  scrofulous  manifestations  of  tuberculosis,  when 
properly  treated,  add  somewhat  to  the  achievement  of  successfully  combating 
the  physical  injuries  and  defects.  If  the  condition  be  the  result  of  other 
etiological  factors  than  hereditary  syphilis,  therapeutic  agents  will  do  little 
or  no  good.  ISTor  is  it  always  that  anti-syjDhilitic  treatment  will  insure  bene- 
fit. These  statements,  startling  as  they  may  appear,  are  borne  out  by  the 
very  nature  of  the  conditions  which  we  are  called  upon  to  treat.  No  thera- 
peutic agent  can  replace  nerve  elements  and  nerve  tracts  which  have  been 
destroyed  by  disease,  nor  develop  nerve  structures  which  have  been  arrested 
or  perverted  in  their  embryological  development. 

The  most  particular  feature  in  the  treatment  of  these  feeble-minded  chil- 
dren is  the  educational.  Under  this  we  would  speak  of  awakening  and 
developing  the  power  of  speech,  of  inducing  the  power  of  thought,  and  of 
attempting  the  almost  hopeless  task  of  developing  a  moral  sense,  which  is  so 
often  lacking  in,  imbecility  and  idiocy.  To  attain  any  degree  of  success  it  is 
imperative  tliat  the  child  be  removed  from  home  influences.  Mothers  are 
usually  over-indulgent,  a  fault  which  is  most  injurious  when  manifested  toward 
these  childi'en.  Fathers,  as  a  rule,  are  impatient  and  irritable,  are  apt  to 
follow  the  proverb,  "  spare  the  rod  and  spoil  the  child."  Punishment  has 
rarely  if  ever  been  the  means  of  producing  good  in  the  idiotic  or  imbecile. 
Nothing  is  to  be  gained  by  severity.  Do  not  advise  the  use  of  the  rod  or 
other  means  of  physical  punLshment.  Above  all,  enjoin  patience  and  self- 
control.  jMore  good  will  be  attained  by  kindness  toward  these  unfortunates 
than  by  the  use  of  all  the  correctional  instruments  in  the  world.  As  stated, 
the  child  should  be  removed  from  the  injudicious  influence  of  its  parents,  and 
placed  in  an  institution  for  the  weak-minded.  This  should  be  done  as  early 
as  possible.  Perhaps  it  is  possible  to  find  a  physician  trained  in  the  education 
of  the  weak-minded  to  undertake  the  care  of  a  few  of  these  patients.  If  the 
idea  of  sending  an  imbecile  child  to  an  institution  be  repugnant  to  parents, 
although  such  a  course  is  the  best  in  the  vast  majority  of  cases,  a  trial  might 
be  given  to  a  trained  kindergartnerin.  The  object-method  of  teacliing  these 
defective  children  is  the  only  system  which  has  produced  any  good.  Too 
much  must  not  be  expected  under  any  circumstances.  It  is  not  practical, 
owing  to  the  restriction  as  to  space,  to  lay  down  the  rules  which  should  gov- 
ern the  mental,  moral,  and  manual  training  which  these  children  should  be 
given. 

Even  under  the  best  of  conditions,  the  cerebral  defect  may  be  of  such  a 
nature  that  the  power  of  speech  is  wanting.  Some  of  these  patients  may  not 
be  taught  to  speak,  because  they  cannot  register  impressions,  or  because  there 
may  be  a  defective  development  of  the  speech  centres,  or  because  they  have 
no  mental  conceptions.  These  defects  are  all  too  common  among  the  higher 
grades  of  idiots,  and  it  is  but  a  waste  of  time  and  energy  to  attempt  any  educa- 

1  Idiocy  and  its  Troatmeut  by  the  Physiological  Method,  1886. 


GENERAL  DISEASES  OF  THE  BRAIN.  337 

tional  measures.  All  that  should  be  done  in  these  cases  is  to  pay  attention  to 
the  control  of  the  sphincters  of  the  rectum  and  bladder.  These  patients  should 
be  led  to  the  closet  at  definite  periods  and  kept  there  until  they  have  voided 
the  contents  of  the  bowels  and  bladder.  In  some  cases  there  is  a  lack  of 
control  of  these  sphincters,  and  these  unfortunates  are  in  a  constant  condition 
of  filth.  Under  these  circumstances,  the  rule  of  having  them  led  to  the 
closet  at  stated  intervals  and  the  careful  use  of  strychnine  internally  may 
remedy  this  feature. 

Their  attention  may  be  developed  by  giving  them  bright-colored  objects 
with  which  to  play,  and  placing  them  in  the  company  of  other  children  in 
the  institution.  The  social  element  in  these  places  seems  to  exercise  a  benefi- 
cent influence. 

With  those  having  a  higher  mental  development  the  features  of  all  these 
educational  institutions  should  be  directed  to  manual  training.  The  use  of 
tools  is  easily  learned  by  them,  and  imbeciles  may  become  fair  laborers,  and 
even  fair  artisans.  Some  have  been  taught  agi'iculture,  others  carpentering, 
plastering,  and  a  few  others  plumbing.  These  are  fields  in  w^hich  they  may 
become  useful  members  of  society.  This  training  should  only  be  attempted 
in  those  grades  of  imbecility  in  which  the  educational  system  adopted  has 
produced  the  ability  to  form  concej)tions  and  simple  judgments.  At  no  time 
should  the  physical  development  be  slighted,  for  it  is  almost  axiomatic  in 
these  cases  that  the  potential  of  mental  development  is  increased  by  the 
attention  bestowed  to  acquiring  a  good  j^hysical  development.  Of  course, 
physical  hindrances,  such  as  contractures,  should  be  removed.  The  orthopedic 
surgeon  should  correct  by  tenotomy  and  the  usual  special  surgical  measures 
these  obstacles  where  he  can. 

Success  in  manual  training  is  aided  by  the  faculty  of  mimicry  and  imita- 
tion, which  these  patients  possess  in  a  marked  degree.  We  can  readily  get 
an  imbecile,  and  occasionally  an  idiot,  to  use  a  tool  in  the  way  that  he 
has  seen  it  used.  Thus  the  use  of  the  saw,  the  hammer,  the  spade  the, 
plough,  may  be  put  to  good  purpose  both  for  the  object  of  exciting  the  pa- 
tient's interest  and  increasing  his  physical  powere. 

As  to  the  moral  training,  in  a  large  proportion  of  these  patients  little  can 
be  done.  It  seems  almost  impossible  to  awaken  their  moral  sense.  This  is 
owing  to  their  defective  cerebral  development,  and  is  a  common  feature 
among  imbeciles.  The  term  of  moral  insanity  has  been  applied  to  these 
cases,  a  classification  wdiich  seems  to  me  to  be  useless.  The  term  imbecility 
implies  the  defective  development  of  mental  faculties.  The  moral  faculty  or 
sense  is  certainly  included  among  the  mental,  and  as  such  is  defective  to  a 
greater  or  lesser  degree  in  all  imbeciles.  Hence,  when  we  speak  of  imbeciles, 
that  term  includes  the  cases  of  so-called  moral  insanity.  As  just  stated,  it  is 
almost  useless  to  attempt  to  awaken  in  these  unfortunates  the  moral  sense.  I 
know  of  no  means  yet  applied,  either  philanthropic,  educational,  correctional, 
or  penal,  which  has  been  attended  with  success.  In  fact,  it  is  questionable 
whether  in  those  cases  in  which  the  moral  sense  is  lacking,  or  very  defective, 
it  is  wise  to  carry  on  any  educational  training,  for  by  it  you  simply  increase 
the  power  of  these  beings  to  do  injury  and  harm.  Tuke  believes  that  this 
class  of  imbeciles  should  be  isolated  and  sul)jected  to  detention  and  restraint 
in  a  suitable  institution,  where,  he  thinks,  that  by  a  uniform,  temperate,  and 
positive  restriction  their  existence  may  be  made  useful. 

During  the  past  few  years  physicians  had  been  led  by  the  report  of  suc- 
cessful cases  to  turn  the  treatment  of  some  of  these  cases  over  to  the  surgeons, 
who  have  performed  craniectomy,  tapped  the  ventricles,  and  performed  sun- 
dry other  operations  in  their  desire  to  correct  these  states  of  arrested  develop- 
ment.    Notwithstanding  the  d  x>riori  absurdity  of  craniectomy  as  a  corrective 

22 


338  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

agent,  surgeons  have,  nevertheless,  performed  the  operation  with  the  hope  of 
success.  Time  and  experience  have  proven  the  falsity  of  their  statistics  and 
the  absolute  uselessness  of  such  a  surgical  procedvire.  I  should  advise  all 
physicians,  therefore,  to  try  other  than  surgical  means.  The  operation  is  now 
falling  into  disuse  in  these  cases,  as  it  deserves,  for  it  certainly  had  no  rational 
excuse  for  its  existence. 

Developmental  Defect  of  Cerebellum.  The  cerebellum  is  likewise 
the  seat  of  defective  development.  It  may  be  totally  absent  or  simply  show 
an  arrested  development  of  one  or  more  lobes.  Asymmetry  of  the  cerebel- 
lum without  any  discoverable  pathological  process  which  might  occasion  it  is 
not  rare. 

Even  the  gyri  of  the  cerebellum  may  be  the  seat  of  a  microgyria.  These 
conditions  are  sometimes  associated  with  micrencephalia  and  may  occur  en- 
tirely independent  of  any  developmental  defect  in  the  cerebrum. 

Total  absence  of  the  cerebellum  is  rare.  The  celebrated  case  of  Combetta, 
cited  by  Longet,^  deserves  mention.  In  this  case  in  ]3lace  of  the  cerebellum 
there  was  found  a  hemispherical  gelatinous  mass  which  was  attached  to  the 
medulla  by  two  similar  pedicles  upon  which  were  two  masses  or  accumula- 
tions of  isolated  and  separated  white  substance  of  the  size  of  peas.  There 
was  no  fourth  ventricle,  no  trace  of  a  pons. 

The  most  frequent  form  of  cerebellar  arrest  is  a  rudimentary  condition  of 
one  or  more  lobes.  One  hemisphere  of  the  cerebellum  may  be  diminished  to 
such  an  extent  that  it  forms  but  a  rudimentary  appendage  to  the  others. 
When  microgyria  of  the  cerebellum  is  present  it  sho^^*s  the  same  general 
features  as  microgyria  of  the  cerebral  hemispheres.  In  these  cases  the  Pur- 
kinje  cells  are  small  and  defectively  developed,  and  the  nucleus  dentatus  is 
rudimentary. 

The  fissures  which  divide  the  cerebellum  into  lobes  do  not  run  parallel  to 
the  posterior  margin  of  the  cerebrum,  but  assume  a  position  at  right  angles 
to  it. 

The  most  important  feature  of  arrested  development  of  the  cerebellum  is 
the  ru.dimentary  condition  of  the  tracts  to  which  the  cerebellum  serves  as  an 
intercalar  ganglion.  Thus  the  pons  is  diminished  in  size,  as  is  the  restiform 
body  and  the  tegmenti  brachium.  One  or  the  other  of  the  olivary  bodies  is 
rudimentary  according  to  the  lobe  of  the  cerebellum  which  is  involved.  The 
medulla  itself,  therefore,  becomes  involved  in  the  malformation ;  it  is  dimin- 
ished in  size,  asymmetrical,  and  presents  a  defective  or  absent  olivary  emi- 
nence. If  the  cerebellum  be  bilaterally  involved,  both  olivary  bodies  will 
be  rudimentarily  developed  ;  if  but  one  hemisj)here  be  the  seat  of  the  defect, 
the  opposite  olivary  body  is  the  one  which  is  rudimentary.  In  a  case  de- 
scribed by  Hujopert,*  he  found  the  crura,  pons,  medulla,  and  thalami  much 
smaller  than  normal. 

Symptomatology.  It  is  impossible  to  make  a  diagnosis  of  this  defect  dur- 
ing life,  for  there  are  no  symj)toms  which  characterize  it.  Those  which  have 
been  noticed  are  common  with  micrencephaha ;  thus,  there  is  idiocy  or  imbe- 
cility, a  paretic  condition  of  the  extremities,  and  a  motor  inco-ordination. 
The  ataxia  possesses  no  special  characters,  however. 

Heterotopia  of  the  Gray  Substance.  An  interesting  deviation  from 
normal  cerebral  structure  is  that  condition  of  excessive  focal  growth  of  gray 
matter  which  occurs  in  abnormal  situations  in  the  white  substance  of  the 
brain.  The  favorite  sites  of  this  development  are:  1.  ISTear  the  ganglionic 
masses,  the  thalamus,  and  caudate  nucleus ;  2.  Near  the  walls  of  the  ven- 

1  Hitzig.  Ziemssen  :  Cycloptedia  of  the  Practice  of  Medicine,  vol,  sii.  p.  844. 
^  Max  Huppert :  Archiv  flir  Psychiatrie,  Bd.  vii.  p.  98  et  seq. 


GENERAL  DISEASES  OF  THE  BRAIN.  339 

tricles,  more  frequently  the  lateral  ventricles ;  3.  In  the  Avhite  substance  of 
the  cerebellum  between  the  corpus  dentatus  and  the  cerebellar  cortex. 

It  was  first  pointed  out  by  Virchow^  that  these  insular  accumulations  of 
ganglionic  material  had  no  direct  communication  with  the  cerebral  cortex. 
And  yet  it  appears  to  us  that  these  masses  wliich  in  their  microscopical  ap- 
pearance do  not  deviate  from  the  true  structure  of  the  cortex,  being  formed 
of  ganglionic  cells,  nerve  fibres,  and  neuroglia,  must  have  a  direct  relation 
with  the  gray  mantle,  for  their  identity  in  structure  and  their  situation 
denote  them  as  ofishoots  or  detachments  from  the  cerebral  ganglionic  forma- 
tion. Their  position  seems  to  be  due  to  two  factors.  First,  the  development 
of  the  subcortical  tracts  may  occur  in  an  abnormal  or  aberrant  position,  de- 
taching from  the  parent  mass  some  of  the  original  gray  of  the  hemispheric 
vesicles,  or  of  the  prosencephalon  during  the  invasion  of  that  part  of  the 
foetal  brain  by  the  developing  fibre  systems.  Second,  the  original  embryo- 
logical  ganglionic  units  may  have  assumed  fr'om  the  beginning  an  abnormal 
position,  and  are  subsecjuently  caught  or  entrapped  in  the  developing  fibre 
systems  which  developed  in  a  normal  course.  On  any  other  supposition  the 
aberrant  position  of  these  masses  cannot  be  satisfactorily  explained. 

The  cerebellum  seems  to  be  more  fi'equently  the  seat  of  this  abnormality 
than  the  cerebrum.  Perhaps  this  preponderance  is  due  to  the  fact  that  the 
fibre  systems,  because  they  are  concentrated  in  the  cerebellum  in  a  smaller 
area,  are  more  apt  to  entrap  some  of  its  cortical  or  ganglionic  gray  than  where 
these  systems  are  relatively  less  concentrated. 

When  it  occurs  in  the  cerebrum  the  site  of  selection  is  near  the  ventricu- 
lar walls.     This  is  the  situation  of  these  masses  in  two-thirds  of  all  the  cases.^ 

Its  occurrence  in  the  cerebrum  was  found  by  Meschede^  in  cases  of  epilep- 
tic insanity.  Otto,  however,  has  found  it  in  apparently  perfectly  healthy 
individuals.  Spitzka,*  however,  says  that  "  heterotopia  of  the  gray  substance 
in  the  cerebrum  must  be  ahvays  regarded  as  an  abnormal  occurrence  ;  in  the 
cerebellum  it  may  be  found  in  perfectly  healthy  individuals."  When  heter- 
otopia does  occur  in  persons  who  during  life  have  shown  a  defective  mental 
integrity  its  occurrence  must  be  assumed  as  an  indication  of  a  cerebral  mor- 
phological stigma. 

Cerebral  Hyperplasia.  A  redundancy  in  development  of  the  essential 
cerebral  elements  may  occur  independently  of  a  pathological  process,  and  be 
associated  with  errors  in  the  developmental  growth  of  both  the  gray  and  the 
white  substance.  When  both  are  increased  there  results  a  condition  of  ma- 
crencephalia,  or  hypertrophy  of  the  brain. 

When  the  gray  matter  alone  is  involved,  it  is  only  so  in  limited  area^ 
always  on  the  surface.  Here  they  form  small  rounded  excrescences,  which 
are  usually  about  2  mm.  in  diameter,^  and  which  are  directly  connected  with 
the  cortical  layer  beneath.  Their  most  frequent  site  is  over  the  convexity 
of  the  frontal  lobes,  lying  at  times  free  on  the  gyri,  at  others  on  the  cortex 
within  the  sulci.  Their  size  varies  from  that  of  a  millet-seed  to  that  of  a 
bean,  although  the  smaller  growths  are  the  most  common. 

Microscopically,  these  mavSses  show  an  analogous  structure  to  that  of  the 
cortex,  the  ganglionic  cells,  however,  being  usually  smaller. 

Macrencephalia,  or  hypertrophy  of  the  brain,  is  not  of  very  frequent  occur- 
rence. It  is  not  to  be  referred  to  an  acquired  pathological  process,  but  to  a 
congenital  excess  of  growth  of  the  brain.     The  size  of  the  brain  may  be 

1  R.  Virchow:  Virchow's  Archiv.,  Bd.  xxxviii.  p.  138. 

-  R.  Otto  :  Virchow's  Archiv.  Bd.  ex.  p.  SI  et  seq. 

3  Meschede  :  Virchow's  Archiv.  Bd.  Ivi. 

*  Spitzka:  The  Somatic  Etiologv  of  Insanity,  American  Journal  of  Neurology  and  Psychiatry,  1882. 

5  Otto  :  Ueber  hyperplasia  der  Hirurinde,  etc.,  Virchow  Archiv,  Bd.  ex.  1887. 


340  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

extreme ;  thus  Ziegler^  reports  a  brain  of  a  twenty-year-old  girl  which 
weighed  1857  grammes ;  Virchow,'  that  of  a  three-year-old  child,  which 
weighed  1911  grammes;  and  Landousi'*  one,  1590  grammes  in  weight.  The 
enlargement  may  be  partial  or  general,  and  is  due  to  an  increase  in  the  neu- 
rogha.  The  brain  cortex  is  thicker  than  normal,  this  increase  being  mostly 
confined  to  the  superficial  or  so-called  barren  layer.  Notwithstanding  the 
increase  in  depth  of  the  gray  cortex,  the  ganglionic  elements  do  not  seem  to 
be  increased  in  number.  The  augmentation  of  cortical  growth  depends  upon 
the  increase  in  the  connective-tissue  formation.  This  is  more  apparent,  how- 
ever, throughout  the  white  substance. 

The  skull  gives  evidences  of  internal  pressure,  the  head  showing  a  com- 
mensurate enlargement.  The  bones  of  the  skull  are  thin  and  the  fissures 
separated.  The  articular  cartilages  of  the  base  are  suflfused  and  reddened. 
On  opening  the  skull  the  dura  is  found  adherent  to  the  cranium.  The  gyri 
are  flattened. 

This  disease  is  one  of  childhood.  The  child  is  either  born  with  the  anoma- 
lous cerebral  condition,  or  it  is  developed  soon  after  birth.  The  enlargement 
of  the  skull  is  of  such  a  character  that  one  is  apt  to  make  a  hasty  diagnosis 
of  hydrocephalus  congenitus.  The  shape  of  the  enlargement  is,  however, 
different,  the  outlines  of  the  skull  being  angular,  while  in  hydrocephalus  it  is 
round  and  the  head  globular.  Fletcher  Beach*  gives  the  following  points  of 
distinction  between  the  two :  "  The  enlargement  of  the  skull  in  cerebral 
hypertrophy  is  more  marked  just  above  the  superciliary  ridges  than  at  the 
temples,  and  the  fontanelle  is  often  depressed  instead  of  being  full  and  elastic." 

Fagge,  in  commenting  on  this  condition  of  the  fontanelle,  judges  it  as 
inconsistent  with  the  accounts  which  have  been  given  of  the  dura  mater 
bulging  as  soon  as  the  calvaria  was  opened. 

The  etiology  of  this  affection  is  yet  unsettled.  Alcoholism  of  the  parents, 
syphilis,  and  rhachitis  have  all  been  spoken  of  as  a  possible  cause.  Trauma- 
tism to  the  infant's  head  is  also  cited  as  a  factor. 

Clinically,  the  disease  manifests  itself  in  imbecility  or  idiocy,  paresis  of  the 
extremities,  as  shown  by  the  lolling,  tottering  walk,  drowsiness,  and  epilepti- 
form convulsions. 

Encephalocele  and  Other  Defects.  There  are  certain  malforma- 
tions of  the  brain  which  are  commonly  associated  with  defects  in  the  cranial 
bones.  These,  which  include  anencephalia,  which  is  described  on  page  317, 
may  be  summed  up  as  follows  :  Encephalocele,  cyclopia,  and  arhinencephalia. 
The  cause  of  these  defects  lies  in  an  arrest  of  development  of  the  structures 
of  the  mesoblast,  which  are  involved  in  the  formation  of  the  cranial  bones. 
The  cranium,  like  the  spinal  column,  is  foi-med  from  the  mesoblast  by  the 
development  of  protovertebral  masses  situated  on  either  side  of  the  neural 
tube ;  these  finally  coalesce  and  include  the  central  nervous  system  in  their 
interior.  When  they  fail  to  unite  dorsally  they  leave  a  cleft  through  which 
the  brain  or  the  spinal  cord  may  protrude.  To  this  condition  are  applied  the 
terms  of  cranioschisis  and  rachischisis,  respectively.  Sometimes  both  the 
brain  and  spinal  cord  are  uncovered,  a  condition  which  is  called  cranio- 
rachischisis.  The  cause  of  the  non-closure  of  the  bony  canal  is  ascribed  to 
an  accumulation  of  fluid  in  the  canal  and  to  external  pressure. 

When  the  cranial  vault  fails  to  close  either  from  an  arrest  of  development 
of  the  bony  structures  or  from  causes  arising  within  the  cavity,  the  brain 
forces  itself  through  the  opening,  producing  a  tumor  on  the  surfiice  of  the 

1  Ziegler :  Lehrbuch  der  speciellen  Pathologischeu  Anatomie,  p.  326,  1893. 

2  Virchow  :  Gesammte  Abhandl.,  1856. 

3  Landousi :  Gaz.  m6d.  de  Paris,  1874. 

*  Fletcher  Beach  :  Fagge's  System  of  Medicine,  vol.  i.  p.  572. 


GENERAL  DISEASES  OF  THE  BRAIN.  341 

head.  The  tumor  may  consist  of  the  meninges  alone,  which  are  pressed  out- 
ward by  an  accumulation  of  fluid  Avithin  the  subarachnoidal  space,  or  the 
brain  itself  may  form  with  them  part  of  the  tumor.  In  the  latter  case  the 
condition  is  called  meniugo-encephalocele.  The  membranes  at  times  do  not 
appear  in  the  hernial  protrusion,  and  the  brain  covered  with  remnants  of  pia 
alone  forms  the  tumor.  This  is  called  encephalocele.  When  the  hernia  is 
formed  of  the  meninges  alone  the  condition  is  called  meningocele.  Some- 
times when  hydrocephalus  internus  is  present  the  distended  ventricle  forms 
with  the  brain  substance  a  part  of  the  tumor.  When  this  occurs  there  is 
present  a  hydrencephalocele.  Usually  these  hernial  tumors  are  covered 
with  the  skin  of  the  scalp ;  in  some  cases,  however,  this  is  even  absent,  and 
the  tumor  is  devoid  of  covering. 

The  position  of  the  protruding  mass  varies.  Miller,^  who  carefully  ana- 
lyzed forty-two  cases  which  had  come  under  his  observation,  found  that  the 
most  frequent  position  for  these  hernias  was  the  anterior  portion  of  the  skull. 
Of  his  cases  thirty-four  occurred  in  this  situation,  while  only  eight  occurred 
in  the  region  of  the  occiput.  Of  the  former  the  most  frequent  were  those 
in  the  naso-frontal  region.  Among  these  cases  there  was  none  that  occurred 
at  the  base  of  the  skull.  The  character  of  these  tumors  was  as  follows : 
Encephalocele,  17  cases;  hydrencephalocele,  20  cases;  the  rest  being  men- 
ingoceles. Another  noteworthy  feature  of  his  observation  was  that  the  occi- 
pital herniie  were  almost  invariably  meningoceles,  while  the  sinciput  hernise 
were  either  encephaloceles  or  hydrencephaloceles.  In  other  words,  cerebral 
protrusions  were  extremely  rare  in  the  occipital  regions  and  meningeal 
protrusions  equally  rare  in  the  frontal  region.  These  observations  would 
seem  to  militate  against  the  theory  formerly  held,  that  it  was  owing  to 
the  position  of  the  foetal  head  in  utero  that  hernial  protrusions  when  associ- 
ated with  conditions  of  increased  intra-cerebral  pressure  occurred.  The  occi- 
put being  the  region  of  the  cranium  most  dependent  in  the  uterine  cavity 
ought,  hence,  to  be  the  seat  of  hernial  protrusions  more  frequently  than  the 
sincijiut ;  but  the  observations  of  Miller  show  that  occipital  hernise  occur  in 
less  than  twenty  per  cent,  of  all  cases.  That  increased  cerebral  pressure  from 
excessive  secretion  of  fluid  within  is  the  cause  of  these  hernias  there  can  be 
no  doubt,  but  that  it  is  the  main  cause  cannot  be  aflirmed.  Some  other 
factor  independent  of  the  cranial  defect  is  operative  in  the  causation  of  these 
malformations.  Adhesion  of  the  amnion  to  the  cephalic  end  of  the  embryo 
is  most  probably  an  important  etiological  factor  in  the  production  of  this 
condition  when  congenital.  Changes  arising  from  diseased  states  of  the 
meninges,  which  render  the  membranes  of  the  brain  less  resistant,  may  be 
another  cause. 

Sex  does  not  appear  to  have  any  influence  in  the  production  of  these 
hernise,  since  they  occur  about  equally  as  often  in  the  female  as  in  the  male 
infants. 

Maternal  impressions  and  fright  or  other  psychical  shocks  are  the  chief 
inciting  causes  of  these  malformations. 

The  size  of  these  tumors  varies  from  that  of  a  hazelnut  to  that  of  a  two- 
year-old-child's  head  (Miller). 

Sincipital  protrusions,  according  to  their  sites  of  exit  from  the  cranial 
cavity,  are  divided  into  naso-frontal,  naso-ethmoidal,  and  uaso-orbital,  for 
each  of  these  articulations  may  be  defective  and  serve  as  the  origin  of  escape 
of  the  extruded  mass.  Any  of  the  membranous  parts  of  the  infant  skull 
may  be  the  seat  of  these  tumors,  though  the  lateral  aspect  of  the  skull  does 
not  seem  to  be  a  seat  of  selection  for  them  ;  still  they  occur  there  a  little  less 

1  N.Tb.  Miller  :  Ein  Seltener  Fall  von  Gekirnbruch,  Jahrb.  de  Kindeihellk,  N.  F.  Bd.  xxv.  p.  195. 


342  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

rarely  than  at  the  base.  When  the  hernia  occurs  at  the  base  it  usually  pre- 
sents in  the  pharynx,  and  sometimes  pushing  that  structure  before  it  takes 
its  exit  from  the  mouth,^ 

I  am  aware  of  the  fact  that  former  writers  on  hernia  cerebri,  especially 
surgical  writers,  have  been  accustomed  to  name  the  occiput  as  the  most  fre- 
quent seat  of  all  hernial  protrusions  of  the  skull  contents.  This,  however, 
does  not  appear  to  be  affirmed  by  more  recent  contributions  to  this  subject, 
and  cannot  be  reconciled  with  the  observations  of  JNIiller''  and  von  Berg- 
mann.^ 

In  frontal  hernias  both  cerebral  lobes  are  usually  extended,  though  the 
apex  of  a  single  lobe  not  infrequently  is  contained  in  the  tumor.  The  same 
relative  ratio  as  to  both  lobes  exists  in  occipital  encephalocele,  though  a 
true  hernia  cerebri  is  rare  in  this  region. 

The  character  of  the  tumor  depends  upon  the  structures  which  are  con- 
tained in  it.  Meningoceles  or  hydrencephaloceles  are  usually  large,  globu- 
lar, and  constricted  at  the  base,  although  they  cannot  be  said  to  have  a 
pedicle.  Encephaloceles,  as  a  rule,  are  much  smaller.  The  protruding  cere- 
bral tissue  shows  a  condition  of  defective  or  arrested  growth,  as  well  as  in- 
trinsic evidences  of  pathological  destructive  processes.  Thus  the  gangli- 
onic elements  may  not  be  recognizable,  or  they  may  be  small  and  atrophic ; 
the  neuroglia  is  usually  increased  in  amount  and  contains  at .  times  sclerotic 
patches.  At  other  times  one  may  find  hemorrhages  into  the  cerebral  tissue 
and  spots  of  focal  softening  in  the  mass. 

The  larger  size  of  meningo-encephaloceles  and  of  hydro-encephaloceles 
and  the  much  smaller  size  of  encephaloceles  would  lead  one  to  suppose  that 
the  defect  in  embryological  development  which  gives  rise  to  the  former  must 
have  occurred  early  in  the  foetal  life,  that  which  gives  rise  to  the  latter  later 
during  that  period  of  existence. 

It  is  often  very  difficult  to  determine  the  character  of  these  tumors  unless 
some  operative  procedure  such  as  aspirating  has  been  adopted  ;  for  the  ten- 
sion is  often  so  great  in  a  meningocele  or  hydrencephalocele  that  it  is  im- 
possible to  determine  fluctuation,  and  difficult  to  distinguish  it  from  a  solid 
tumor.  As  a  rule,  encephaloceles  pulsate  synchronously  Avith  the  normal  pul- 
sation of  the  brain,  although  exceptions  to  this  are  not  rare,  and  fluctuation 
may  often  be  elicited  in  the  other  forms.  From  a  surgical  standpoint  it  is 
desirable  that  a  diagnosis  be  made,  as  the  nature  of  the  operation  will  de- 
pend upon  the  character  of  the  hernia. 

Usually  the  length  of  life  of  infants  afflicted  with  this  disease  does  not 
extend  beyond  one  year,  although  some  cases  have  been  reported  in  which 
adult  age  has  been  reached.  A  large  number  die  soon  after  birth.  Where 
the  tumor  is  mostly  fluid  rupture  occasionally  occurs  during  the  process  of 
labor,  and  death  ensues. 

The  symptoms  depend  upon  the  size  and  portion  of  the  brain  extruded 
and  the  amount  of  pressure  to  which  the  brain  is  subjected.  Drowsiness, 
weakness  in  gait,  convulsions,  and  mental  enfeeblement  are  the  most  im- 
portant. 

The  relief  of  this  condition  is  to  be  found  in  surgical  interference  alone. 
Good  results  have  been  obtained  by  such  measures  in  a  number  of  cases. 
Excision  of  the  mass,  especially  in  the  sincipital  encephaloceles,  has  given 
the  best  results.  Concerning  the  operations,  see  Chapter  XXXIIL,  on  Brain 
Surgery. 

Cyclopia  and  Arhinencephalia.    The  hemispheric  vesicles  may  be  arrested  in 

1  Lichtenberg  :  Path.  Soc.  Transactions  of  London,  vol.  xviii.  p.  250. 

2  ^f.  Th.  Miller,  loc.  cit.  ' 

3  Ernst  von  Bergmann :  Die  chirurgische  Behandluag  der  Hirnkrankheiten,  2te  Auflage,  Berlin. 


GENERAL  DISEASES  OF  THE  BRAIX.  343 

their  development  from  the  first  cerebral  vesicle  or  may  be  defectively  devel- 
Of>ed,  whereupon  the  latter  vesicle  may  appear  aljnormally  large.  This 
condition  is  generally  accompanied  by  a  defect  in  the  growth  of  the  other 
embryonic  derivative  of  the  first  cerebral  vesicle,  viz.  :  the  ocular  vesicles. 
The  defect  in  growth  may  cause  but  one  ocular  vesicle  to  develop.  This 
derivative  of  the  first  cerebral  vesicle  may  appear  with  the  latter  in  front 
of  the  skull,  a  condition  which  is  called  cyclo-encephalia. 

At  times  both  ocular  vesicles  are  formed  in  close  proximity  and  may  ap- 
pear with  the  cerebral  mass  through  a  central  opening  in  the  frontal  bone 
at  the  root  of  the  nose  or  in  the  nasal  space.  The  two  ocular  vesicles  may 
develop  separate  eyes,  and  as  such  appear  in  the  central  opening,  or  both  ves- 
icles may  coalesce  to  form  one  eye,  which  may  present  at  the  same  defective 
opening  in  the  skull.  This  abnormality  of  growth  is  termed  cyclopia,  or  syn- 
ophthalmos.  Associated  with  the  latter  condition  is  an  absence  of  the  nose 
as  such,  a  rudimentary  organ  presenting  as  a  cartilaginous  and  cutaneous 
attachment  or  stump  to  the  ethmoid,  and  situated  above  the  protruding  cen- 
tral eye.  When  the  nose  is  thus  arrested  in  development  in  cases  of  cycloj)ia 
the  condition  is  named  arhinencephalia. 

Hydrocephalus  Ixteenus.  Many  of  the  states  of  arrested  cei'ebral 
development  of  which  we  have  spoken,  and  of  defective  growth  of  the  brain, 
are  intimately  associated  with  this  morbid  condition,  but  whether  the  associ- 
ation be  one  of  cause  or  effect  has  not  yet  been  satisfactorily  determined. 

The  affection  with  which  we  are  to  deal  is  characterized  by  an  excessive 
secretion  of  fluid  in  the  cerebral  ventricles,  chiefly  the  lateral,  by  reason  of 
which  the  brain  becomes  expanded,  its  walls  thinned,  and  the  cranial  case 
greatly  enlarged  through  distention  and  spreading  of  the  cranial  bones  and 
scalp.  It  may  be  congenital  or  acquired.  When  the  disease  is  acquired  after 
ossification  of  the  craiual  bones,  no  enlargement  of  the  head  occurs,  nor  is 
there  any  spreading  of  the  cranial  bones. 

Authors  have  divided  the  affection  into  two  groups,  hydrocephalus  con- 
genitus  and  hydrocephalus  of  the  adults.  While  it  is  true  that  the  clinical 
features  of  the  two  forms  vary,  owing  to  the  differences  in  the  cerebral  and 
cranial  development  between  childhood  and  adult  life,  the  pathological  pro- 
cess upon  upon  which  each  form  depends  seems  to  be  similar  if  not  identical. 

Such  a  division,  therefore,  appears  to  be  unnecessary.  We  prefer  to  call 
this  affection  hydrocephalus  internus.  Tubercular  meningitis  was  formerly 
called  acute  hydrocephalus,  but  since  the  last  term  has  fallen  into  disuse 
there  is  no  danger  of  confounding  the  two  terms. 

Some  authors  speak  of  an  original  accumulation  of  fluid  in  the  sub-arach- 
noidean  space,  by  which  the  brain  becomes  compressed  and  atrophied  and 
the  skull  itself  distended,  a  condition  which  they  call  hydrocephalus  externus. 
But  in  view  of  the  fact  that  the  occurrence  of  such  a  condition,  unless  it  be 
accompanied  by  an  original  defect  or  arrest  of  development  in  the  brain,  or 
some  part  of  it,  is  denied  by  many,  its  description  will  not  be  treated  of  in 
this  chapter. 

Synonyms.  Chronic  hydrocephalus,  leptomeningitis  infantum,  meuingo- 
ependymitis,  dropsy  of  the  brain,  water  on  the  brain. 

Effusion  into  the  ventricular  cavities  may  be  the  result  of  an  arrested 
development  of  some  portion  of  the  brain,  by  reason  of  which,  should  the 
cranium  not  be  implicated  in  the  defect,  a  transudation  of  fluid  occurs,  eitlier 
on  the  surface  of  the  brain,  into  the  subarachnoidean  space,  or  in  the  interior 
into  the  ventricles,  or  into  both.  This  is  the  result  of  physical  causes  and  is  a 
hydrops  ex  vacuo.  This  condition  is  sometimes  called  hydrocephalic-auen- 
cephalia. 

Again,  ventricular  effusion  may  be  the  result  of  morbid  growths  in  the 


344  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

vicinity  of  the  ventricle.  Closure  of  the  foramen  of  Monro  is  said  to  pro- 
duce an  effusion  into  and  a  dilatation  of  the  ventricle.  Interference  with  the 
return  circulation  in  the  veins  is  also  mentioned  as  a  cause. 

In  the  great  majority  of  cases  the  effusion  seems  to  be  the  result  of  an 
anomalous  condition  of  the  ependyma  of  the  ventricles,  by  reason  of  which 
an  increased  amount  of  secretion  or  effusion  takes  place  from  its  surface  and 
fills  the  cavities,  which  it  lines.  In  these  cases  the  ependyma  is  thicker  than 
normal,  grayish  in  color,  and  it  presents  a  finely  beaded  or  granular  condition, 
entirely  distinct  from  its  normal  smooth,  glistening  appearance.  In  most  of 
the  congenital,  and  more  markedly  so  in  the  adult  cases,  is  this  to  be  found. 
Whether  the  condition  can  be  called  an  ependymitis  is  a  great  question, 
although  the  changes  in  the  ependyma  and  the  occasional  presence  of  leuco- 
cytes and  pus  cells  in  the  fluid  would  lead  one  to  think  that  the  process  was 
inflammatory  in  character.  It  is  improbable,  however,  that  the  embryonic  or 
fcetal  brain  should  be  the  seat  of  an  inflammatory  process. 

However,  we  are  still  in  the  dark  as  to  the  causation  of  the  disturbance  of 
equilibrium  between  the  vascular  walls  and  the  ependyma,  which  induces  the 
former  in  these  cases  to  transude  the  fluid  constituent  of  the  blood  to  such  an 
excessive  degree. 

The  affection  in  some  cases  seems  to  have  an  hereditary  character,  the  dis- 
ease appearing  in  a  number  of  children  of  the  same  parents.  Alcoholism  on 
the  part  of  the  parents  is  also  a  supposed  factor  in  its  production,  likewise  is 
syphilis. 

When  the  disease  occurs  after  the  birth  of  the  child,  traumatism  has  been 
noted  in  several  cases  to  be  the  direct  cause  of  its  development. 

It  has  also  been  known  to  develop  after  an  attack  of  epidemic  cerebro- 
spinal meningitis. 

Some  of  the  congenital  cases  are  associated  with  the  developmental  defect 
called  porencephalia.     This  has  already  been  described.     (See  page  319.) 

The  fluid  which  is  contained  in  the  ventricles  is  usually  clear,  slightly 
yellow,  sometimes  almost  colorless,  of  low  specific  gravity,  and  contains  only 
a  trace  of  albumin,  differing  thus  very  little  from  normal  cerebro-spinal 
fluid.  In  some  cases,  however,  the  specific  gravity  is  higher  and  the  amount 
of  albumin  considerable,  varying  from  3  to  over  11  parts  of  albumin  in 
1000.  It  is  owing  to  the  differences  in  the  physical  and  chemical  properties 
of  the  fluid  in  these  cases  that  led  Huguenin^  to  beheve  that  a  decision 
as  to  inflammatoty  or  inflammatory  origin  of  the  fluid  could  be  reached. 
While  it  is  true  that  the  fluid  is  sometimes  cloudy  and  contains  leucocytes 
and  pus  cells,  it  is  a  question  whether  these  are  the  result  of  an  original 
ependymitis  or  whether  such  an  inflammation  of  the  ependyma  followed 
from  the  pressure  and  presence  of  an  excessive  amount  of  fluid.  Huguenin 
insists  upon  the  presence  of  a  larger  amount  of  albumin  in  the  fluid,  when 
due  to  inflammatory,  and  less  than  2.5  per  1000  when  due  to  pressure 
causes.  Fagge,^  who  has  given  a  masterly  description  of  this  affection,  takes 
issue  with  Huguenin  on  this  assumption,  and  mentious  the  notes  of  four 
cases  of  his  own  with  an  inflammatory  condition  of  the  ependyma  in  which 
only  a  trace  of  albumin  could  be  found  in  the  fluid.  I  am  inclined  to  agree 
with  Fagge  in  this  regard ;  for  it  is  a  well-known  fact  that  the  amount  of 
albumin  in  inflammatory  fluids  depends  directly  upon  the  cellular  elements 
contained  therein.  The  fluid  in  subacute  pleurisy  varies  in  this  percentage 
owing  to  this  cause,  and  no  one  will  assert  that  this  fluid  when  the  percent- 
age of  albumin  is  small,  is  not  the  result  of  an  inflammation  of  the  pleura. 

1  HuKuenin  :    Ziemssen's  Practice  of  Medicine,  vol.  xii. 
-  C.  H.  Fagge :    Practice  of  Medicine,  vol.  i.  p.  574, 1886. 


GENERAL  DISEASES  OF  THE  BRAIN.  345 

The  quantity  of  the  fluid  varies  according  to  the  length  of  time  the  dis- 
ease has  existed  in  each  case.  Thus,  after  death,  as  much  as  three  gallons  of 
fluid  has  been  found  in  a  case.  Numerous  cases  have  been  reported  in 
which  six  and  eight  pints  of  fluid  were  obtained. 

Pathological  Anatomy.  As  a  usual  rule  the  lateral  ventricles  are  alone 
involved  in  the  distention  ;  occasionally  the  third  and  fourth  ventricles  par- 
ticipate. The  lateral  ventricles  may  be  both  equally  distended,  or  one  may 
be  more  distended  than  the  other.  Cases  have  been  reported  in  which  the 
one  ventricle  alone  was  expanded  and  the  other  apparently  of  normal  size. 
In  the  last  cases  occlusion  of  the  foramen  of  Monro  has  been  found. 

In  well-developed  cases  the  brain  is  distended  to  a  mere  shell,  the  convo- 
lutions are  flattened,  the  sulci  indistinguishable,  and  the  whole  cortex  has 
the  appearance  of  a  membranous  layer.  Microscopical  analysis  of  the  cor- 
tex has  not  as  yet  been  satisfactorily  made,  and  observations  are  not  suffi- 
ciently numerous  to  define  absolutely  the  changes  occurring  therein.  Thus 
far  have  been  noted  atrophy  and  obliteration  of  the  ganglion  cells,  fusion 
and  disintegration  of  the  medullated  nerve  fibres. 

The  basal  ganglia  are  flattened,  spread  out,  and  firmer  than  normal, 
as  are  the  pons,  crura,  and  the  other  anatomical  structures  at  the  base. 

Sometimes  the  septum  lucidum  is  obliterated,  commonly  in  cases  of  enor- 
mous distention. 

The  cranial  bones  are  thin,  the  diploe  obliterated,  and  at  times  they  are 
translucent.  Owing  to  the  intra-cerebral  j)ressure  exerted  by  the  fluid,  the 
sutures  are  separated,  sometimes  to  three-quarters  of  an  inch.  The  fonta- 
nelles  are  much  enlarged  and  exceedingly  tense.  The  scalp  is  involved  in 
the  distention  and  is  very  thin,  and  is  stretched  over  the  skull  like  a  mere 
membrane.  The  veins  shine  through  this  very  prominently,  the  skin  of  the 
scalp  having  a  glistening,  bluish  appearance.  The  head  reaches,  at  times, 
an  enormous  size,  a  circumference  of  27  and  even  32  inches  having  been 
noted.  In  cases  of  separation  of  the  cranial  sutures,  o-ssa  triquetra  have 
formed  in  the  membranous  expansion  between  them,  and  in  the  fontanelles. 

In  the  congenital  cases,  especially  in  those  in  which  the  third  and  fourth 
ventricles  were  distended,  atrophy  of  the  optic  tracts,  defective  development 
of  the  pons,  the  medulla,  and  cerebellum  have  occurred,  showing  that  the 
process  had  its  beginning  early  in  fcetal  life. 

The  bones  of  the  skull  are  pressed  out,  so  that  the  frontal  projects  beyond 
the'  orbits  at  an  oblique  angle ;  its  orbital  plates  are  flattened,  driving  the 
eyes  downward  to  such  an  extent  that  the  cornea  is  almost  entirely  con- 
cealed by  the  lower  lids,  and  the  sclerotic  above  is  visible.  The  occipital 
bone  assumes  a  horizontal  position,  and  the  parietal  and  temporal  are  driven 
laterally  to  such  an  extent  as  to  conceal  the  ears  when  the  skull  is  viewed 
from  above. 

The  cerebral  meninges  show  few,  if  any,  pathological  changes ;  occasion- 
ally the  pia  of  the  base  is  found  to  be  thickened.  The  choroid  plexus  is  at 
times  hypersemic,  thickened,  swollen,  and  firmer  than  normal. 

The  changes  in  the  ependyma  have  already  been  mentioned. 

When  hydrocephalus  is  acquired  after  the  cranial  bones  are  united  the 
pathological  changes  in  the  brain  and  skull  differ  somewhat.  Thus,  owing 
to  the  lack  of  resiliency  of  the  brain  case,  all  the  pressure  effects  are  exerted 
on  the  brain  cavities,  so  that  the  distention  of  all  the  ventricles,  including 
the  third  and  fourth,  is  common.  The  third  not  infrequently  stands  out 
from  the  base  like  a  pendant  bladder.  For  the  same  reason  the  amount  of 
fluid  contained  in  the  ventricles  rarely  exceeds  fourteen  or  fifteen  ounces,  as 
the  external  pressure  seems  to  act  as  a  check  to  any  large  transudation  of 


346  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

fluid.  Other  changes  are  similar,  but  not  as  great  in  degree  as  in  the  con- 
genital form. 

Symptoms.  Some  of  the  congenital  cases  show  even  at  birth  a  distention 
of  the  fontanelles  and  an  enlarged  head.  The  head  in  these  cases  may  be  so 
large  as  to  form  an  obstacle  to  the  delivery  of  the  child.  Not  infrequently 
has  rupture  occurred  during  parturition,  and  death  of  the  child  ensued. 

In  the  majority  of  cases  the  disease  does  not  show  a  rapid  development 
until  between  the  first  and  fifth  months  of  extra-uterine  life. 

The  head  immediately  attracts  attention ;  it  is  large,  globular,  and  gives 
the  child  great  discomfort.  Frequently  can  the  child  be  seen  laying  its  head 
ujion  its  hand  or  supporting  it  upon  a  table.  Infants  are  unable  to  raise 
their  heads  from  the  pillow  or  bed  on  which  they  lie.  The  skin  of  the  fore- 
head is  wrinkled  into  a  constant  frown,  perhaps  expressive  of  joain,  for  the 
afflicted  patient  often  gives  a  moan  or  whining  cry.  Headache  is  complained 
of  by  older  children.  The}"  are  irritable  and  cross.  The  eyeballs  protrude 
somewhat  and  are  directed  downward,  the  cornea  being  for  the  most  part 
covered.     Occasionally  nystagmus  is  noticed. 

Children  with  the  disease  well  developed  do  not  like  to  move  about,  even 
if  they  can,  for  motion  of  the  head  produces  in  them  vertigo,  vomiting,  and 
ofttimes  convulsions. 

Somnolency  and  drowsiness  are  common.  The  sight  is  impaired  and  blind- 
ness, owing  to  atrophy  of  the  optic  nerves,  not  u^n common.  Sometimes  sight 
is  not  affected  and  remains  good  throughout. 

Motion  is  more  or  less  diminished.  There  may  be  a  complete  paralysis  of 
all  the  limbs,  or  a  paraplegia.  Hemiplegia  has  been  noted  in  a  few  cases. 
When  it  occurs  it  is  probably  due  to  some  other  local  cause  in  the  brain.  The 
child  may  be  able  to  walk.  Its  gait,  however,  is  shambling  and  tottering, 
slow  and  methodical.  All  signs  denote  muscular  weakness.  The  child  in 
rising  usually  places  his  hands  upon  his  knees,  keeps  his  neck  stiff"  to  support 
his  head,  lifts  his  upper  body  with  the  strength  of  his  arms  exerted  against 
his  knees,  and  then  assumes  the  erect  posture.  In  walking  they  frequently 
hold  their  heads  between  their  hands  to  steady  it  and  support  its  weight. 

The  voice  of  older  children  is  peculiarly  strident  and  high-pitched. 

The  intelligence  is  usually  impaired.  When  the  disease  begins  in  infancy 
the  child  shows  no  aptitude  to  acquire  impressions.  They  do  not  learn  to 
talk,  to  recognize  their  parents,  although  a  high  degree  of  idiocy  is  rare. 
Imbecility  is  the  more  usual  status.  Children  with  this  affection  are  "  back- 
ward," as  it  is  termed.  That  is,  they  possess  a  degree  of  intelligence  which 
belongs  to  a  much  younger  period  of  normal  life.  If  the  disease  be  arrested 
in  its  course  they  can  acquire  speech,  and  learn  to  read  and  write. 

Not  unusually  do  tonic  and  clonic  spasms  of  the  limbs  appear  as  well  as 
nystagmus.  General  convulsions  sometimes  terminate  the  scene,  or  the  child 
falls  into  a  condition  of  coma,  and  an  epileptiform  convulsion  ends  its  life. 

The  general  nutrition  of  the  child  participates  in  the  disease.  Such  chil- 
dren are  emaciated,  their  skin  pale  and  translucent,  and  generally  wrinkled 
over  the  body  owing  to  the  loss  of  the  subcutaneous  fat.  The  body  is  usually 
moist  and  the  head  especially  bathed  in  a  profuse  perspiration. 

When  the  disease  approaches  a  fatal  issue  the  drowsiness  increases,  the 
whining,  moaning  cry  appears  at  more  frequent  intervals,  stubborn  vomiting 
supervenes,  and  finally  life  ends  with  coma  or  convulsions. 

Objective  Signs.  Fluctuation  is  easily  elicited ;  sometimes  a  cracked-pot 
resonance  may  be  obtained  when  percussion  is  made  on  the  fontanelle  and 
the' patient  is  asked  to  open  his  mouth.  In  extreme  distention,  a  light  held 
on  one  side  of  the  head  will  be  diffused  through  it,  and  the  glare  can  be  dis- 
tinguished when  the  eye  of  the  observer  is  placed  on  the  other  side. 


GENERAL  DISEASES  OF  THE  BRAIN.  347 

The  symptoms  of  acquired  hydrocephalus,  when  that  disease  develops  after 
the  total  ossification  of  the  ci'anial  bones,  are  not  as  distinctive.  In  fact,  there 
is  nothing  sufficiently  characteristic  to  enable  one  to  form  a  positive  diagnosis. 

After  a  traumatism,  which  is  usually  the  exciting  cause  of  the  affection  in 
the  adult,  headache  is  complained  of,  insomnia,  and  a  loss  or  impairment  of 
memory  soon  comes  on.  These  may  be  soon  followed  by  a  succession  of 
epileptiform  convulsions,  during  Avhich  a  hemiplegia  may  develop.  In  fact, 
hemiplegia  in  these  cases  is  more  frequently  observed  than  the  other  forms  of 
motor  impairment ;  the  hemiplegia  may  be  general  or  partial.  The  pupils 
are  mostly  dilated  and  not  responsive  to  light,  or  only  sluggishly  so.  Some- 
times they  show  an  inequality  in  their  dilatation.  Strabismus  not  infrequently 
occurs.  These  patients  suddenly  lose  consciousness  and  have  no  control  of 
their  sphincters,  passing  their  urine  and  feces  in  bed.  Sometimes  an  aphasia 
and  complete  loss  of  speech  are  present  before  unconsciousness  makes  its  ap- 
pearance. Coma  may  supervene  or  death  come  suddenly  without  coma  or 
convulsions.  The  autopsy  alone  can  demonstrate  the  cause  of  death  in  these 
cases,  as  it  is  impossible  to  make  a  diagnosis  during  life.  The  presence  of 
the  disease  may  be  surmised,  but  not  determined. 

Course  and  Duration.  The  course  of  the  disease  is  by  no  means  con- 
stant. At  times  when  it  is  present  at  birth,  no  progress  is  noted  until  a 
few  months  have  elapsed.  Again  it  may  be  rapidly  progressive  and  ter- 
minate life  within  a  few  months.  The  disease  may  slowly  progress,  and 
then  remain  at  a  standstill,  and  finally  recovery  take  place ;  or  the  progress 
may  be  rapid,  a  considerable  enlargement  of  the  head  occur,  and  the  infant 
grow  to  childhood,  and  death  occur  from  some  intercurrent  aflTection.  Roki- 
tansky  reports  a  case  in  which  the  distention  was  so  great  that  spontaneous 
rupture  took  place  through  one  of  the  sutures,  the  fluid  escaping  through  the 
scalp  and  partly  diffiised  itself  underneath  that  covering,  and  ultimate  recovery 
resulted.  The  disease  may  be  fatal  in  early  childhood,  and  occasionally  it 
persists  through  adolescence  even  up  to  the  fortieth  year,  although  as  a  usual 
thing  death  results  before  the  age  of  adolescence. 

Prognosis.  The  prognosis  is  always  grave,  the  afifection  usually  ending  in 
death.  Length  of  life  depends  upon  the  rapidity  of  development  and  the 
amount  of  compression  to  which  the  brain  is  subjected. 

Treatment.  Little  good  is  to  be  obtained  by  medicinal  means.  The  best 
results  have  attended  surgical  measures.  Those  usually  employed  are  strap- 
ping and  compression  of  the  head  and  draining  of  the  fluid.  For  an  account 
of  the  surgery  of  hydrocephalus  see  Chapter  XXXIII  on  Surgery  of  the 
Brain. 


CHAPTER   XIII. 


GENERAL  DISEASES  OF  THE  BRAIN. 

(Continued.) 


By  F.  X.  DERCUM,  M.D. 


PACHYMENINGITIS. 

The  dura  mater  of  the  bram  is  a  dense  fibrous  membrane  consisting  of  two 
distinct  layers,  the  outer  of  which  is  the  periosteal  covering  of  the  internal 
table  of  the  skull.  The  inner  layer  alone  can  be  regarded  as  directly  related 
to  the  brain.  In  harmony  with  these  facts  these  layers  are  subject  to  some- 
what different  pathological  processes. 

The  affections  of  the  outer  layer  consist  of  acute  and  chronic 
inflammation.  The  first  occurs  as  the  result  of  blows  upon  the  skull,  with  or 
without  fracture ;  and  if  air  have  access  to  the  membrane,  as  through  a 
wound,  the  inflammation  may  become  purulent.  Acute  external  pachymen- 
ingitis is  largely  a  surgical  affection,  and  does  not  require  extended  considera- 
tion here.  In  rare  cases  it  makes  its  appearance  without  traumatic  cause, 
and  is  then  probably  due  to  secondary  infection  from  disease  of  surface 
structures,  e.  g.,  erysipelas  of  the  head  or  face.  If  it  be  the  result  of  trauma, 
the  history,  the  appearance  of  the  wound,  local  pain  and  tenderness  render 
the  diagnosis  easy.  In  the  rare  cases  just  mentioned  the  diagnosis  is  often 
diflficult,  and  the  affection  may  not  be  suspected  until  pus  has  collected  in  con- 
siderable amount,  when  focal  symptoms,  referable  to  compression  or  irritation 
of  the  cortex,  may  be  present.  Fever  may  or  may  not  be  noticed.  The 
treatment,  of  course,  consists  in  trephining  over  the  affected  area. 

Chronic  simple  inflammation  of  the  external  layer  is  of  considerable  im- 
portance. Every  now  and  then  we  notice  in  making  autopsies  that  it  is 
impossible  to  remove  the  calvarium  without  at  the  same  time  lacerating  the 
dura  or  without  the  use  of  very  considerable  force.  The  dura  in  such  cases 
is  firmly  adherent  to  the  calvarium,  and  when  we  examine  the  latter  we 
find  that  it  is  thicker,  denser,  and  heavier  than  normal,  and  that  the 
spongy  structure  or  the  diploe  has  largely  disappeared.  In  other  words,  there 
has  been  an  increase  in  osseous  tissue  throughout.  Chronic  inflammation  of 
the  external  dura  is  therefore  equivalent  to  chronic  external  ossific  pachymen- 
ingitis. The  existence  of  this  affection  is  frequently  overlooked  during  life, 
though  occasionally  it  is  of  great  clinical  importance.  A  certain  number  of 
permanent  headaches  have  their  explanation  in  this  condition.  Among  the 
few  neurologists  to  recognize  this  fact  is  S.  Weir  Mitchell.  He  places  as 
among  the  probable  causes,  trauma,  which  in  young  children  may  be  com- 
paratively slight.     Thus  he  says:    ,"A  slight  injury  causes  in  the  young 


GENERAL  DISEASES  OF  THE  BRAIN.  349 

hyperostosis ;  the  boue  remains  somewhat  thickened,  with  no  marked  depres- 
sion, but  there  is  a  limited  area  of  adhesions  of  the  dura  without  clear  evi- 
dences of  present  inflammation.  These  conditions  may  give  rise  to  nearly 
constant  pain,  great  sensitiveness  of  head,  incapacity  for  study,  and  frequent 
unendurable  additions  to  the  permanent  distress."^ 

Instead  of  being  comparatively  limited,  it  may  in  given  cases  be  widely 
diffused.  It  is  so  found  occasionally  in  autopsies  in  chronic  insanity,  epilepsy, 
trauma  of  long  standing,  and  in  old  age.  Often  it  is  uuassociated  with  any 
special  symptoms,  and  is  unsuspected  during  life.  However,  as  we  have  seen, 
the  possibility  of  its  occurrence  should  always  be  considered  in  chronic  head- 
aches, especially  if  they  are  more  or  less  limited  in  distribution  and  have 
followed  blows  upon  the  skull.  The  fact  that  external  signs,  such  as  depres- 
sion or  scars,  are  absent  does  not  militate  against  the  diagnosis.  A  symptom 
of  value  in  these  cases  is  tenderness  upon  deep  firm  pressure,  and  upon  per- 
cussion of  the  skull.  My  own  observations  have  convinced  me  that  the 
condition  follows  trauma  far  more  frequently  than  is  supposed. 

If  traumatic  external  meningitis  be  severe  it  does  not  remain  limited  to 
the  external  layer,  but  affects  the  internal  dura  as  well.  In  such  case  it  also 
frequently  involves  the  subjacent  pia-arachnoid.  Bands  of  adhesions  unite 
the  surface  of  the  dura  with  the  soft  membranes,  and  the  latter  show  markedly 
the  signs  of  inflammatory  infiltration.  A  typical  instance  of  a  traumatic 
meningitis  of  such  severity  may  make  clear  the  character  of  this  affection. 

A  man,  thirty  years  of  age,  fell  a  distance  of  some  twelve  feet,  striking 
upon  the  head,  a  little  to  the  left  of  the  vertex.  After  the  immediate  symp- 
toms had  passed  away,  though  there  was  not  even  a  laceration  of  the  scalp 
nor  any  depression  of  the  skull,  chronic  headache,  referred  to  the  seat  of  the 
blow,  persisted.  This  was  constant  and  severe,  and  failed  to  yield  to  internal 
medication  or  to  active  counter-irritation.  Finally,  epileptic  seizures  devel- 
oped which  were  focal  in  character.  Two  years  afterward  the  man  died  of 
an  intercurrent  affection,  and  the  autopsy  revealed  beneath  the  site  of  the 
injury  a  thickened  dura  adherent  to  the  calvarium.  It  was  also  adherent  by 
delicate  bands  to  the  subjacent  pia-arachnoid,  which  was  infiltrated  and 
thickened.  Careful  examination  of  the  calvarium  failed  to  reveal  any  trace 
of  fracture.  Cases  like  the  above  are  exceedingly  important,  inasmuch  as 
they  may  be  improved  by  early  surgical  interference. 

Traumatic  meningitis  may  therefore  involve  either  the  external  dura  alone, 
or  may  involve  both  layers  of  the  membrane  and  also  the  pia-arachnoid.  It 
is  not  always  possible  during  life  to  determine  whether  a  meningitis  resulting 
from  a  trauma  involves  merely  one  or  all  of  the  membranes.  If  the  pia- 
arachnoid  be  involved  we  may  have  in  addition  to  circumscribed,  constant 
headache,  also  the  symptoms  of  focal  disease  of  the  brain,  such  as  were  pre- 
sented in  the  case  just  cited.  Neither  is  it  possible  to  decide  whether  inflam- 
mation of  the  membranes  is  the  only  lesion  present,  whether  or  not  there  has 
also  been  a  fracture,  with,  perhaps,  the  projection  of  a  spicule  of  bone  from 
the  internal  table.  In  the  latter  instance,  there  may  be  reflex  epilepsy  due 
to  the  constant  irritation  of  the  dura,  and  this,  too,  when  the  pia-arachnoid  and 
the  cortex  are  not  directly  involved.  The  diagnosis  of  a  given  case  must,  of 
course,  be  based  upon  the  special  symptoms  presented. 

Treatment.  If  the  diagnosis  of  traumatic  meningitis  has  been  made, 
most  active  treatment  should  be  instituted.  Internal  medication  is  of  slight 
benefit.  In  this  connection  the  iodides,  bromides,  and  mercurials  naturally 
suggest  themselves,  and  it  is  well  always  to  make  a  thorough  trial  of  them. 
More  important,  however,  is  active  counter-irritation.     This  should  consist 

1  S.  Weir  Mitchell :  "  Permanent  Headaches."  International  Clinics,  October,  1S91,  p.  273. 


350  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

preferably  of  supei-ficial  burns  made  with  a  wliite-liot  iron,  or  a  Paquelin 
cautery,  over  the  back  of  the  neck.  It  is  my  own  custom  to  make  such  a 
burn  the  size  of  a  silver  half  dollar,  and  to  destroy  simply  the  superficial 
layers  of  the  epithelium ;  then  to  allow  the  burn  to  heal  rapidly,  and  in  the 
course  of  a  week  or  ten  days  to  burn  again.  Occasionally  it  is  expedient  to 
make  the  first  burn  rather  high  up,  close  to  the  occiput,  and  to  make  the 
second  burn  a  little  lower  down,  but  also  in  the  median  line.  In  this  way, 
by  making  the  second  burn  before  the  first  has  had  time  to  heal,  and  a  third 
before  the  second  has  healed,  an  almost  constant  active  counter-irritation 
may  be  maintained.  In  a  limited  number  of  cases  I  have  seen  decided 
relief  follow  this  measure.  However,  in  no  instance  of  well-marked  trau- 
matic meningitis  have  I  had  reason  to  believe  that  a  cure  had  been  efiected. 
By  all  means  the  most  satisfactory  way  of  dealing  with  these  cases  is  sur- 
gically. We  can  never  be  absolutely  sure  that  we  have  only  a  traumatic 
meningitis  to  deal  with.  It  is  always  possible  that  the  trouble  is  accompanied 
by  some  affection  of  the  internal  table,  and,  therefore,  trephining  is  not  only 
indicated  for  its  therapeutic  effect,  but  also  as  an  exploratory  and  precaution- 
ary measure.  It  is  impossible  to  foretell  whether  a  given  case  will  be  limited 
to  simple  chronic  local  headache,  or  whether  sooner  or  later  there  may  not  be 
serious  complications,  such  as  epilepsy.  If  trephining  be  performed  for  an 
uncomplicated  traumatic  meningitis  it  will  be  sufficient  simply  to  remove  a 
button  of  bone  without  interfering  with  the  dura.  The  button  of  bone 
should  not  be  replaced.  If  the  meningitis  be  difflised  over  a  rather  large 
area  it  may  be  wise,  as  was  done  in  one  of  my  own  cases,  to  make  two  small 
trephine  opening's  at  some  distance  apart.  Just  in  what  manner  trephining 
produces  amelioration  of  the  symptom  is  not  clear.  However,  it  is  probable 
that  the  new  conditions  under  which  the  inflamed  membrane  is  placed,  such 
as  the  relief  of  local  pressure  and  altered  local  circulation,  may  be  the  agen- 
cies at  work.  Certain  it  is  that  the  relief  which  accompanies  this  procedure 
is  very  decided. 

A  variety  of  chronic  external  pachymeningitis  which  has  been  met  with  in 
a  few  instances  needs  passing  mention.  Thus  far  but  two  observers  have  des- 
cribed it,  Lannelongue'  and  Alexis  Thompson.^  In  every  instance  the  patient 
has  been  a  child,  and  its  discovery  has  been  either  during  the  performance 
of  an  operation,  such  as  craniectomy,  or  upon  the  post-mortem  table.  As  in 
the  ordinary  form,  the  dura  is  very  firmly  adherent  to  the  calvarium  ;  on  its 
external  layer,  however,  are  seen  numerous  granulations,  reddish  in  color, 
which  are  imbedded  in  the  bone ;  the  latter,  instead  of  being  thickened, 
becomes  very  much  thinned,  in  other  words,  the  inflammation,  instead  of 
being  attended  by  deposit,  is  attended  by  absorption  of  bone.  The  affection 
is  exceedingly  rare,  and  its  symptomatology  is  as  yet  obscure. 

The  inner  layer  of  the  dura  mater  is  far  less  frequently  diseased 
than  the  outer  layer.  HoAvever,  it  is  at  times,  as  we  have  seen,  the  seat  of 
inflammation  the  direct  result  of  trauma,  being  in  such  cases  involved  con- 
comitantly with  the  outer  layer.  Occasionally  such  a  traumatic  inflamma- 
tion is  adhesive,  and  more  or  less  marked  bauds  of  union  may  be  formed 
with  the  subjacent  pia.  Extensive  adhesion  is,  however,  rare.  Adhesions 
between  the  inner  layer  and  pia-arachnoid  also  occur  as  the  result  of 
syphilitic  inflammation.  The  inner  layer  of  the  dura  may  likewise  be  the 
seat  of  purulent  inflammation,  and  in  such  instances  there  is  generally  a 
similar  involvement  of  the  pia-arachnoid,  and  the  symptoms  cannot  be 
separated  from  those  of  purulent  leptomeningitis.     Finally,  at   the  post- 

1  Lannelongue ;    Congres  Francais  Chirurgical,  1891,  p.  75. 

-  Alexis  Thompson  on  Pachymeningitis  Chronica  Externa,  Journal  of  Pathology  and  Bacteriology, 
1893,  October  9,  p.  75. 


GENERAL  DISEASES  OF  THE  BRAIN. 


351 


mortem  table  we  not  rarely  find  bony  deposits  in  the  internal  layer,  more 
especially  in  its  prolongations,  for  example,  in  the  falx.  This  condition  is 
rather  of  pathological  than  of  clinical  interest. 

Almost  all  writers  describe  as  a  disease  of  this  membrane  a  condition 
variously  known  as  internal  hemorrhagic  pachymeningitis,  haematoma  of  the 
dura,  or  arachnoid  cyst.  Every  now  and  then,  in  making  autopsies  upon  the 
brain,  we  find  the  inner  layer  of  the  dura  covered  by  more  or  less  dense 
layers  of  reddish  fibrin.  The  deposit  looks  like  an  exudation  of  blood  under- 
going organization.  The  exudation  can  frequently  be  stripped  in  layers 
from  the  inner  dura  without  difficulty.  Occasionally,  however,  instead  of 
finding  merely  this  deposit,  cysts  of  greater  or  less  size  are  met  with,  and 
these  being  opened  are  found  to  contain  altered  blood.  Virchow  and  others 
have  considered  this  affection  as  inflammatory  in  origin.      Later  investi- 

FiG.  77. 


Section  of  false  membrane  in  hemorrhagic  pachymeningitis,  showing  excessive  vascularity  of  dura 
at  a  and  6,  and  newly  formed  vessels  at  c,  d  and  /. 

gators,  however,  notably  Wigglesworth,  Hoyt,  Whittaker,  and  the  writer, 
have  attributed  the  condition  to  a  subdural  hemorrhage.  It  is  exceedingly 
probable  that  the  latter  view  is  correct.  The  affection,  which  in  itself  is 
rare,  is  most  frequently  found  among  the  chronic  insane,  in  just  that  class  of 
patients  in  Avhom  degeneration  of  the  bloodvessels  is  apt  to  be  marked. 
That  a  simple  escape  of  blood  into  the  subdural  space  is  sufficient  to  produce 
the  lesions  of  this  so-called  hemorrhagic  pachymeningitis  has  been  proved  l')y 
Sperling,  who  injected  blood  into  the  subdural  space  in  animals.  It  is  prob- 
ably a  matter  of  little  consequence  as  to  whether  the  initial  hemorrhage  come 
from  the  pia  or  from  the  dura.  It  is  true  that  the  exudation  is  most  fre- 
quently found  more  or  less  adherent  to  the  dura.  However,  that  the  hemor- 
rhage does  at  times  come  from  the  pia  has  been  absolutely  demonstrated  by 
Hoyt.  It  appears  that  after  the  exudation  has  taken  place  that  some 
attempt  at  organization  is  made  (see  Fig.  77),  and  that  sooner  or  later  vessels 


352  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

are  formed  with  poorly  differentiated  walls,  which,  in  turn,  give  rise  to 
renewed  bleedings.  Such  vessels  are  readily  seen  in  microscopic  sections  of 
the  exudation  in  the  dura.  Hoyt  in  one  instance  has  also  traced  such  a 
vessel  in  the  exudation  from  the  pia.  As  to  the  cause  of  these  hemorrhages, 
writers  agree  in  attributing  them  to  the  degeneration  of  bloodvessels  and 
especially  to  the  lessened  iutra-cranial  pressure,  which,  in  all  probability, 
accomj)auy  degeneration  and  atrophic  changes  in  the  convolutions.  That  this, 
however,  is  not  the  entire  truth  is  proved  by  an  observation  published  some 
years  ago  by  the  writer.  In  this  instance  there  was  no  mental  disease  what- 
ever, no  degenerative  affection  of  the  nervous  system,  and,  notwithstanding, 
large  hsematomata  of  the  dura  were  found  covering  both  hemispheres  at  the 
autopsy.  In  this  instance,  also,  the  affection  was  not  limited  to  the  internal 
dura,  but  affected  the  external  dura  as  well,  and  with  it  the  calvarium,  that 
is,  the  vessels  of  the  external  dura  were  exceedingly  enlarged  and  the  cal- 
varium was  soft  and  spongy  and  riddled  with  a  large  number  of  foramina 
containing  distended  vessels.^  It  is  probable,  therefore,  that  there  are  other 
agencies  at  work  in  the  production  of  this  affection,  agencies  which  are 
ti'ophic  in  character,  and  the  writer  has  advanced  the  view  that  haematoma 
of  the  dura  is  really  trophic  in  origin,  and  that  it  is  in  every  way  comparable 
to  such  allied  conditions  found  in  the  insane  as  hsematoma  of  the  cartilages 
of  the  ear  or  of  the  cartilages  of  the  nose. 

As  has  been  stated,  the  condition  has  been  most  frequently  met  with  in 
autopsies  of  cases  of  chronic  and  terminal  insanities.  Occasionally,  however, 
it  follows  an  old  trauma  of  the  head,  and  sometimes  a  sunstroke.  It  is  also 
occasionally  met  with  in  alcoholic  subjects.  It  has  at  times  followed  ex- 
hausting fevers,  and  rarely  is  met  with  in  autopsies  upon  cases  of  anemia. 
Doehle'^  describes  the  occurrence  of  a  pachymeningitis,  which,  from  the 
description,  was  undoubtedly  hseamatoma  of  the  dura,  in  young  children. 
Northrup^  adds  similar  cases  to  the  literature. 

Owing  to  the  nature  of  the  affection  it  is  rarely  i-ecognized  during  life.  If 
met  with  in  patients  who  are  not  insane,  or  at  least  are  able  to  give  an  account 
of  their  symptoms,  we  find  headache  most  frequently  complained  of.  The 
fact  that  the  headache  is  continuous  would,  of  course,  suggest  meningeal  or 
other  serious  organic  disease.  Special  symptoms  may  be  present,  depending 
upon  the  locality  and  the  extent  of  the  exudation.  Thus,  for  instance,  if  the 
exudation  be  large  and  limited  to  one  hemisphere,  a  more  or  less  marked 
hemiplegia  may  be  the  result.  Such  a  hemiplegia  may  be  ushered  in  by 
an  increased  headache,  vomiting,  somnolence,  coma,  convulsions,  conjugate 
deviation  of  the  eyes,  contracted  pupils,  or  nystagmus.  Instead  of  the  hemi- 
plegia there  may  be  simply  a  general  muscular  weakness.  Eye-ground 
changes  are  not  often  present,  though  optic  neuritis,  it  is  claimed,  occasionally 
occurs.  These  symptonxs,  however,  may  be  caused  by  various  lesions,  and 
the  diagnosis  is  at  best  unsatisfactory.  Should  it,  however,  be  reasonably 
established,  surgical  measures  should  be  instituted  (see  Chapter  XXXIII),  and 
if  doubtful,  a  treatment  based  upon  general  principles  should  be  adopted. 
This  should  include  absolute  abstinence  from  alcoholic  stimulants,  a  carefully 
regulated  diet,  laxatives,  alteratives,  and  possibly  counter-irritation  to  the 
back  of  the  neck. 

Rarely  pachymeningitis  is  tuberculous.  Such  a  case  is  recorded  by  Gussen- 
bauer*  in  which  the  disease  followed  a  blow  upon  the  skull  in  a  man  with 

1  Dercum:   University  Med.  Mag.,  October,  1889. 

-  Doehle :  Ueber  Chronische  Pachj-meningltis  bei  Kinder,  etc.  Verhandlg.  d.  X.  Internationalen 
Congresses, -1890,  Bd.  v.  Abthl:  svii.  p.  40.  Doehle,  in  395  autopsies  on  children  below  the  age  of 
ten,  found  48  instances  ;  of  these,  30  occurred  in  infants  under  one  year. 

s  Northrup :  Journ.  New  York  Path.  Soc,  1891,  pp.  59-67,  Three  cases  in  starved  and  emaciated 
infants. 

*  Gussenbauer  :  "  Ueber  Pachymeningitis  Circumscripta  "  Prag,  Med.  Wochenschr.    1892,  xvii.  91. 


GENERAL  DISEASES  OF  THE  BRAIN.  353 

a  bad  family  history.  The  dura  may  also  be  involved  in  syphilitic  disease  of 
the  cranial  bones.  Primary  specific  pachymeningitis  is  generally  diiFuse  and 
characterized  by  headache,  and  often  by  tenderness  of  the  skull  on  percussion. 
Other  syphilitic  stigmata  are  present.  (See  Chapter  XXIV.)  In  children 
pachymeningitis  appears  to  be  occasionally  due  to  inherited  syphilis.^ 


LEPTOMENINGITIS. 

Because  of  their  close  anatomical  relations  inflammations  of  the  arach- 
noid and  pia  mater  are  considered  together  under  the  name  of  leptomenin- 
gitis. These  inflammations  are  various  in  character.  A  leptomeningitis  may 
be  simple,  purulent,  tuberculous,  or  syphilitic,  or  it  may  be  secondary  to  pneu- 
monia, scarlet  fever,  typhoid  fever,  ulcerative  endocarditis,  measles,  variola  or 
septicsemia.  Further,  it  may  be  rheumatic  in  origin  or  the  result  of  some  toxic 
agent,  as  alcohol.  Sunstoke  is  another  undoubted  factor  in  the  production 
of  meningitis.  Traumata  of  various  kinds,  especially  blows  upon  the  skull, 
are  also  not  infrequent  causes  of  meningitis.  Such  a  meningitis  may  or  may 
not  be  accompained  by  a  wound  or  fracture  of  the  skull.  Various  dis- 
eases of  the  cranial  bones  and  of  the  sinuses  of  the  dura  mater  may  give 
rise  to  meningitis  by  contiguity.  A  very  common  instance  of  this  is  the 
meningitis  which  has  its  origin  in  disease  of  the  petrous  portions  of  the  tem- 
poral bone.  Finally  meningitis  may  be  present  without  special  or  discovera- 
ble cause,  and  in  such  case  is  spoken  of  as  idiopathic. 

Every  now  and  then  a  cerebral  leptomeningitis  invades  also  the  pia-arach- 
noid  of  the  spinal  cord,  and  in  such  a  case  the  symptoms  closely  resemble  those 
found  in  the  epidemic  form  of  cerebro-spinal  meningitis.  (See  page  203.) 
Leptomeningitis  varies  greatly  as  to  its  distribution.  It  may  be  widely  dif- 
fused, but  is  generally  most  marked  over  some  one  portion  of  the  brain,  and 
at  times  is  even  limited  to  certain  areas.  Thus  it  is  occasionally  most  marked 
or  limited  to  the  vertex,  in  which  case  we  speak  of  a  vertical  meningitis.  At 
other  times  it  is  most  marked  at  or  limited  to  the  base,  and  in  this  instance 
we  speak  of  a  basal  meningitis ;  or,  it  may  be  limited  to  some  area  either  of 
the  base  or  vertex,  and  then  it  is  spoken  of  as  a  local  meningitis. 

Prominent  among  predisposing  causes  are  general  ill-health,  mental  over- 
work, and  especially  the  ages  of  early  childhood  and  youth  and  the  male 
sex.  It  is  well  known  that  children  suffer  far  more  frequently  from  menin- 
gitis than  adults,  and  boys  more  than  girls. 

Symptomatology.  When  we  reflect  that  the  etiology  of  the  affection  is  so 
various,  and  when  we  consider  the  great  extent  of  the  meninges,  that  they 
cover  not  only  the  lateral  and  mesial  surfaces  of  the  brain,  but  also  line  it  at 
the  base,  and  further  are  intimately  related  to  the  various  cranial  nerves,  we 
can  readily  understand  that  the  symptoms  and  course  should  vary  greatly  in 
different  cases.  We  see  at  once  that,  while  there  may  be  general  symptoms 
common  to  all  forms,  the  detailed  symptoms  depend  largely  upon  the  char- 
acter of  the  inflammation  and  especially  upon  the  locality  to  which  the  dis- 
ease is  limited  or  at  which  it  is  most  accentuated. 

In  order  that  we  may  intelligently  study  the  subject  it  Avill  be  well  to  con- 
sider the  symptoms  present  in  the  various  diffused  forms  of  meningitis.  The 
patient  may  present  for  a  variable  period  jDreceding  the  more  profound  symp- 
toms, general  malaise,  hebetude,  and  irritability  ;  but  at  times  the  onset  is  sud- 
den, being  ushered  in  by  a  chill.  Among  the  earlier  symptoms  are  vertigo  and 
vomiting.     Soon  fever  makes  its  appearance.     The  headache  is  almost  always 

1  Moussons  :    Journ.  de  Med.  de  Bordeaux,  1891-2,  xxi.  3,  17, 
23 


354  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  great  severity  and  is  unceasing.  At  the  same  time  the  patient  becomes 
hypersesthetic  to  touch,  to  noises,  and  to  bright  light.  The  general  surface  of 
the  body  is  everywhere  very  sensitive,  as  are  also  certain  muscles,  especially 
those  of  the  back  of  the  neck  and  of  the  calves.  The  vomiting  occurs  inde- 
pendently of  the  presence  of  food  in  the  stomach  or  of  any  attack  of  indi- 
gestion. In  a  short  time  delirium,  muscular  twitchings,  and,  perhaps,  con- 
vulsions manifest  themselves.  The  tongue  at  first  shows  nothing  peculiar, 
but  later  in  the  general  adynamic  condition  it  becomes  heavily  ilirred.  There 
is  also  obstinate  constipation  and  retraction  of  the  abdomen.  Retention  of 
urine  is  frequent.  As  the  case  progresses  somnolence  and  coma  may  super- 
vene, together  with  involuntary  evacuations  of  urine  and  feces.  The  temper- 
ature in  the  average  case  is  not  very  high,  ranging  generally  from  100°  to 
102^,  although  sometimes  as  much  as  105°  or  more  is  noted.  The  pulse, 
instead  of  being  increased  in  frequency,  as  we  would  naturally  expect  it  to 
be,  is  markedly  slower  than  normal,  its  rate  falling  to  seventy,  sixty,  or  fifty 
beats  to  the  minute,  or  even  less.  In  addition  it  is  frequently  irregular. 
If  the  case  goes  on  from  bad  to  worse  the  rate  finally  increases,  and  at  last 
becomes  excessively  rapid.  The  respiration  is  at  first  but  little  affected.  Later 
it  becomes  frequent,  sighing  and  interrupted,  and  may  even  assume  the  char- 
acter of  the  Cheyne-Stokes  respiration.  In  addition  to  these  symptoms  others 
are  present  dejiending  upon  the  special  seat  of  the  inflammation.  Thus  we 
are  apt  to  have  signs  of  involvement  of  various  cranial  nerves.  This  is  true 
especially  of  the  ocular  nerves,  strabismus  being  as  a  rule  an  early  symptom. 
In  addition  there  is  almost  always  some  modification  of  the  pupils.  At  first 
contracted,  they  may  later  on  be  unequally  dilated.  Sometimes  there  is 
ptosis,  though  this  is  generally  slight.  There  may  also  be  signs  of  involve- 
ment of  the  facial  nerve,  and  there  may  be  more  or  less  distinct  facial 
palsy.  Instead  of  paralysis,  however,  marked  twitchings  or  spasms  may  be 
present.  If  the  inflammation  involve  the  posterior  cranial  fossa  there  is 
more  or  less  marked  spasm  or  rigidity  of  the  muscles  of  the  back  of  the 
neck.  This  symptom  is  rarely  if  ever  absent  in  posterior  basal  meningitis, 
and  is  one  of  the  most  valuable  guides  that  we  have.  The  head  is  retracted 
and  nearly  immobile ;  attempts  at  movement  and  handling  of  the  neck  give 
rise  to  pain.  Further,  trismus,  gritting  of  the  teeth,  rigidity  of  the  muscles 
of  the  abdomen,  spasms  of  the  muscles  of  a  limb  or  localized  convulsive 
movements  may  also  be  present.  Optic  neuritis,  and  if  pressure  be  great, 
as  from  extensive  exudation,  blindness  may  also  supervene. 

The  knee-jerks  are  at  first  increased,  but  later  diminished,  and  finally 
lost.  Vasomotor  disturbances  are  occasionally  noted.  Thus,  if  the  skin  be 
lightly  stroked  by  the  finger  a  persistent  red  streak  may  make  its  appearance. 
This  is  the  so-called  "tache  cerebrale."  It  depends  upon  a  weakness  of  the 
vasomotor  apj)aratus,  and  is  not  pathognomonic  of  meningitis,  but  is  found 
in  other  adynamic  conditions.  Small  reddish  spots  may  make  their  appear- 
ance spontaneously.  Herpetic  eruptions  also  occur,  and  bed-sores  are  not 
infrequent.  Occasionally  albumin  or  sugar  is  found  in  the  urine,  and  at 
times  there  is  an  actual  or  relative  increase  in  the  amount  of  phosphates 
eliminated.  Rapid  general  emaciation  also  is  apt  to  take  place,  and  is  often 
one  of  the  most  alarming  symptoms  of  the  disease. 

The  detailed  symptoms  in  a  given  case  depend  largely  upon  the  position  of 
the  inflammation.  When  the  inflammation  is  most  marked  at  the  base, 
vomiting,  basal  or  occipital  headache,  more  or  less  marked  interference  with 
the  various  cranial  nerves,  and  especially  rigidity  of  the  muscles  of  the 
back  of  the  neck,  are  prominent  symptoms.  Optic  neuritis,  is  also  likely  to 
be  present,  coming  on,  as  a  rule,  after  the  affection  has  lasted  for  some  time, 
a  week  or  more.     Occasionally  a  paresis  of  one  side,  or  even  a  well-marked 


GENERAL  DISEASES  OF  THE  BRAIN.  355 

hemiplegia,  is  noted.  It  is  due  either  to  pressure  upon  the  crus  of  one  side 
or  to  interference  with  the  vascular  supply  of  one  of  the  hemispheres. 
Aphasia  is  also  occasionally  present. 

In  meningitis  of  the  vertex,  delirium  and  convulsions  are  perhaps  more 
marked  than  in  meningitis  of  the  base.  Headache  is  also  present  and  is 
very  severe.  It  is  referred  to  the  top  of  the  head.  Vomiting  is  much  less 
frequent  in  verticalar  meningitis  than  in  the  basal  form.  Gross  motor  dis- 
turbances, such  as  palsies  of  an  entire  limb  and  well-marked  hemiplegias,  are 
more  apt  to  occur.  Disturbances  of  the  various  cranial  nerves  are  much 
less  frequent.  Oj^tic  neuritis  also  may  remain  entirely  absent  or  occur  only 
as  a  very  late  symptom ;  similarly  rigidity  of  the  back  of  the  neck  may  be 
wanting. 

Limited  forms  of  meningitis  are  to  be  distinguished  by  the  fact  that  the 
headache  is  referred  to  some  one  portion  of  the  head,  and  that  there  are 
often  focal  cerebral  symptoms,  such  as  disturbances  of  motor  centres  or  in- 
terference with  special  cranial  nerves. 

The  various  forms  of  meningitis  present  special  features. 

Purulent  Meningitis.  In  purulent  meningitis  the  onset  is  apt  to  be 
rapid,  and  is  often  marked  by  a  chill.  The  symptoms  soon  become  pro- 
nounced, and  when  once  established  the  case  frequently  runs  a  very  rapid 
course,  a  fatal  termination  may  take  place  in  twenty-four  or  forty-eight 
hours,  though  at  other  times  the  duration  of  the  disease  may  extend  to  a 
Aveek  and  sometimes  longer.  The  temperature  is  apt  to  run  higher  than  in 
other  forms,  and  may  be  very  irregular.     Optic  neuritis  is  infrequent. 

Serous  Meningitis,  to  which  Quincke'  has  especially  called  attention,  is 
characterized  by  a  rather  mild  and  prolonged  course,  a  short  febrile  period 
and  symptoms  indicating  diffuse  pressure  rather  than  localized  symj^toms. 
Headache  and  rigidity  of  the  back  of  the  neck  are  less  pronounced  than  in  the 
purulent  form.     Oi^tic  neuritis,  on  the  other  hand,  is  much  more  common. 

Tuberculous  Meningitis  is  characterized  in  the  vast  majority  of  cases 
by  a  very  gradual  onset.  For  days  and  weeks  preceding  the  outbreak  of 
symptoms  the  child  seems  to  be  in  ill  health.  It  seems  to  be  growing  thinner, 
is  irritable,  nervous  and  suffers  from  broken  sleep,  and  often  complains  of  head- 
ache. It  is  only  after  these  symptoms  have  persisted  for  a  long  time  that  the 
actual  signs  of  meningitis  are  noted.  However,  rarely,  the  onset,  instead 
of  being  gradual,  is  quite  sudden,  vomiting  and  convulsions  being  among 
the  ■  earliest  symptoms.  In  tubercular  meningitis,  further,  the  headache  is 
intense  and  agonizing,  and  when  disturbed  the  child  often  gives  vent  to  a 
shrill  scream,  the  so-called  "  hydrocephalic  cry."  Signs  of  basal  trouble, 
such  as  gritting  of  the  teeth,  strabismus,  etc.,  are  common.  Optic  neuritis, 
also,  is  present.  Kegarding  the  ophthalmoscopic  appearances,  it_  is  also  of 
importance  to  remember  that  if  tubercles  be  detected  in  the  choroid  that  the 
diagnosis  must  be  considered  as  established  The  temperature  is  but  slightly 
raised  and  pursues  an  uneven  course.  The  pulse  is  at  first  slow,  but  may 
suddenly  increase  in  rapidity,  especially  in  the  later  stages.  It  is  subject  to 
considerable  variation.  The  respiration,  likewise,  becomes  frequent  and 
irregular.  The  disease  may  run  an  acute  and  rapid  course,  the  case  termin- 
ating fatally  at  the  end  of  a  few  days.  Much  more  frequently,  however,  its 
course  is  subacute  and  chronic,  the  duration  extending  over  two,  three,  four 
or  many  weeks.  It  may,  indeed,  be  exceedingly  protracted,  and  temporary 
remissions  may  even  take  place. 

Syphilitic  Inflammations  of  the  pia-arachnoid  are  in  the  majority  of 
cases  chronic,  though  cases  of  acute  specific  meningitis  have  been  described. 

1  Quincke  :  Sammlung  Klinischer  Vorlrage,  1893,  No.  67,  p.  655. 


356  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Specific  meningitis  is  rarely,  if  ever,  diffuse,  but  almost  always  localized.  It 
often  consists  of  welt-like  or  flattened  gummatous  formations.  The  symptom- 
atology varies  according  to  the  locality  of  the  disease.  Most  frequently, 
however,  we  find  the  lesion  situated  at  the  base,  and  more  pronounced  on 
one  or  the  other  side.  Basal  headache  with  localizing  signs  of  pressure  are, 
therefore,  among  the  most  constant  symptoms.  A  gummatous  inflammation 
of  the  membranes  at  the  base  may  involve  the  vessels  of  one  hemisphere  of 
the  brain,  and  frequently  also  one  or  more  of  the  cranial  nerves,  especially 
the  oculo-motor.  The  symptoms,  therefore,  are  often  those  of  a  crossed 
hemiplegia ;  the  leg  and  arm  are  paralyzed  on  the  opposite  side,  while  the 
oculo-motor  or  other  cranial  nerve  is  paralyzed  on  the  same  side  as  the 
lesion.  If  the  disease  be  situated  upon  the  upper  surface  of  the  brain,  symp- 
toms indicative  of  interference  with  various  cortical  centres  may  be  present. 
Common  among  these  are  palsies  limited  to  one  limb,  convulsive  attacks  re- 
sembling focal  epilepsy,  local  headache  and  tenderness  to  deep  pressure  or 
percussion.  If  the  disease  be  not  well  localized,  but  rather  diffuse,  noctur- 
nal headache,  somnolence,  and  impairment  of  the  mental  faculties  may  be 
the  only  symptoms  presented.  Optic  neuritis  may  also  exist  in  specific  menin- 
gitis as  in  other  forms  of  organic  intra-cranial  disease.  For  a  more  detailed 
account  of  the  symptoms  the  reader  is  referred  to  Chapter  XXIV. 

Alcoholic  Meningitis  is  chronic  in  character,  and  is  simply  to  be  looked 
upon  as  one  of  the  many  lesions  to  which  alcoholics  are  liable.  The  affec- 
tion is  vertical  and  diffuse,  and  therefore  focal  symptoms  are  lacking.  Con- 
stant headache,  dull  in  character,  and  dementia,  slight  or  marked,  together 
with  an  alcoholic  history,  are  the  features  presented.  Convulsions  resem- 
bling ordinary  epilepsy  also  frequently  occur.     (See  also  page  191.) 

Simple  Meningitis  is  not  readily  distinguished  from  the  other  forms. 
However,  cases  of  meningitis  are  constantly  met  with  in  which,  at  the  au- 
topsy, neither  pus,  tuberculous  deposit,  nor  other  specific  cause  is  observed. 
It  is  probable  that  of  these  cases  some  at  least  are  due  to  undiscovered  gen- 
eral infection.  For  practical  purposes,  however,  simple  meningitis  must  be 
admitted  into  our  classification.  It  is  found  mainly  as  an  acute  affection. 
In  rare  instances,  however,  a  chronic  form,  basal  in  distribution  and  symp- 
toms, is  met  with  among  infants.  It  may  exist  for  months  and  in  its  milder 
degrees  for  much  longer  periods.  In  these  cases  the  possibility  of  inherited 
syphilis  is  always  to  be  considered. 

Meningitis  secondary  to  disease  of  a  contiguous  structure  is 
generally  localized  in  character.  It  is  to  be  distinguished  by  localized  head- 
ache and  various  focal  symptoms.  A  common  instance  of  such  a  meningitis 
is  furnished  by  the  basal  meningitis  following  necrosis  of  the  temporal  bone  in 
otitis  media.  Here  intense  basal  headache  on  the  side  of  the  affected  ear, 
facial  palsy,  and  perhaps  involvement  of  the  ocular  nerves,  may  be  the  symp- 
toms presented.  Often  this  form  of  meningitis  is  complicated  by  the  symp- 
toms of  thrombosis  of  the  lateral  sinus  (see  page  366),  or  by  the  symptoms  of 
brain  abscess.  (See  page  374).  Very  rarely  a  basal  meningitis,  instead  of 
being  due  to  necrosis  of  the  temporal  bone,  is  due  to  necrosis  of  the  sphenoid.' 

Pathology  and  Morbid  Anatomy.  The  pia-arachnoid  may  present  in  cases  of 
meningitis  the  following  peculiarities  :  First,  it  may  be  the  seat  of  more  or 
less  milky  or  white  opacities,  which  are  indicative  of  chronic  thickening  or 
simple  chronic  leptomeningitis,  such  as  is  found  in  alcoholic  subjects.  Fre- 
quently this  condition  is  accompanied  by  oedematous  infiltration  of  the  mem- 
branes and  by  loose  attachment  of  the  membranes  to  the  convolutions,  and 
by  the  formation  of  subpial  lymph  spaces  here  and  there ;  at  times,  also, 

1  Mackenzie,  St.  Thomas  Hosp.  Rep.,  1889-90,  N.  S.  six.  p.  350. 


GENERAL  DISEASES  OF  THE  BRAIN.  357 

by  a  marked  increase  in  the  size  and  number  of  the  Pacchionian  bodies. 
Secondly,  the  membranes  may  be  injected  and  hyperaemic  and  the  seat  of 
serous  exudation,  and  may  be  slightly  clouded.  This  is  a  condition  sometimes 
met  with  in  meningitis  secondary  to  the  exanthemata.  Far  more  commonly, 
however,  the  signs  of  acute  meningitis  are  more  marked,  and  the  meshes  of 
the  pia-arachnoid  are  infiltrated  with  yellowish  exvidation.  This  exudation 
is  purulent,  and  is  most  frequently  found  along  the  course  of  the  veins.  The 
latter  are  often  outlined  by  yellowish  or  yellowish-white  borders.  Occasion- 
ally, however,  when  the  pus  is  on  the  surface  of  the  membranes,  the  veins  are 
entirely  hidden  from  view.  These  changes  are  as  a  rule  more  marked  over 
the  vertex,  though  they  may  be  found  at  the  base.  Collections  of  pus  are  also 
found  in  the  sulci  and  around  the  nerve-roots  and,  at  times,  over  the  sur- 
face of  the  dura.  Distinct  inflammation  of  the  intra-cranial  portions  of  vari- 
ous nerves  may  also  be  present,  and  there  may  be  marked  infiltration  or  even 
minute  hemorrhages  into  their  sheaths.  The  cortex  of  the  brain  may  be  red- 
dened here  and  there,  or  it  may  reveal  minute  areas  of  softening.  The  ven- 
tricles may  be  somewhat  dilated  and  filled  with  clouded  lymph.  The  epen- 
dyma  may  also  show  signs  of  inflammation,  and  may  be  slightly  granular  and 
thickened. 

In  tuberculous  meningitis  we  note  in  the  pia-arachnoid  of  the  base,  rarely 
of  the  vertex,  a  yellowish  gelatinous  infiltration.  This  is  at  times  firm,  at 
times  soft.  Especially  is  it  seen  about  the  optic  chiasm,  and  it  may  extend 
for  some  distance  into  the  Sylvian  fissure  on  either  side.  Small  tubercles 
can,  as  a  rule,  be  readily  detected  along  the  base  of  the  frontal  lobe  and 
island  of  Keil,  where  they  follow  the  course  of  the  vessels,  and  are  less 
obscured  by  the  infiltration  of  the  surrounding  tissues.  Instead  of  these 
appearances,  we  may  simply  have  a  very  difluse  infiltration  of  the  mem- 
branes. The  lateral  ventricles  are  much  dilated  in  the  majority  of  cases. 
This  may  be  either  due  to  direct  tuberculous  infection  of  the  ependyma  or  to 
closure  of  the  foramen  of  Majendie. 

In  syphilitic  inflammation  the  membranes  may  be  the  seat  of  more  or  less 
extensive  flat,  gummatous  formations.  Sometimes  the  gummata  are  large, 
and  present  signs  of  caseous  degeneration.  At  other  times  they  are  dense 
and  fibrous.     They  are  most  frequently  found  at  the  base. 

Bacteriological  examination  has  revealed  in  the  epidemic  form  of  cerebro- 
spinal meningitis  the  presence  of  the  diplococcus  described  by  Leyden  in 
1883.  Fraenkel  identified  this  germ  with  the  pneumococcus  in  1886.  This 
fact  is  exceedingly  interesting  when  we  remember  that  meningitis  is  not  in- 
frequently secondary  to  pneumonia.  In  such  cases  the  diplococcus  has  also 
been  found  in  the  meningeal  exudation.  The  streptococcus  pyogenes  has 
been  found  in  the  purulent  form,  though  Zoerkendoerfer'  holds  that  the  latter 
is  most  frequently  caused  by  the  pneumococcus. 

In  the  various  secondary  forms  of  meningitis  the  infection  may  be  carried 
to  the  membranes  either  by  the  bloodvessels  or  by  the  lymphatics.^  In  the 
meningites  complicating  ulcerative  endocarditis,  typhoid  fever,  typhus  and 
relapsing  fevers,  cholera,  variola,  scarlet  fever,  measles,  pneumonia  and  septic 
infection  generally,  the  germs  probably  gain  access  to  the  membranes  through 
the  blood.  In  ulcerative  endocarditis  it  is  probable  that  a  minute  fragment 
of  valve  containing  pyogenic  micro-organisms  is  carried  to  the  meninges, 
and  that  as  a  result  there  is  a  small  hemorrhagic  enfarct.  Inflammation  is 
thus  set  up  which  by  extension  leads  to  more  or  less  general  involvement  of 
the  meninges.     It  is  possible  also  that  other  cases  are  due  to  general  infection 

1  Zoerkendoerfer  :  Prag.  Med.  Woehenschr.,  1893,  vol.  xviii.  p.  211. 

2  Huguenin :  Correspondenzbl  d.  Schweizer  Aerzte,  1890,  vol  xx.  p.  739. 


358  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  the  blood  with  micro-organisms.  In  typhoid  fever  it  is  probable  that  the 
meningitis  is  generally  due  to  a  secondary  septic  infection ;  in  some  cases 
probably  to  the  typhoid  bacillus  itself.  Regarding  typhus  fever,  it  is  prob- 
able that  the  meningitis  is  generally  due  to  streptococcus  infection.  This  is 
probably,  also,  the  case  in  relapsing  fever.  In  variola  we  must  remember  that 
in  addition  to  meningitis  arising  from  general  infection  we  may  also  have  a 
meningitis  the  result  of  middle-ear  disease.  This  is  also  true  of  scarlet  fever 
and  measles.  Meningitis  complicating  pneumonia  is  generally  due  to  the 
pneumococcus  of  Fraenkel,  as  just  pointed  out.  Post-mortem  diagnosis  of 
this  meningitis  can,  it  is  said,  be  made  by  simj)le  inspection.^  The  pus  is 
thick,  viscid  and  consistent  on  account  of  the  abundance  of  fibrin  jDresent. 
The  various  forms  arising  in  the  course  of  general  septic  infection  are  all 
streptococcus  meningitis.^ 

The  various  forms  of  meningitis  having  their  origin  in  the  lymph  stream 
are  almost  ahvays  due  to  streptococcus  infection.  The  course  may  be  that  of 
the  lymphatics  of  the  sheaths  of  the  various  cranial  nerves  and  bloodves- 
sels. Erysipelas  of  the  face  and  head,  carbuncles,  etc.,  may  give  rise  to 
meningitis  by  infection  through  the  veins. 

To  the  above  channels  of  infection  we  should  also  add  cerebral  meningitis 
arising  by  extension  from  spinal  meningitis.  Such  cases  may  occur  as  a  re- 
sult of  infection  from  bed-sores,  coxitis,  sacral  diseases,  etc. 

Many  of  the  symptoms  can  be  readily  explained  by  the  lesions  found. 
Thus  it  is  probable  that  the  headache  is  caused  by  the  direct  pressure  of  the 
swollen  membranes  upon  the  sensitive  dura  mater.  Similarly,  the  symptoms 
of  interference  with  the  various  nerve-trunks  are  due  to  pressure  and  irrita- 
tion and  to  the  infiltration  of  their  sheaths.  It  is  exceedingly  probable  that 
the  rigidity  of  the  muscles  of  the  back  of  the  neck  is  due  to  the  irritation  of 
the  roots  of  the  spinal  accessory  nerves,  and  in  some  cases  also  to  irritation  of 
the  roots  of  the  upper  cervical  nerves.  The  delirium,  convulsions  and  coma 
are  to  be  ascribed  to  a  direct  interference  of  the  inflammation  and  exudation 
with  the  bi*ain  cortex.  The  slowing  of  the  pulse  can  reasonably  be  ascribed 
to  irritation  of  the  vagus. 

Diagnosis.  The  recognition  of  meningitis,  especially  of  the  basal  form,  is 
as  a  rule  not  difficult.  Various  special  symptoms,  however,  may  be  absent,  and 
at  times,  though  rarely,  headache  is  not  marked.  In  such  cases  it  is  neces- 
sary to  j)roceed  with  caution.  The  entire  absence  of  headache,  however, 
should  always  throw  doubt  upon  the  diagnosis,  as  headache  is  one  of  the 
most  constant  symptoms.  Vomiting  is  also  a  rather  constant  symptom,  espe- 
cially in  the  basal  form.  Coma,  delirium  and  convulsions,  however,  are  com- 
mon to  a  number  of  affections,  and  here  difficulties  may  occur. 

Thus  the  question  may  arise  as  to  whether  a  given  case  is  suffering  from 
ursemia  or  meningitis.  A  moment's  reflection  will  convince  us  that  these 
two  affections  present  numerous  symptoms  in  common.  Among  these  are 
headache,  vomiting,  vertigo,  delirium,  coma,  convulsions,  either  general  or 
limited,  and  even  local  or  hemiplegic  palsies.  Further  albumin  is  occasion- 
ally present  in  meningitis.  Should,  however,  a  given  case  present  the  signs 
of  acute  nephritis,  that  is,  numerous  tube-casts  and  blood  corpuscles,  oedema 
of  the  face  and  of  the  extremities,  the  question  would  be  easy  of  solution. 
The  more  chronic  forms  of  renal  trouble  would  reveal  by  the  ophthalmoscope 
albuminuric  neuro-retinitis.  Difficulty  could  only  arise  in  the  vertical  form 
of  meningitis,  and  even  here  the  age  of  the  patient  and  the  history  of  the 
affection- would  aid  us. 

Sometimes  it  is  difficult,  to  differentiate  meningitis  from  typhoid  fever. 

1  Hutinel :  Semaine  Med.  Par.,  1892,  vol.  xix.  p.  776.  -  Huguenin,  loc.  cit. 


GENERAL  DISEASES  OF  THE  BRAIX.  359 

AVe  have  here,  however,  such  points  to  serve  us  as  the  temperature-curve  of 
tvphoid  fever,  the  regular  pulse,  the  enlargement  of  the  sj)leen,  the  diarrhcea 
and  the  rose-colored  spots.  We  should  remember,  however,  that  in  meningitis 
spots  somewhat  resembling  the  latter  may  also  be  present.  Finally  we 
may  avail  ourselves  of  Ehrlich's  reaction,  that  is  the  diazo-reaction  of  the 
urine  which,  when  present,  would  throw  the  weight  of  our  decision  in  favor 
of  typhoid  fever  Doubt,  however,  is  throAvn  upon  the  value  of  this  symp- 
tom, as  it  is  found  occasionally  in  other  diseases  with  high  temperature. 

Occasionally  it  is  difficult  to  decide  whether  the  patient  is  suffering  from 
acute  meningitis  or  from  delirium  tremens.  If  the  meningitis  runs  its  usual 
course,  and  especially  if  it  is  basal,  the  diagnosis  is  not  difficult ;  but  if  it  be 
mainly  or  exclusively  vertical,  so  that  delirium  and  restlessness  are  promi- 
nent, delirium  tremens  may  be  simulated.  We  must  be  on  the  lookout  in 
such  cases  for  focal  symptoms,  for  if  they  are  present  they  point  at  once  to 
meningitis.  Rigidity  of  the  neck,  intense  headache  and  optic  neuritis  do  the 
same.  Similarly  it  is  at  times  difficult  to  distinguish  between  delirium  grave 
(typhomania)  and  meningitis.  The  early  appearance  of  somnolence,  rigid- 
ity of  the  back  of  the  neck,  localizing  phenomena,  optic  neuritis,  hyperses- 
thesia  and  convulsions  point  to  meningitis. 

Occasionally  infants  who  have  suffered  from  exhaustive  attacks  of  cholera 
infantum  present  symptoms  which  closely  simulate  meningitis,  though  no 
affection  of  the  membranes  is  found  on  autopsy.  These  cases  have  been 
termed  by  Marshall  Hall,  "Hydrocephaloid."  They  are  distinguished  from 
true  meningitis  l)y  the  previous  history  and  by  the  fact  that  the  fontanelles, 
instead  of  being  full  and  prominent,  are  sunken. 

Differential  Diagnosis  of  the  Various  Porms.  It  is  necessary  to  differen- 
tiate the  various  forms  of  meningitis  from  each  other.  Epidemic  cerebro- 
spinal meningitis  is  to  be  distinguished  from  the  other  forms  by  the  presence 
of  spinal  symptoms  and  by  the  existence  of  the  malady  in  an  epidemic  form. 
However,  we  now  and  then  meet  cases  of  cerebro-spinal  meningitis  in  which 
brain  symptoms  predominate,  and  also  cases  of  other  forms  of  meningitis  in 
which,  while  brain  symptoms  are  present,  the  spinal  cord  is  also  involved. 
Further,  cases  are  met  with  in  which  the  symptoms  of  the  epidemic  form  are 
closely  simulated,  though  no  epidemic  may  exist  at  the  time.  We  see  at  once 
that  the  differential  diagnosis  as  regards  epidemic  cerebro-spinal  meningitis 
from  the  other  forms  is  not  ahvays  possible.  However,  in  addition  to  the 
general  facts  already  stated,  we  should  remember  that  the  course  of  the  dis- 
ease in  the  epidemic  form  is  usually  very  rapid  ;  sometimes,  indeed,  it  is  light- 
ning-like, yet  in  many  instances'^ the  diagnosis  of  meningitis  alone  can  be 
made,  and  its  special  character  must  remain  a  conjecture. 

Purulent  meningitis,  we  should  bear  in  mind,  is  sometimes  the  result  of 
ear  disease  with  concomitant  necrosis  of  the  petrous  bone,  less  often  the  result 
of  suppurative  catarrh  of  the  sinuses  of  the  frontal  bone,  and  more  rarely 
still,  of  disease  of  the  orbit.  Traumata,  such  as  complicated  fractures  of  the 
cranial  bones  are  also  prominent  factors  in  its  production.  To  these  causes 
must  be  added  septic  thrombosis  of  the  sinuses  and  brain  abscess.  Further, 
it  may  be  secondary  to  septic  processes  elsewhere,  such  as  puerperal  fever. 
As  regards  meningitis  the  result  of  ear  disease,  frontal  sinus  disease,  traumata, 
etc.,  we  have  much  in  the  history  of  the  case  to  guide  us  in  making  oiir  diag- 
nosis. However,  if  such  a  history  and  localizing  symptoms  be  wanting,  and 
the  case  do  not  accord  in  symptomatology  with  cerebro-spinal  meningitis, 
causes  or  evidences  of  general  septic  infection  should  be  sought  for ;  in  such 
cases  we  may  find  endocarditis,  inflammations  of  the  joints,  septic  nephritis, 
abscesses  of  the  lungs,  etc. 

The  features  which  distinguish  serous  meningitis  have  already  been  indi- 


360  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

cated.  In  addition,  it  is  important  to  remember  that  it  occurs  most  fre- 
quently in  early  childhood  and  in  youth,  though  it  is  occasionally  met  with 
among  adults.  The  symptoms  frequently  resemble  those  of  ordinary  hydro- 
cephalus. In  adults  the  error  is  not  infrequently  made  of  mistaking  the 
condition  for  brain  tumor.  The  presence  of  focal  symptoms,  in  the  latter, 
will  serve  in  many  cases  to  make  the  distinction. 

Tuberculous  meningitis  is  distinguished  by  the  fact  that  it  is  much  slower 
in  its  course  than  the  other  forms  and  that  the  temperature  is  rarely  much 
elevated.  When,  therefore,  we  have  symptoms  pointing  to  a  meningitis 
which  are  slow  in  their  development  and  subacute  in  course  we  should  be 
very  carefiil  to  search  for  evidences  of  general  tuberculous  infection.  The 
lungs,  the  pleura,  the  joints,  the  bones,  the  lymphatic  glands,  especially 
those  of  the  neck,  should  be  examined.  Further,  we  should  remember  that 
tuberculous  meningitis  is  that  form  which  occurs  most  frequently  in  children. 
It  is  apt  to  have  a  long  prodromal  period,  during  which  there  is  a  gradual 
loss  of  appetite,  emaciation,  sleeplessness,  general  malaise  and  apathy,  and 
there  is  also  a  predominance  of  symptoms  referable  to  the  base  of  the  brain. 
Persistent  vomiting,^  marked  irregularity  of  the  pupils,  irregularity  of  the 
respiration,  more  or  less  marked  interference  with  the  ocular  nerves,  pa]Dillitis, 
transient  or  persistent  facial  palsy,  monoplegia,  hemiplegia,  aphasia,^  are 
among  the  symptoms  witnessed.  Should  doubt  arise  as  regards  the  differen- 
tiation between  this  and  the  purulent  form  of  meningitis  some  assistance  may 
be  given  to  the  diagnosis  by  testing  the  urine  for  pef)tones.  Peptones  will 
very  probably  be  present  in  the  urine  if  marked  suppuration  is  taking  place. 

A  not  unimportant  caution  remains  to  be  given  regarding  tuberculous 
and  even  other  forms  of  meningitis  when  they  occur  in  young  girls.  In 
such  cases  the  symptoms  are  often  hysteroid  in  character,  and  the  mistake 
has  at  times  been  made  of  regarding  them  as  hysterical,  due  consideration 
not  being  given  to  the  possibility  of  organic  disease.  Again,  it  is  important 
to  bear  in  mind  that  the  course  pursued  by  tuberculous  meningitis  is  in  rare 
instances  latent.  Autopsies  have  been  made  in  cases  of  sudden  death  which 
have  revealed  an  entirely  unsuspected  and  symptomless  tuberculous  menin- 
gitis.* Finally,  tuberculous  meningitis,  though  occurring  most  frequently  in 
infants  and  the  young*  may  occur  much  later.  Thus  Rendu  and  Bulloche* 
report  a  case  occurring  in  a  woman  aged  thirty-eight  years.  Bastian"  reports 
a  case  of  tuberculous  meningitis  in  a  man  aged  fifty-two  years.  Matthes® 
reports  a  case  of  miliary  tuberculosis  involving  the  meninges  in  a  man  aged 
sixty-seven  years,  and  Archambault,  the  case  of  a  man  sixty-eight  years  of  age. 

Rarely  tuberculous  meningitis  involves  in  addition  to  the  membranes  of 
the  brain  also  those  of  the  cord,^  and  in  such  case  spinal  symptoms  are 
present. 

Alcoholic  meningitis  differs  markedly  in  its  ordinarily  chronic  course. 
There  is  always  present  a  marked  history  of  alcoholism,  chronic  headache, 
occasional  slight  delirium,  mental  weakness,  and  sometimes  slight  papillitis. 

In  localized  meningitis,  such  as  occurs  from  blows  upon  the  skull,  we  have 
not  only  the  history  of  the  accident  but  also  the  symptom  of  headache,  more 
or  less  severe  and  local  in  character.     Very  frequently  there  are  also  focal 

1  Northrup :  Trans.  Am.  Pediatric  Soc,  1890,  :891,  ii.  68-69  ;  also  Jacobi,  ibid  (Discussion),  Jacobi 
maintains  that  vomiting  is  present  only  in  meningitis  of  the  base. 

2  Among  unusual  affections  of  speech  noted  in  tuberculous  meningitis  must  be  mentioned  echolalia. 
Ferret,  Echolalie  dans  la  meningite  tuberculeuse,  Lyon  Medical,  1891,  Ixvi.  577. 

3  Herzog:  Internat.  Klin.  Rundschau,  Wien,  1892,  vi.  545. 

*  Rendu  et-Boulloche  :    Bull,  et  Mem.  Soc.  med  des  hOpitaux  de  Paris,  1891,  viii.  458. 
5  Bastian  :    Trans.  Clin.  Soc.  London,  1891,  xxiv.  29. 

5  Matthes:    Muench.  med.  Wochenschr.,  1892,  869;  Archambault  (Diet,  encyclop.  des  so.  med 
Paris,  1873). 
7  Mertz  :    Deutsche  med  Wochenschr  ,  1893,  xix.  206. 


GENERAL  DISEASES  OF  THE  BRAIN.  361 

symptoms  pointing  definitely  to  some  cortical  centre.  A  meningitis  having 
its  origin  in  disease  of  the  sinuses  or  of  the  bones  of  the  skull  also  presents 
more  or  less  definite  localizing  symptoms.  Of  these  affections,  the  meningitis 
arising  from  middle-ear  disease  and  consequent  necrosis  of  the  petrous  bone 
may  be  taken  as  an  example.  In  such  a  case  we  have  the  history  of  an  ear 
trouble  of  some  standing ;  often  there  is  a  chronic  purulent  discharge  from 
the  external  auditory  meatus.  The  involvement  of  the  meninges  is  made 
evident  by  intense  unilateral  basal  headache,  the  pain  being  so  great  that  it 
is  with  difficulty,  if  at  all,  relieved.  If  the  case  persist,  as  is  most  likely,  we 
have  not  only  deafness  upon  the  side  affected,  but  also  the  symptoms  of  a 
peripheral  facial  palsy.  This  palsy  is  shown  to  occur  through  pressure  on 
the  nerve  in  its  course  through  the  Fallopian  canal,  by  loss  of  taste  upon  the 
anterior  two-thirds  of  the  tongue  of  the  side  affected,  and  by  unilateral  paral- 
ysis of  the  soft  palate.  Other  cranial  nerves  may  become  involved,  espe- 
cially the  various  ocular  nerves.  Even  the  crus  of  a  hemisphere  may  suffer, 
and  in  such  an  instance  we  may  have  the  symptoms  of  a  crossed  hemiplegia. 
Abscess  of  the  brain  is  very  frequently  a  direct  outcome  of  this  form  of  puru- 
lent meningitis,  and  it  is  often  associated  with  thrombosis  of  the  lateral  sinus. 

Prognosis.  The  prognosis  in  meningitis  varies  greatly  according  to  the 
character  of  the  case.  In  the  various  forms  of  diffuse  meningitis  and  in  the 
local  suppurative  form  the  prognosis  is  very  grave.  Even  in  severe  cases, 
however,  the  termination  is  not  necessarily  fatal.  Indeed,  recovery  ensues 
occasionally  from  even  purulent  and  tuberculous  forms.  However,  when  re- 
covery does  result,  the  patient  runs  the  risk  of  suffering  from  some  permanent 
injury  either  to  the  brain  or  cranial  nerves.  We  need  only  be  reminded  of 
the  well-known  case  of  Laura  Bridgman,  in  which  a  meningitis  secondary  to 
scarlet  fever  was  followed  by  destruction  of  both  optic  and  auditory  nerves. 
Again,  we  may  have  a  condition  of  chronic  internal  hydrocephalus  as  a  per- 
manent result. 

Non-purulent  forms  of  traumatic  meningitis,  meningitis  following  sun- 
stroke, serous  meningitis,  and  alcoholic  meningitis  do  not  immediately 
threaten  life.  Complete  recovery  from  them,  however,  is  uncertain.  Puru- 
lent traumatic  meningitis  and  meningitis  from  extension  of  neighboring  in- 
flammation is  very  fatal.  Syphilitic  meningitis  presents  a  prognosis  good  in 
proportion  to  the  shortness  of  the  interval  between  the  origin  of  the  condition 
•  and  the  beginning  of  treatment. 

Treatment.  The  treatment  of  meningitis  must  be  based  upon  general 
principles.  In  the  acute  forms  rest  in  bed  is,  of  course,  imperative.  Various 
general  and  special  measures  must  be  used  to  combat  the  disease,  to  maintain 
the  strength  and  to  relieve  the  suffering  of  the  patient.  Among  the  most  dis- 
tressing symptoms  is  the  intense  headache,  and  to  control  this  antipyrin, 
antifebrin,  phenacetin,  with  or  without  the  bromides,  should  be  freely  used, 
at  least  in  the  beginning  of  the  case.  Antipyrin  and  its  congeners  are  not 
contraindicated  unless  there  be  marked  depression.  They  should,  however, 
be  used  for  a  short  period  only.  Morphine  is  theoretically  contraindicated, 
but  in  a  large  number  of  cases  it  is  the  only  drug  that  gives  relief  to  the 
patient.  Application  of  ice  to  the  head  or  of  cold  to  the  general  surface  of  the 
body,  if  the  temf)erature  be  high,  is  important.  We  should  remember  that 
occasionally  ice  is  not  well  borne  by  young  children.  Buch,^  for  instance, 
found  that  cold  applications  in  cases  of  meningeal  tuberculosis  in  children 
have  a  tendency  to  produce  spasm  of  the  glottis.  In  many  cases,  l^listei'S  to 
the  back  of  the  neck  or  back  of  the  ears  may  be  applied  with  advantage. 
Especially  is  this  the  case  in  children.     In  adults  the  application  of  a  large 

1  Buch,  St.  Petersburg.  Med.  Wochenschr.,  1891.  N.  F.  viii.  203. 


362  2iERV0US  DISEASES  AND  THEIR  TREATMENT. 

number  of  wet  cups  to  the  back  of  the  neck,  or  of  leeches  to  the  temples, 
constitute  an  excellent  expedient.  General  principles  must,  of  course,  guide 
us  with  regard  to  these  measures,  particularly  with  regard  to  blood-letting 
and  to  the  special  form  of  counter-irritation  to  be  adopted.  In  ansemic  or 
tuberculous  subjects  the  local  abstraction  of  blood  is  contraindicated. 

The  patient  being  constipated,  it  is  necessary  to  bring  about  active  purga- 
tion, and  for  this  purpose  no  drug  is  better  than  calomel.  Not  only  does  it 
produce  revulsion  by  acting  upon  the  bowels,  but  it  has  also  a  tendency  to 
favorably  influence  the  inflammation  of  the  membranes.  With  the  latter 
end  in  view,  mercurial  inunctions  should  also  be  used.  Children  tolerate 
mercurials  very  well.  In  adults,  however,  considerable  caution  should  be 
exercised. 

Special  symptoms,  such  as  a  persistent  vomiting,  demand  and  often  baffle 
our  best  efforts.  Small  doses  of  bismuth,  or  bismuth  with  cocaine,  the  car- 
bonated waters,  or  iced  champagne  are  among  the  measures  at  our  disposal. 
After  the  more  violent  symptoms  subside,  supporting  measures  should  be 
used  to  their  fullest  extent.  Alcohol  must  be  used  guardedly,  if  at  all. 
Digitalis  and  strophanthus  may  be  used,  provided  the  period  of  initial  slow 
pulse  has  been  passed.  Strychnine,  for  obvious  reasons,  is  not  a  suitable 
tonic,  and  this  is  also  true  of  quinine,  foil  doses  of  which  increase  meningeal 
irritation.  If  the  case  has  passed  into  a  subacute  stage,  iodides  tind  mercurials 
may  be  used  sparingly  for  a  long  time.  Experience  inveighs  against  the  use 
of  tuberculin  in  tuberculous  meningitis.  Brehm'  found  that  the  remedy 
made  the  disease  more  foudroy ant. 

Surgical  measures^  also  have  been  resorted  to  in  the  treatment  of  tubercu- 
lous meningitis.  C.  A.  Morton  tapped  the  arachnoid  space  in  four  cases  and 
noted  slight  improvement  in  two  of  them.  Wallace  Ord  and  Waterhouse 
trephined  through  the  cerebellar  fossa  in  a  child  of  five  years.  A  small  quan- 
tity of  fluid  escaped,  a  drainage-tube  was  inserted,  and  the  child  did  well. 

The  treatment  of  syphilitic  meningitis  does  not  merit  special  description. 
It  is  to  be  based  upon  general  principles,  again  bearing  in  mind,  however, 
to  make  free  use  of  the  mercurials.  The  chronic  forms  of  meningitis  which 
result  from  insolation  and  other  causes  are  much  benefited  by  the  actual 
cautery  applied  to  the  back  of  the  neck  at  frequent  intervals  in  the  manner 
already  indicated  in  the  discussion  of  pachymeningitis  (p.  349). 

The  surgical  treatment  of  traumatic  meningitis  has  already  been  alluded 
to  (see  p.  350),  and  is  considered  in  detail  in  Chapter  XXXIII. 


MENINGEAL    HEMORRHAGE. 

Hemorrhages  of  the  meninges  of  the  brain  may  occur  in  various  situations. 
They  may  take  place  first  into  the  meshes  of  the  pia  mater,  and  in  such  cases 
they  almost  of  necessity  involve  the  cortex.  Secondly,  they  may  occur  in 
the  subdural  space ;  and,  lastly,  they  may  occur  between  the  external  layer 
of  the  dura  and  the  cranium,  i.  e.,  be  supra-dural.  They  may  have  their 
origin  in  lesions  of  the  arteries  of  the  brain,  of  the  cranium,  of  the  veins  of 
the  pia  mater,  or  of  the  sinuses  of  the  dura.  They  may  occur  either  as  a 
result  of  disease  of  vessel  walls  or  gross  intra-cranial  disease,  but  far  more 
frequently  they  have  as  their  cause  injuries  of  the  skull. 

Spontaneous  Meningeal  Hemorrhage.  When  due  to  vascular  degen- 
eration meningeal  hemori'hages  arise  under  conditions  similar  to  those  which 

1  Brehm,  Kinder  Artz.  Berlin,  1891,  ii.  1-7. 

-  C.  A.  Morton,  Brit.  Med.  Journ.,  1891,  vol.  ii.  p.  840 ;  also  Wallace  Ord,  and  Waterhouse,  Brit. 
Med.  Jouru.,  March  10, 1894. 


GENERAL  DISEASES  OF  THE  BRAIN.  363 

occasion  ordinary  cerebral  hemorrhage — that  is,  middle  or  advanced  life, 
renal  and  arterial  disease.  Spontaneous  meningeal  apoplexy  is,  however,  quite 
rare.  The  symptoms  presented  are,  of  course,  very  variable,  depending  entirely 
upon  the  seat  and  extent  of  the  extravasation.  Headache  followed  by  coma, 
convulsions,  or  other  palsies  may  be  the  symptoms  produced.  Occasionally, 
as  we  have  seen,  when  occurring  in  the  arachnoid  space,  in  degenerative  states, 
such  as  are  present  in  the  chronic  insane,  the  hemorrhage  may  give  rise  to  a 
condition  known  as  hsematoma  of  the  dura.     (See  p.  351.) 

In  rare  cases  a  small  hemorrhage  may  suddenly  take  place  on  the  inner 
surface  of  the  dura  in  plethoric  persons.  The  symptoms  presented  are  so 
violent  as  to  demand  the  most  active  interference,  and  it  is  therefore  impor- 
tant that  the  condition  should  be  promptly  recognized.  Occurring  in  per- 
sons of  full  habit,  often  just  after  eating  a  full  meal,  or  while  in  the  act  of 
defecation  or  other  eiFort  requiring  muscular  strain,  the  symptoms  are  those 
of  an  agonizing  headache,  often  localized  and  coming  on  with  great  sudden- 
ness. The  pain  is  so  great  that  the  patient  becomes  pale  and  depressed. 
Often  vomiting  is  present,  or  sudden  and  repeated  movements  of  the  bowels 
occur.  Sometimes  other  signs  of  meningeal  irritation,  such  as  conti^acted 
pupils,  are  seen.  Photophobia  and  excessive  sensitiveness  to  noises  may  also 
be  present.  At  times  the  pain  increases  paroxysmally,  and  may  radiate  down 
the  back  of  the  neck  and  trunk.  Indeed,  many  of  the  symptoms  actually 
suggest  a  meningitis.  However,  the  fact  that  the  attack  occurs  in  a  plethoric 
individual,  after  eating  and  after  muscular  exertion,  as  well  as  the  course  of 
the  affection,  will  enable  us  to  make  the  differential  diagnosis.  Localizing 
symptoms  may  be  absolutely  wanting,  as  may  also  somnolence  and  coma. 

Treatment.  The  treatment  of  spontaneous  meningeal  hemorrhage  is  prac- 
tically that  of  ordinary  apoplexy  (see  Chapter  XY).  However,  in  those  rare 
instances  in  which  a  small  sub-dural  hemorrhage  occurs,  and  in  which  the 
symptoms  resemble  those  of  a  meningitis,  most  active  treatment  should  be 
instituted.  Wet  cups  should  be  freely  applied  to  the  back  of  the  neck,  and 
it  may  even  be  necessary  to  resort  to  general  blood-letting.  Morphia  suffi- 
cient to  relieve  pain,  ice  to  the  head,  and  mercurial  purgation  are  among  the 
other  measures  indicated.  The  headache  is  only  with  difficulty  relieved,  and 
is  apt  to  persist  for  days,  though  with  a  lessening  severity. 

Traumatic  Meningeal  Hemorrhage.  The  traumatic  form  of  menin- 
geal hemorrhage  is  comparatively  frequent.  In  the  great  majority  of  the 
cases  there  is  fracture  of  the  skull  as  a  result  of  a  blow,  the  fracture  being- 
accompanied  by  the  rupture  of  some  vessel.  Cases,  however,  are  met  with 
in  which  no  fracture  is  present,  and  in  which,  notwitlistanding,  meningeal 
hemorrhage  occurs.  The  fracture  may  be  exceedingly  small  and  difficult  to 
recognize,  even  when  the  skull  is  exposed.  It  may  be  limited  to  one  table. 
In  almost  half  the  cases,  according  to  Jacobson's^  studies,  there  is  not  only  a 
fracture  of  the  vault,  but  also  of  the  base.  The  middle  meningeal  artery  is 
more  frequently  the  seat  of  traumatic  hemorrhage  than  any  other  vessel.  Its 
main  trunk  is  seldom  injured,  the  rupture  usually  involving  one  of  the 
branches.  Blows  upon  the  skull  of  sufficient  violence  to  cause  fracture,  or 
meningeal  hemorrhage,  are  at  times  accompanied  by  ecchymosis  or  contusion 
of  the  brain  substance.  Frequently  the  contusion  is  not  immediately  beneath 
the  site  of  the  fracture,  but  is  found  at  some  distance.  Thus  a  blow  upon  the 
side  of  the  head  may  be  accompanied  by  contusion  of  the  tip  of  the  opposite 
temporal  lobe ;  a  blow  upon  the  occiput  may  be  accompanied  by  ecchymosis 
of  the  tips  of  the  frontal  lobes.  Extensive  softening  and  even  abscess  have 
been  described  as  occurring  in  these  situations. 

1  Jacobson :  Guy's  Hospital  Reports,  1885-86,  xxviii.  p.  147. 


364  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Symptoms.  In  extensive  injuries  to  the  skull  the  symptoms  of  hemorrhage 
are  often  complicated  and  obscured  by  those  of  concussion.  However,  iu 
those  forms  in  which  the  hemorrhage  follows  a  blow  at  the  side  of  the  head, 
and  is  due  to  the  rupture  of  the  middle  meningeal  artery,  unconsciousness 
and  coma  do  not  immediately  supervene.  The  hemorrhage  in  such  cases 
takes  place  between  the  dura  and  the  bone — that  is,  is  entirely  extra-dural. 
Time  is  required  for  the  outpouring  blood  to  accomplish  extensive  separation 
of  the  dura  and  for  compression  symptoms  to  make  their  appearance.  There 
is,  therefore,  almost  always  a  distinct  interval  of  consciousness.  This  interval 
varies  from  a  few  minutes  to  several  hours.  It  is  not  uncommon  to  learn 
that  after  receiving  the  blow  the  patient  was  quite  himself,  and  even  attended 
for  some  time  to  his  ordinary  duties,  and  that  gradually  he  became  somno- 
lent, more  and  more  difficult  to  arouse,  and  finally  comatose. 

In  some  cases  the  unconsciousness  never  deepens  into  absolute  coma.  In 
others,  again,  instead  of  coming  on  gradually,  it  may  come  on  very  suddenly. 
According  to  Weismann,^  it  may  be  exceedingly  delayed,  one  instance  of 
eleven  days  being  given.  Associated  with  the  significant  fact  of  an  interval 
preceding  the  loss  of  consciousness,  we  may  have  also  certain  motor  disturb- 
ances dependent  upon  the  seat  of  the  hemorrhage.  Among  these  may  be 
hemiplegia  or  aphasia.  Sometimes,  too,  there  is  rigidity  of  one  or  both  legs, 
or  of  both  legs  and  arms.  Often  with  this  rigidity  we  have  associated  mus- 
cular twitchings.  The  hemiplegia  may  be  only  temporary,  and  varies  greatly 
in  degree.  According  to  Jacobson,'''  paraplegia  may  also  be  present  in  these 
cases.  Finally,  we  should  remember  that  motor  disturbances  may  be  entirely 
wanting.     There  may  be  no  paralysis  whatever. 

Interesting  and  important  pupillary  phenomena  are  also  apt  to  be  present. 
Not  infrequently,  as  I  have  myself  seen,  the  pupil  upon  the  injured  side  is 
dilated,  perhaps  widely  so,  while  that  of  the  opposite  side  is  either  normal  or 
contracted.  This  dilated  pupil,  termed  Hutchinson's  pupil  by  Jacobson, 
appears  to  be  a  pressure  symptom.  At  times  both  pupils  are  dilated,  and  at 
others,  again,  both  are  normal,  but  if  unilateral  dilatation  is  present  the 
symptom  is  of  great  value. 

The  pulse  is  slow,  though  it  may  become  more  frequent  later  on.  The 
respiration  is  apt  to  be  slow,  labored,  and  even  stertorous.  Vomiting,  also, 
may  be  present.  A  rise  of  temperature  may  take  place,  and  this  is  sometimes 
very  high.     Thus,  according  to  Weismann  108.8^  F.  has  been  reported.^ 

Diagnosis.  If  meningeal  hemorrhage  occur  in  the  arachnoid  space,  that  is, 
be  sub-dural,  such  as  may  arise  from  injury  of  a  sinus,  the  onset  of  symptoms 
may  be  so  sudden  and  so  complicated  by  concussion,  that  attempts  at  localizing 
the  extravasation  may  be  futile.  However,  the  value  of  a  careful  study  of  the 
localizing  symptoms  in  every  case  is  shown  by  the  experience  of  Starr  and 
McBurney,*  in  which  a  traumatic  hemorrhage  from  a  vein  in  the  pia  mater 
gave  rise  to  apoplexy,  partial  right  hemij^legia,  and  hemiansesthesia.  Tre- 
phining, with  removal  of  the  clot,  resulted  in  recovery.  In  supra-dural  hemor- 
rhage, as  we  have  seen,  a  number  of  distinct  and  valuable  signs  are  present. 
Among  these  is  to  be  placed  first  and  foremost  the  interval  of  consciousness 
which  precedes  the  somnolence  and  coma.  Secondly,  the  occurrence  of  a 
hemiplegia  on  the  side  opposite  to  that  upon  which  the  blow  upon  the  head  has 
been  received,  is  of  the  greatest  significance.  A  dilated  pupil  upon  the  injured 
side  ranks  next  in  importance.  If  associated  with  these  symptoms  we  have 
a  slow  pulse,  labored  breathing,  vomiting  and  rigidity  of  the  limbs,  with 
twitching  and  possibly  a  rise  of  temperature,  a  supra-dural  hemorrhage  is 

1  Weismann  :  Deutsche  Zeitung  f.  Chirurgie,  vol.  iv.  1-3.  -  Loc.  cit. 

3  Loc.  cit.  *  Starr  and  McBurney  :  Brain,  1891-92,  siv.  284. 


GENERAL  DISEASES  OF  THE  BRAIN.  365 

indicated.  In  the  majority  of  cases  some  evidences  of  trauma  are  also  present 
upon  the  scalp  or  skull,  and  if  these  are  marked  the  diagnosis  is  still  further 
assured.  We  must  remember,  however,  that  all  signs  of  external  injury  may 
be  wanting.  This  was  the  case  in  a  patient  reported  by  Bremer,  in  whom  the 
principal  symptom  was  aphasia,  and  in  which  trephining  was  followed  by 
recovery.^ 

Prognosis.  The  prognosis  of  traumatic  meningeal  hemorrhage  depends 
largely  upon  its  seat  and  whether  it  is  surgically  accessible.  Extensive  effu- 
sions of  blood  in  the  sub-dural  space  are,  for  reasons  ah-eady  stated,  not  only 
difficult  to  recognize,  but  offer  less  hope  of  relief  by  trephining.  In  the  case 
of  supra-dural  hemorrhage  great  good  can  be  accomplished,  provided  the 
case  be  recognized  sufficiently  early. 

Treatment  The  treatment  of  meningeal  hemorrhage  is,  of  course,  a  sur- 
gical one  purely.  As  Jacobson  correctly  says,  "  We  are  to  trephine  and  to 
trephine  early."  Delay  greatly  increases  the  patient's  danger.  That,  how- 
ever, trephining  at  even  a  late  day  may  be  successful  is  shown  by  the  experi- 
ence of  Stokes,''  who  reports  a  case  of  secondary  operation  nine  days  after 
the  accident,  with  recovery,  although  at  the  time  of  the  operation  the  patient 
was  comatose.  In  this  case  the  patient  had  the  associated  symptoms  of 
brachial  and  facial  paralysis.     (See  Chapter  XXXIII  on  Surgery.) 


DISEASES  OF  THE   SINUSES  OP  THE  DURA  MATER. 

As  a  result  of  various  causes,  thrombosis  of  sinuses  may  occur,  and  because 
of  the  peculiar  relation  which  the  sinuses  bear  to  the  venous  circulation  of 
the  brain  as  well  as  to  certain  portions  of  the  extra-cranial  venous  circula- 
tion, symptoms  arise  which  it  is  very  important  to  recognize.  A  thrombus 
forms  in  a  sinus  as  a  result  of  one  of  two  conditions :  first,  as  a  consequence 
of  an  altered  state  of  blood  and  feeble  circulation,  conditions  present  in 
various  adynamic  states ;  for  example,  in  typhoid  fever,  grave  diarrhoea,  in 
the  last  stages  of  phthisis,  cancer,  chlorosis,  grave  ansemia,  etc.,  and,  occa- 
sionally, in  generally  septicaemia.  This  form  of  thrombosis  is  more  frequently 
found  in  the  superior  longitudinal  sinus  than  elsewhere,  and  more  often  in 
children  than  in  adults.  The  conditions  present  in  the  superior  longitudinal 
sinus  are  peculiarly  favorable  to  the  formation  of  a  clot.  The  blood  current 
is  extremely  slow,  the  cavity  of  the  sinus  is  angular  in  shape,  and  it  is 
traversed  by  numerous  fine  trabeculse. 

The  second  cause  of  the  formation  of  a  thrombus  is  the  direct  extension  of 
inflammation  to  the  sinus  from  some  contiguous  structure,  or  by  direct  pres- 
sure, as  from  a  tumor.  It  is  in  this  manner  that  the  thrombi  arise  which  are 
occasionally  met  with  in  brain  abscess,  purulent  meningitis,  suppurative  in- 
flammation of  the  cranial  bones,  of  the  middle  ear,  of  the  orbit,  or  of  the 
nasal  cavity.  Inflammation  of  an  external  vein  sometimes  gives  rise  to  a 
thrombus.  This  every  now  and  then  takes  place  in  phlebitis  of  the  face, 
scalp,  or  neck. 

If  a  clot  form  in  a  sinus  it  is  apt  to  extend  into  the  veins  of  the  j^ia  mater. 
As  a  consequence,  the  circulation  in  the  veins  is  arrested,  and  the  portions  of 
the  brain  supplied  by  them  may  undergo  destructive  softening.  If  veins 
communicating  with  the  surface  of  the  skull,  face,  or  neck  be  involved,  vari- 
ous local  swellings  may  occur,  constituting  sti'iking  symptoms. 

The  thrombus  generally  consists  of  a  laminated  clot  which  may  or  may  not 

1  Bremer :  American  Journal  of  the  Medical  Sciences,  1892,  ciii.  134. 

2  Stokes :  British  Medical  Journal,  1888,  p.  747, 


366 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


show  signs  of  purulent  changes.     Sometimes  when  septic  it  may  give  rise  to 
metastatic  disease  of  the  lung  and  to  a  general  pysemic  infection. 

Alport/  after  collecting  169  cases  of  all  kinds,  showed  that  most  cases 
occur  between  seventeen  and  twenty-six  years  of  age,  though  quite  a  numl^er 
occur  in  the  first  three  years  of  life.  Of  all  the  cases  in  which  the  fact  was 
stated,  namely  128,  118  followed  chronic  otorrhoea. 


Fig.  78. 


Communication,  through- parietal 

foramen  with  external  veins  of  skull. 


Ext.  jugular  vein 


Int.  jugular 
vein 


Diagram  showing  tlie  communications  existing  between  the  superior  longitudinal  and  lateral 
sinuses  and  the  external  veins,  indicated  in  the  figure  by  *.    (Leube.; 


General  Symptoms.  A  sinus  thrombosis,  especially  when  it  involves  the 
longitudinal  sinus,  may  be  masked  by  other  conditions,  and  may  only  be  de- 
tected at  the  autoj)sy.  More  frequently  it  gives  rise  to  decided  symptoms, 
among  which  may  be  very  severe  and  often  localized  headache,  vomiting, 
rigors,  high  temperature,  slow  pulse,  convulsions,  mental  confusion,  and 
rigidity  of  the  back  of  the  neck.  Occasionally  more  or  less  marked  palsies, 
hemiplegic  or  monoplegic  in  type,  are  added.  When  present  they  are  due 
to  secondary  cortical  softening.  Very  often  the  signs  of  thrombosis  are 
complicated  by  those  of  a  meningitis  or  brain  abscess,  and  it  is  therefore 
often  difficult  to  diagnosticate.  In  fact  it  can  only  be  recognized  when 
certain  circulatory  disturbances  pointing  directly  to  the  blocking  up  of  the 
sinuses  are  present.  A  knowledge  of  the  anatomy  of  the  sinuses  and  of  their 
venous  connections,  is,  therefore,  absolutely  necessary.  The  most  important 
clinical  forms  met  with  are  thromboses  of  the  lateral,  longitudinal,  and  the 
cavernous  sinuses. 

Special  Symptoms.  Thrombosis  of  the  Lateral  Sinus.  Disease  of 
the  middle  ear — caries  of  the  petrous  bone — is  the  most  common  cause  of 

1  Alport .  Journal  of  American  Medical  Association,  1892,  xix.  pp.  690,  725,  744. 


GENERAL  DISEASES  OF  THE  BRAIN. 


567 


disease  of  the  lateral  sinus.  Consequently,  signs  of  chronic  otitis  media  are 
almost  invariably  present.  Intense  headache,  sometimes  preceded  by  agoniz- 
ing earache,  are  the  usual  accompaniments.  Vomiting,  optic  neuritis,  and 
fever  pysemic  in  character,  may  also  be  present.  Even  nystagmus  may  l^e 
noted.  The  involvement  of  the  sinus  is  especially  indicated  by  venous 
fulness  and  oedema  back  of  the  ear,  in  the  mastoid  and  occipital  regions. 

Fig.  79. 


faeial  vein 


■Ext.  jugul  vein 


Communication  ivith  veins 
'at  back  of  neck 

Diagram  showing  the  communications  existing  between  the  lateral  and  cavernous  sinuses 
and  the  external  veins,  indicated  in  the  figure  by  *.    (Leube.) 

This  oedema  is  due  to  the  extension  of  the  thrombus  to  the  small  veins  which 
pass  through  the  posterior  condyloid  and  mastoid  foramina.  These  veins 
connect  the  lateral  sinus  Avith  the  veins  of  the  scalp  back  of  the  ear  and  over 
the  lower  portion  of  the  occiput.  In  aolition  there  is  decided  tenderness 
over  the  oeclematous  area,  especially,  as  Bennett^  has  shown,  over  the  mastoid 
foramen.  Another  symptom  that  has  been  observed  is  that  the  external 
jugular  vein  on  the  affected  side  seems  less  full  than  its  fellow,  the  difference 


1  Bennett :    Lancet,  London,  1893,  ii.  pp.  619,  1001. 


368  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

being  brought  out  especially  by  efforts  at  inspiration  (Gerhardt).^  Inasmuch 
as  in  lateral  thrombosis  the  internal  jugular  of  the  same  side  receives  no 
blood  from  the  cranial  cavity  the  external  jugular  empties  itself  more  readily 
into  the  common  trunk.  However,  in  some  cases  the  thrombus  extends  into 
the  internal  jugular  for  such  a  distance  that  it  blocks  the  communication 
with  the  external  vein.  In  such  a  case,  the  latter,  instead  of  being  compara- 
tively emjDty  (Gerhardt's  symptom),  is  over-distended.  When  the  clot 
extends  for  some  distance  into  the  internal  jugular,  the  latter  is  felt  as  a  firm 
and  painful  cord.  Sometimes  the  patient  holds  the  head  inclined  toward 
the  affected  side,  as  in  this  position  the  muscles  are  less  apt  to  cause  pressure 
upon  the  inflamed  vein.  Rarely  it  happens  that  in  cases  where  the  inflam- 
mation is  purulent  and  of  such  severity  as  to  involve  the  tissues  external  to 
the  sinus,  the  .various  nerves  which  accompany  the  jugular  vein  in  its  passage 
through  the  jugular  foramen  may  be  affected.  Symptoms  referable  to  irri- 
tation of  the  pneumogastric,  spinal  accessory,  and  glosso-pharyngeal  have 
been  described,  e.  g.,  excessive  slowing  of  the  pulse,  respiratory  disturbance, 
hoarseness,  aphonia,  spasm  of  the  sterno-mastoid,  and  trapezius,  difficulty  of 
swallowing,  etc. 

Thrombosis  op  the  Cavernus  Sinus.  Thrombus  of  the  cavernous  sinus, 
like  that  of  the  lateral  sinus,  is  frequently  due  to  purulent  inffammation  in 
its  immediate  neighborhood.  Both  sinuses  are  occasionally  involved  at  the 
same  time.  Because  of  the  communication  existing  between  the  cavernous 
sinus  and  the  ophthalmic  vein,  the  special  symptoms  presented  are  very 
striking ;  thus,  there  is  oedema  of  the  eyelids  of  the  same  side,  of  the  con- 
junctiva, and,  later  on,  of  a  great  part  of  the  side  of  the  face.  The  latter 
symptom,  however,  may  not  be  present,  or  may  be  transient  in  character.  In 
adition  there  may  be  more  or  less  marked  exophthalmus,  and  if  we  examine 
the  fundus  of  the  eye  we  find  that  the  retinal  veins  are  distended  and  unusually 
tortuous,  and  there  may  also  be  oedema  of  the  retina  and  of  the  papilla. 
These  appearances  are  all  accentuated  if  the  thrombosis  extends  to  the  cen- 
tral retinal  vein.  There  may  also  be  venous  pulsation,  retinal  hemorrhages, 
etc.  If  the  thrombus  be  septic  in  character  the  symptoms  may  be  those  of  a 
phlegmonous  inflammation  of  the  connective  tissue  of  the  orbit.     (Leube.) 

Inasmuch  as  the  oculo-motor  nerve  and  ophthalmic  branch  of  the  fifth  are 
enclosed  in  the  wall  of  the  sinus,  and  the  pathetic  and  abducent  nerves  pass 
directly  through  it,  various  symptoms  indicative  of  interference  with  these 
nerves  are  present.  Paralysis  of  various  ocular  muscles,  ophthalmic  neu- 
ralgia, and  even  neuroparalytic  ophthalmia  may  occur.  Deep-seated  head- 
ache may  also  exist. 

Thrombosis  of  the  Superior  Longitudinal  Sinus.  Thrombosis  of  the 
superior  longitudinal  sinus  is  almost  always  of"  marantic"  origin,  that  is,  occurs 
in  low,  adynamic  conditions.  It  is  not  an  infrequent  complication  in  various 
affections  of  childhood,  such  as  chronic  exhausting  diarrhoea  or  long  con- 
tinued fevers.  In  adults  it  also  occasionally  occurs  under  similar  conditions, 
but  the  symptoms  are  frequently  masked  by  those  of  the  general  disease, 
and  it  escapes  recognition  altogether,  being  detected  only  on  the  post- 
mortem table.  Special  symptoms,  however,  are  always  present  in  complete 
obstruction  of  the  sinus.  Inasmuch  as  the  sinus  communicates  directly 
with  the  veins  of  the  nasal  cavity,  the  latter  become  very  much  distended, 
and  not  infrequently  marked  epistaxis  ensues.  There  is  also  marked  ful- 
ness and  even  cyanosis  in  the  distribution  of  the  anterior  facial  vein. 
Similarly,  because  the  sinus  is  in  communication  with  the  veins  of  the  scalp, 
(by  way  oi  the  emissary  veins  of  Santorini,  which  pass  through  the  parietal  for- 

1  Gerhardt ;  Deutsche  Klinik,  1857,  vol.  ix,  pp.  437,  445. 


GENERAL  DISEASES  OF  THE  BRAIN.  369 

amina)  there  ensue  fulness  of  the  vems  and  oedema  of  both  temporal  regions 
spreading  up  to  the  vertex.    This  swelling  is  especially  noticeable  in  children. 

In  the  latter,  also,  because  of  the  obstruction  to  the  outflow  from  the  cerebral 
veins  and  the  consequent  increase  of  intra-cranial  pressure,  the  fontanelles 
become  distended  and  prominent.  Various  symptoms  indicative  of  more  or 
less  profound  disturbance  of  the  cerebrum  also  make  their  appearance ;  thus, 
there  may  be  mental  dulness,  delirium,  somnolence,  and  later  on,  stupor  and 
coma.  Convulsions  and  palsies  may  also  occur,  and  these  may  be  more  marked 
on  one  side  of  the  body  than  on  the  other.  Vomiting  is  also  present,  and 
headache  is  quite  constant.  Inasmuch  as  the  affection  is  often  complicated 
by  a  meningitis,  there  may  be,  in  addition,  such  symptoms  as  strabismus, 
rigidity  at  the  back  of  the  neck,  rigidity  of  the  limbs,  etc. 

Diagnosis.  Many  of  the  general  symptoms  presented  by  thrombosis  of  the 
sinuses  are  also  present  in  meningitis.  Among  these  are  headache,  vomiting, 
chills  and  fever,  mental  disturbances,  such  as  delirium,  somnolence,  or  stupor, 
and  at  times  optic  neuritis.  The  diagnosis  of  sinus  thrombosis  depends  upon 
the  special  symptoms  produced  by  sinus  obstruction. 

Thrombosis  of  the  Lateral  Sinus  occurs,  as  we  have  seen,  far  more  frequently 
than  the  other  forms.  Associated,  as  it  is,  with  disease  of  the  middle  ear,  the 
latter,  in  all  suspected  cases,  should  be  carefully  examined.  The  presence  or  a 
past  history  of  a  purulent  discharge  is  of  the  greatest  significance.  Especially  is 
this  the  case  when  headache,  rigors  and  rise  of  temperature  follow  the  sudden 
cessation  of  such  a  discharge.  If  in  addition,  tenderness  and  oedema  be 
present  over  the  mastoid  process,  lower  occipital  or  upper  cervical  region, 
sinus  thrombosis  is  indicated.  Difilise  tenderness  may  be  wanting,  but  a 
painful  point  will  always  be  found  directly  over  the  mastoid  foramen.  It  is 
due  to  a  phlebitis  involving  the  emissary  vein,  which  here  makes  its  exit 
from  the  sinus.  This  point  exists  at  the  posterior  edge  of  the  mastoid  process, 
or  better  still,  it  may  be  found  by  placing  the  finger  tip  firmly  upon  a  spot 
one  inch  behind  and  about  half  an  inch  above  the  middle  of  the  external 
auditory  meatus  (Bennett).^  Sometimes  the  oedema  also  is  very  slight,  is 
circumscribed  and  limited  to  this  small  area.  Lack  of  fulness  in  the  external 
jugular  vein,  cord-like  hardness  and  tenderness  over  the  internal  jugular  are 
also  to  be  sought  for.  We  should  be  careful  to  differentiate  between  lateral 
sinus  thrombosis  and  basal  meningitis,  or  brain  abscess  dependent  upon  ear 
disease.  In  uncomplicated  brain  abscess  the  symptoms  of  sinus  obstruction 
arfe  absent.  However,  we  should  remember  that  in  children  the  symptoms 
of  obstruction  are  now  and  then  but  slightly  marked,  and  in  such  case  the 
differential  diagnosis  from  meningitis  is  exceedingly  difficult  and  at  times 
impossible. 

The  practitioner  should  be  cautioned  in  every  suspicious  case  of  continued 
fever  of  irregular  or  pysemic  type,  to  examine  the  ears  as  possible  sources  of 
infection,  and  it  occasionally  happens  that  in  this  way  a  sinus  thrombosis  is 
detected.  "  Earache  "  in  a  febrile  case  should  always  be  regarded  with 
suspicion. 

The  diagnosis  of  thrombosis  of  the  cavernous  sinus  is  based,  in  addition  to 
the  general  symptoms  mentioned  above,  upon  the  symptoms  caused  by  the 
obstruction  of  the  ophthalmic  vein,  namely,  oedema  of  the  conjunctiva,  of 
the  eyelids,  of  the  upper  part  of  one  side  of  the  face,  exophthalmus,  stra- 
bismus, neuralgia,  fulness  and  tortuosity  of  the  retinal  veins,  etc.  In  sus- 
pected cavernous  thrombosis,  disease  of  the  ear  should  also  be  looked  for. 
What  has  been  said  relative  to  this  point  in  connection  with  thrombosis  of 
■  the  lateral  sinus  is  also  applicable  here.  Disease  of  the  cavernous  sinus  is 
much  less  frequent  than  that  of  the  lateral  sinus. 

1  Loc.  cit. 
24 


370  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  diagnosis  of  ihrombosi-s  of  the  longitudinal  sinus  is  also  to  be  based 
upon  general  symptoms  and  on  the  cedema  of  the  temporal  regions  caused 
by  obstruction  of  the  veins  of  Santorini,  the  occurrence  of  epistaxis,  marked 
mental  symptoms,  somnolence,  coma,  or  delirium,  convulsions  and  palsies, 
and,  in  young  children,  the  prominence  of  the  fontaneUes. 

Prognosis,  Thrombosis  of  the  sinuses  is  ahvays  a  grave  affection.  When 
present  in  the  lateral  sinus,  however,  the  termination  is  by  no  means  alwa3's 
fatal.     Xot  infrequently  cases  are  saved  by  prompt  surgical  interference. 

Treatment,  The  expectant  treatment  of  sinus  thrombosis  offers  very  little 
hope.  Surgical  procedures  alone  promise  relief.  Operations  have  many 
times  been  attempted,  and  often  with  success.  Lateral  sinus  thi'ombosis,  the 
most  common  form,  is  at  the  same  time  that  form  which  admits  most  readily 
of  surgical  treatment.  In  1880,  Zaufal^  proposed  to  ligate  the  internal 
jugular  on  the  affected  side,  in  order  to  prevent,  if  possible,  systemic  infec- 
tion, and  also  to  remove  the  mastoid  process  and  to  expose  and  evacuate  the 
sinus.  He  first  carried  out  his  suggestion  in  1884,  though  unsuccessfrilly. 
Two  years  later,  Horsley'^  recommended  a  somewhat  similar  procedure. 
Since  then,  Lane,^  Ballance,*  Salzer,^  and  others,  have  operated  Avith  more 
or  less  success.  The  operation  consists  of  two  parts — first,  ligation  of  the 
internal  jugular  below  the  thrombus  by  two  ligatures,  and  division  of  the 
vein  between  the  ligatures ;  second,  trephining,  opening  of  the  lateral  sinus, 
and  the  washing  out  of  the  thrombus  from  above,  or  removing  it  by  the 
curette.  For  details,  the  reader  is  referred  to  the  chapter  on  Surgery.  Suc- 
cessful cases  have  also  been  reported  by  Parker,^  Pickering,'  Glutton,^  Har- 
ris,^ and  others.  Of  twenty  cases  of  operation  upon  the  sinuses  collected  by 
Koerner,"  thirteen  were  successfiil.  Hansberg"  suggests  that,  because  in  the 
early  stages  the  diagnosis  may  be  uncertain,  we  should  always  open  the 
mastoid  if,  in  the  course  of  suppurative  ear  disease,  py^emic  fever  develops. 

Regarding  operations  for  thrombosis  of  the  cavernous  sinus,  but  one  case 
is  upon  record,  that  reported  by  Bircher.^^  This  case  was  complicated  by 
thi'ombosis  of  both  the  lateral  and  the  inferior  petrosal  sinuses.  The  opera- 
tion involved  the  removal  of  almost  the  entire  portion  of  the  petrous  bone. 
Thorough  cleansing  and  disinfection  of  the  wound  was  followed  by  recovery 
and  diminution  in  the  ophthalmoplegic  symptoms,  but  with  total  facial  palsy. 

Longitudinal  sinus  thrombosis,  being  of  marantic  origin,  is  not  favorable 
to  sui'gical  interference. 


CEREBRAL    ANEMIA    AND    HYPEREMIA. 

As  in  other  instances  in  which  pathological  investigation  is  difficult  or 
impossible,  much  difference  of  opinion  has  existed  relative  to  anaemia  and 
In^erremia  of  the  brain.  Not  many  years  ago,  it  was  quite  common  to  hear 
the  diagnosis  of  these  conditions  made  almost  daily.  At  the  present  time, 
however,  as  has  been  pointed  out  by  Gray,  such  a  diagnosis  is  rarely  recorded. 

1  Zaufal :  Prag.  med.  Wochenschr.,  1880,  p.  576. 

2  Horslev  :  St.  Thomas's  Hosp.  Rep.,  1886,  vol.  xviii. 
2  Lane  :  "Brit.  Med.  Jouni.,  1889,  i.  p.  998. 

*  Ballance  :  Lancet,  1890,  i.  p.  805. 

5  Salzer:  Wien.  klin.  Wochenschr.,  1890,  p.  051. 

6  Parker  :  Liverpool  Medico-Chirurg.  Journ.,  1892,  xii.  p.  86. 
'  Pickering :  Bristol  Medico-Chirurg.  Journ.,  1891,  ix.  p.  155. 
8  Glutton:  Brit.  Med.  Journ.,  1892,  i.  p.  807. 

'■>  Hams  :  Lancet,  1893,  ii.  p.  93. 

10  Koerner :'  Die  Otitischen  Erkrankungen  des  Hirns,  der  Hirnhaeute  und  der  Blutleiter,  Frank- 
furt a.  M.,  1894,  p.  72. 

11  Hansberg  :  Ann.  d.  mal.  de  I'oreille,  etc.,  1892,  xviii,  p.  eil 

12  Bireher:  Centralbl.  f.  Chirurg.,  1893,  p.  483. 


GENERAL  DISEASES  OF  THE  BRAIN.  37I 

This  is  largely  owing  to  our  better  understanding  of  other  intra-cranial  affec- 
tions, and  to  the  more  frequent  recognition  of  the  various  nervous  phenom- 
ena associated  with  neurasthenia.  It  is  undoubtedly  true  that  anemia  and 
hypersemia  of  the  brain  as  primary  affections  are  excessively  rare.  However, 
they  are  not  infrequently  met  with  secondary  to,  or  associated  with,  some 
other  pathological  condition.  That  cerebral  ansemia  actually  exists,  is  proven 
by  such  simple  instances  as  the  cerebral  symptoms  associated  with  sudden  loss 
of  blood,  and  that  cerebral  hypersemia  also  exists,  at  least  in  the  passive  form, 
is  proven  by  the  symptoms  present  in  cases  of  general  venous  obstruction. 

Symptomatology.  The  symptoms  presented  by  cases  of  undoubted  cerebral 
ancemia,  such  as  are  caused  by  an  excessive  hemorrhage,  consist  of  ringing  in 
the  ears,  dimness  of  vision,  attacks  of  "blackness  before  the  eyes,"  dilated 
pupils,  vertigo,  nausea  or  vomiting,  headache,  mental  confusion  and  delirium, 
insomnia  and  attacks  of  fainting.  These  symptoms  are  all  less  marked  in 
the  recumbent  posture,  and  may  even  be  relieved  when  the  head  is  on  a 
lower  level  than  the  trunk  and  limbs.  The  symptoms  presented  by  an 
ordinary  attack  of  fainting  due  to  fright,  or  to  sudden  depression  of  the 
heart's  action  through  any  cause  whatever,  depend  upon  a  relative  antemia 
of  the  brain,  and  resemble  those  just  recounted.  Similar  though  milder 
symptoms,  are  occasionally  met  with  in  general  ansemia,  chlorosis,  leuksemia, 
the  various  cachexias  and  inanition,  and  at  times  associated  with  neuras- 
thenic conditions.     (See  Chapter  II.) 

The  symptoms  of  cerebral  hypercemia  theoretically  resolve  themselves  into 
two  groups  :  first,  those  attendant  upon  active  or  arterial  congestion ;  and, 
secondly,  those  due  to  passive  or  venous  congestion.  The  first  group  are 
represented  by  the  symptoms  so  often  prodromal  to  cerebral  hemorrhage,  i.  e., 
a  sense  of  fulness  and  heat  of  head,  headache,  throbbing  sensations  in  the 
head,  cerebral  excitement,  tinnitus,  vertigo,  and  insomnia.  From  the  nature 
of  the  case,  the  symptoms  are  such  as  are  often  present  in  other  affections, 
and  the  condition  can  never  be  diagnosticated  with  absolute  certainty.  It  is 
not  improbable  that  such  symptoms  as  photophobia,  auditory  hyperses- 
thesia,  confusion  of  thought,  and  delirium,  which  are  present  in  the  initial 
stages  of  simple  febrile  affections  and  in  the  prodromal  periods  of  menin- 
gitis, are  due  to  an  active  cerebral  hypersemia.  Whether  the  affection  exists 
in  an  independent  and  chronic  form  is  exceedingly  problematic.  The  in- 
somnia associated  with  overwork  is  probably  not  the  insomnia  of  hyper- 
semia,  but  the  insomnia  of  exhaustion  (see  chapter  on  neurasthenia,  page 
66.)  No  changes  are  found  in  the  retinal  circulation  in  the  so-called  cases 
of  chronic  cerebral  hypersemia,  while  the  mere  flushing  of  the  face  cannot 
be  looked  upon  as  bearing  any  relation  to  the  circulation  within  the  cranium. 
The  second  group  of  symptoms,  those  dependent  upon  venous  fulness,  are 
best  illustrated  by  cases  of  disease  of  the  heart  in  which  excessive  venous 
obstruction  is  present.  Here  we  often  have  a  dull  headache,  some  tendency 
to  somnolence,  and  general  weakness,  symptoms  which  in  their  turn  are  too 
ill-defined  to  enable  us  to  establish  an  absolute  diagnosis.  It  is  probable 
that  to  some  extent  they  are  due  to  oedema  of  the  membranes. 

In  some  cases  the  symptoms  of  cerebral  hypersemia  follow  the  sudden 
arrest  of  an  habitual  discharge  of  blood,  such  as  accompanies  hemorrhoids  in 
plethoric  people.  This  remark  applies  especially  to  women  at  the  menopause. 
An  illustrative  case  occurring  in  the  experience  of  the  writer  was  that  of  a 
middle-aged  woman  still  at  the  menopause,  who  had  been  operated  upon  for 
profusely  bleeding  hemorrhoids.  The  operation  had  been  entirely  successful, 
yet  some  three  weeks  afterward,  at  what  seemed  to  be  a  menstrual  epoch, 
the  patient  died  with  all  the  symptoms  of  a  venous  hypei'semia  of  the  brain. 
What  has  been  said  concerning  active  cerebral  hypersemia  in  regard  to  the 


372  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

existence  of  the  affection  in  an  independent  and  chronic  form  applies  equally 
here.  It  is  with  cerebral  hypersemia  and  anaemia,  as  associated  with  other 
states,  that  we  have  especially  to  deal.  A  reference  to  the  chapter  on  neuras- 
thenia in  this  volume  will  show  the  reader  that  in  very  many  neurasthenics 
numerous  obscure  cephalic  sensations  are  present,  such  as  throbbing,  tension 
of  the  head,  sense  of  fulness,  etc.,  which  suggest  the  presence  of  an  increased 
amount  of  blood  in  the  cranial  cavity.  It  is  not  improbable  that  the  exacer- 
bation of  the  head  symptoms  in  female  neurasthenics  at  the  time  immedi- 
ately preceding  the  menstruation,  is  to  be  ascribed  to  such  a  cause.  While 
we  recognize  that  hypersemia  of  the  brain  as  an  independent  condition  is 
rarely  if  ever  existent,  it  is  more  than  probable  that  it  at  times  complicates 
other  functional  troubles,  notably  neurasthenia. 

Treatment.  The  treatment  of  a  cerebral  anaemia  associated  with  loss  of 
blood,  chlorosis,  leukaemia,  general  anaemia,  the  various  cachexias  or  neuras- 
thenia is,  of  course,,  the  treatment  of  these  various  states.  Cerebral  hyper- 
emia occurring  mainly  in  connection  with  other  diseases,  treatment  is  to  be 
directed  to  the  latter.  Thus  a  case  of  heart  disease,  a  case  of  suppressed 
menstruation,  a  case  of  threatening  apoplexy,  demands  each  its  appropriate 
management.  The  symptoms  of  heat  and  fulness,  ringing  in  the  ears,  and 
vertigo  occurring  in  a  plethoric  person,  should  be  met  by  active  purgation, 
general  or  local  blood-letting,  and  the  administration  of  bromides. 

In  neurasthenics  in  whom  we  have  reason  to  believe  that  there  is  a  com- 
plicating hyperaemia,  we  should  associate  with  our  treatment  the  bromides,  and 
especially  ergot.  In  neurasthenic  headaches  in  which  this  complication  is 
believed  to  exist,  the  writer  has  found  ergot  quite  useful.  It  is  unnecessary 
to  say  that  this  drug  is,  not  applicable  in  cases  of  suppressed  menstruation, 
or  that  it  is  not  to  be  used  at  the  eve  of  this  epoch.  Among  the  other 
measures  are  hot  foot  or  sitz-baths  taken  at  bed-time. 


CEREBRAL  INFLAMMATION. 

Inflammation  of  the  brain  appears  to  be  present,  as  in  other  viscera,  in  two 
forms,  a  parenchymatous  and  an  interstitial  form.  Our  knowledge  of  the 
parenchymatous  inflammations  is  not  by  any  means  satisfactory.  It  is  exceed- 
ingly probable  that  they  occur  in  at  least  three  clinical  varieties :  First, 
polioencephalitis  cortiealis,  an  inflammation  of  the  cortex  of  the  brain,  the 
lesion  which  Striimpel  believes  to  be  the  essential  factor  in  the  cerebral  pal- 
sies of  childhood  ;  secondly,  polioencephalitis  superior,  by  which  is  meant  an 
inflammation  of  the  gray  matter  about  the  aqueduct  of  Sylvius,  i.  e.,  the 
nuclei  of  the  various  cranial  nerves  supplying  the  extrinsic  and  intrinsic 
muscles  of  the  eyeball ;  thirdly,  polioe^icephalitis  inferior,  in  which  various 
motor  nuclei  of  the  medulla  are  involved.  Polioencephalitis  superior  and 
inferior  are  analogous,  it  will  be  seen,  to  poliomyelitis  (see  Chapter  XX). 
Polioencephalitis  superior,  which  gives  rise  to  op hthalmoplegia,  is  described 
in  Chapter  XXVI.,  while  polioencephalitis  inferior,  bulbar  palsy,  is  described 
in  Chapter  XXI.  Polioencephalitis  corticaHs,  at  times  the  lesion  of  cerebral 
palsy  of  childhood,  is  considered  in  Chapter  XVII. 

Interstitial  inflammation  of  the  brain  may  be  either  acute  or  chronic  and 
may  result  in  more  or  less  rapid  destruction  of  tissue  with  or  without  the  for- 
mation of  pus,  or  in  slowly  progressive  changes,  such  as  sclerosis.  Acute 
interstitial  inflammation  of  the  brain  is  very  rare,  but  it  appears  to  result 
every  naw  and  then  from  severe  trauma  of  the  head,  and  at  times  it  arises  in 
the  course  of  one  of  the  infectious  diseases,  such  as  erysipelas,  influenza, 
typhoid  fever,  diphtheria,  variola,  typhus  fever,  etc.     It  is  probable  also  that 


GENERAL  DISEASES  OF  THE  BRAIN.  373 

a  less  acute  form  is  occasionally  due  to  syphilis.  It  may  be  widely  diffused 
or  there  may  be  numerous  foci  of  inflammation  scattered  through  the  euceph- 
alon.  At  times  a  localized  interstitial  inflammation  is  the  result  of  direct 
trauma  of  the  brain  as  by  a  stab-wound,  or  from  the  irritation  of  depressed  or 
diseased  bone  or  from  the  presence  of  a  foreign  body,  or  a  neoplasm.  The 
symptoms  of  acute  interstitial  inflammation  are  vague,  ill  defined,  and  not 
characteristic.  Among  them  are  headache  dull  in  character,  vomiting,  deli- 
rium, coma,  convulsions,  and  hemiplegia  and  other  palsies.  The  optic  papillae 
appear,  in  the  cases  thus  far  reported,  to  have  presented  no  peculiarities. 
Various  conditions  of  the  pupils  have  been  noted.  As  a  rule,  mydriasis  has 
been  present,  though  in  a  case  reported  by  Schmidt^  the  pupils  were  distinctly 
contracted.  Their  reaction  is  uncertain.  Death  is  preceded  by  a  period  of 
coma. 

Autopsies  reveal  the  brain  tissue  as  a  whole  to  be  somewhat  reddened.  At 
times  this  reddening  is  present  only  in  foci  here  and  there.  Upon  micro- 
scopic examination,  and  in  some  cases  apj)arent  to  the  naked  eye,  are  found 
numerous  hemorrhages.  These  may  be  capillary  or  punctiform  or  somewhat 
diffuse.  In  other  words  red  softening  may  be  noted  in  the  wdiite  matter,  the 
basal  ganglia  and  less  often  the  cortex.  At  times  the  hemorrhages  are  so 
marked  that  the  condition  has  been  termed  hemorrhagic  encephalitis. 

The  fact  that  the  symptoms  are  vague  and  common  to  other  intra-cranial 
affections  renders  an  absolute  diagnosis  impossible.  However,  the  history  of 
a  blow  on  the  head,  such  as  is  present  in  profound  concussion  of  the  brain, 
the  absence  of  optic  neuritis  and  the  generalized  character  of  the  symptoms 
should  suggest  to  us  a  diffuse  encephalitis.  Similarly  if  these  symptoms  occur 
in  a  case  of  infectious  fever  a  diffuse  encephalitis  may  again  be  suspected. 
From  the  uncertainty  of  the  diagnosis  and  the  nature  of  the  affection  treat- 
ment can  only  be  tentative  and  general.  The  principles  laid  down  in  dis- 
cussing the  treatment  of  meningitis  apply  equally  here. 

The  various  localized  interstitial  inflammations  of  the  brain  occurring  in 
the  neighborhood  of  tumors,  diseased  bone,  hemorrhages,  etc.,  may  compli- 
cate the  symptoms  resulting  from  the  original  lesion.  They  cannot  be  separ- 
ately considered.  Occasionally,  however,  local  inflammation  results  in  the 
brain  immediately  beneath  the  site  of  a  blow  upon  the  head  or  at  some  dis- 
tant point,  and  is  often  of  such  an  intensity  that  it  results  in  the  formation  of 
pus.  At  other  times,  septic  material  introduced  from  without  may  give  rise 
to  purulent  inflammation  and  to  consequent  formation  of  an  abscess.  (See  page 
374).  Among  very  rare  forms  of  inflammation  of  the  brain  must  be  men- 
tioned the  case  of  anthrax  of  the  brain  reported  by  Merkel.^  On  admission 
to  the  hospital  the  patient  was  exceedingly  pale  and  anaemic,  totally  uncon- 
scious, and  presented  epileptiform  attacks.  An  ophthalmoscopic  examination 
revealed  the  margins  of  the  disk  on  the  right  side  to  be  obscured ;  nothing 
else  abnormal.  Death  occurred  shortly  afterward.  The  autopsy  revealed, 
among  other  things,  an  injected  pia  and  cortex  with  numerous  small,  red 
specks,  apparently  hemorrhages,  and  small  hemoiThages  in  the  basal  ganglia. 
Microscopic  examination  showed  the  vessels  to  be  filled  wdth  anthrax  bacilli. 
In  some  situations  the  bacteria  had  apparently  penetrated  the  vessel  walls 
and  were  in  the  perivascular  spaces.  No  bacilli  were  found  in  the  brain  sub- 
stance proper. 

Chronic  interstitial  inflammation  of  the  brain  constitutes  various  forms 
of  sclerosis.  Insular  or  disseminated  sclerosis  (see  Chapter  XXII)  is  an 
affection  which  appears  to  have  its  origin  in  multiple  foci  of  inflammation, 

1  Schmidt:  Deutsche  Med.  Wochenschr,  1892,  xviii.  703. 

"  Merkel:  Muenchener  Med.  Wochenschrift,  1892,  No.  47,  840. 


374  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

AYidely  diffused  sclerosis,  such  as  leads  to  atrophy,  hypertrophy  or  gross  de- 
formity of  the  brain  as  a  whole  or  of  its  lobes,  is  probably  most  often  degenera- 
tive in  character,  though  now  and  then  it  likewise  appears  to  have  its  origin 
in  an  inflammatory  process.  It  is  most  often  seen  in  the  brains  of  idiots  and 
other  cases  of  arrested  mental  development.  These  are  considered  at  length 
in  Chapter  XII. 

BRAIN  ABSCESS. 

Etiology.  Abscesses  of  the  brain  are  the  direct  result  of  septic  infection. 
One  of  the  most  common  causes  is  the  extension  of  some  suppurative  process 
from  contiguous  structures,  as  from  caries  of  the  temporal  bone,  from  otitis 
media,  from  suppurative  processes  in  the  naso-pharynx  or  in  the  nasal  cavity, 
from  suppuration  in  the  sinuses  of  the  frontal  bone,  or  in  the  orbits,  and  from 
erysipelas  and  cellulitis  of  the  face  and  head.  Infection  may  also  be  carried 
from  a  distance.  Empyema,  lung  abscess,  putrid  bronchitis,  and  septic  endo- 
carditis are  all  sources  of  brain  abscess.  General  septicaemia,  pysemia  and 
influenza  are  among  the  less  common  causes.  Frequently  a  trauma  attended 
by  a  wound  or  other  injury  of  the  skull,  such  as  a  complicated  fracture 
of  the  cranium  with  or  without  injury  to  the  brain,  results  either  in  a 
purulent  meningitis  or  brain  abscess,  or  perhaps  both.  Occasionally  abscess 
occurs  in  cases  in  which  no  septic  infection  can  be  traced.  Thus  it  sometimes 
happense  that  an  abscess  develops  after  blows  to  the  head  when  no  lesion  of 
either  table  of  the  cranium  or  of  the  dura  has  been  produced.  In  such  in- 
stances the  abscess  may  form  immediately  beneath  the  site  of  the  blow  or  in 
a  distant  part  of  the  brain ;  thus,  a  blow  upon  the  vertex  has  been  followed 
by  an  abscess  in  the  temporal  lobe,  a  blow^  upon  the  occiput  by  an  abscess  in 
the  frontal  lobe.  Sometimes  a  blow  upon  the  head  may  give  rise  to  an  abscess 
at  the  seat  of  the  blow  and  a  second  one  at  a  distant  point.^ 

Judging  from  the  statistics  of  Pitt,'*  almost  one-third  of  the  cases  of  brain 
abscess  are  due  to  disease  of  the  middle  ear  or  of  the  temporal  bone,  less 
than  one-sixth  to  disease  of  other  cranial  bones,  about  one-sixth  to  trauma, 
about  one-sixth  to  pysemia,  and  the  remaining  portion  to  diseases  of  the  lungs 
and  other  causes. 

In  a  statistical  study  of  13,000  miscellaneous  cases  of  ear  trouble  Jansen^ 
found  eight  complicated  with  brain  abscesses.  Of  these  only  seven  can  be 
properly  included.  These  seven  occurred  in  something  over  5000  cases  of 
suppuration  in  the  middle  ear.  One  occurred  in  2650  acute  cases  and  six  in 
2500  chronic  cases.  It  is  seen,  therefore,  that  chronic  suppurative  otitis  is 
more  dangerous  than  the  acute  form.  That  long  continuance  of  suppurating 
diseases  of  the  middle  ear  without  complications  is  no  guarantee  of  immunity, 
is  shown  by  the  case  of  Ransom*  in  w^hich  a  discharge  from  the  left  ear, 
present  for  thirty  years  and  then  suddenly  ceasing,  was  followed  by  brain 
abscess. 

Symptoms.  General  symptoms.  The  symptoms  of  brain  abscess  are  of 
two  kinds  :  First,  those  which  are  common  to  cases  of  brain  abscess  as  a 
whole ;  and,  secondly,  those  which  depend  upon  the  location  and  mode  of 
origin.  Among  those  of  the  first  group  are  headache,  vomiting,  vertigo  and 
disturbances  of  the  intelligence,  i.  e.,  apathy,  somnolence,  stupor  and  deli- 
rium.    To  these  symptoms  we  must  add  rigors,  slight  fever,  normal  or  even 

!•  Norbur>' :  Medical  News,  Philadelphia,  1892,  Ix.  p.  549. 

2  Pitt :  Goulstonian  Lectures,  Brit.  Med.  Journ.,  1890,  i.  pp.  643,  771,  827. 

3  Jansen  :  Berliner  klin.  Wochenschr.,  1891.  xxviii.  p.  1160. 
*  Ransom  :  Brit.  Med.  Journ.,  1892,  i.  p.  863. 


GENERAL  DISEASES  OF  THE  BBAIK  375 

abnormal  temperature,  slow  pulse  and  constipation.     Optic  neuritis,  as  we 
will  see,  is  also  j^resent  at  times. 

Headache  is  one  of  the  most  constant  symptoms,  and  is  often  so  severe  as  to 
cause  intense  suffering.  It  is  usually  continuous,  though  occasionally  inter- 
mittent, and  recurring  at  irregular  intervals.  It  may  be  diffuse,  or  localized 
in  certain  areas ;  the  latter  is  often  the  case  Avhen  the  meninges  in  the  neigh- 
borhood of  an  abscess  are  inflamed.  It  is  an  error,  however,  to  suppose  that 
the  seat  of  headache  corresponds  to  the  location  of  an  abscess.  Frequently 
the  two  are  widely  separated ;  for  instance,  frontal  headache  may  be  ob- 
served in  cerebellar  abscess.  Vomiting  possesses  here  the  same  significance 
as  it  does  in  brain  tumor  and  in  meningitis.  It  is  present  more  frequently 
in  abscesses  of  the  cerebellum.  Disturbances  of  the  intelligence  vary  greatly 
both  in  degree  and  kind.  In  the  typical  case  the  patient  answers  slowly, 
hesitates,  and  frequently  the  question  must  be  repeated  a  number  of  times 
before  he  appears  to  thoroughly  comprehend  it.  Often  he  uses  the  wrong 
word  or  gives  the  wrong  name  to  objects,  though  true  aphasic  symptoms  oc- 
cur rather  infrequently,  and  then  of  course,  have  a  special  significance.  It 
is  also  difficult  to  secure  his  attention  for  any  length  of  time.  He  is  dull, 
and  sleepy.  Delirium  is  among  the  less  frequent  symptoms.  Rigors  occur  in 
the  beginning,  and  are  especially  observed  in  cases  secondary  to  suppuration 
in  one  of  the  cavities  about  the  head ;  for  example,  those  depending  on  pur- 
ulent otitis  media  or  empyema  of  the  frontal  sinuses.  The  temperature  also 
runs  a  somewhat  significant  course.  In  a  large  number  of  cases  there  is  a 
slight  rise  of  temperature  in  the  early  period,  and  it  is  not  uncommon  to 
meet  with  a  temperature  of  100^  to  101°,  or  even  102°.  However,  as  the 
case  progresses  the  temperature  falls,  and  is  apt  to  be  subnormal,  falling  as 
low  as  97°  or  96°.  It  is  probable  that  subnormal  temperature  occurs, 
especially  in  simple  and  uncomplicated  cases.  A  co-existing  meningitis 
or  sinus  thrombosis  is  often  met  with,  and  it  is  probably  for  this  reason 
that  more  or  less  rise  of  temperature  is  noted  throughout  in  many  cases. 
Thus  in  a  series  of  twenty -three  miscellaneous  cases  collected  by  the  writer, 
sixteen  presented  temperatures  varying  from  100°  to  103°  and  higher.  In 
three  cases  the  temperature  was  normal.  In  four  it  was  subnormal.  The 
importance  of  these  facts  in  diagnosis  will  be  again  alluded  to.  The  pulse 
is  generally  markedly  slow,  resembling  in  this  respect  the  pulse  observed  in 
meningitis  and  in  some  cases  of  brain  tumor.  Its  rate  varies  from  60  to  50,  or 
40  beats  per  minute,  but  in  lethal  cases  rapidly  increases  toward  the  end.  At 
times  convulsions  occur,  but  it  is  probable  that  they  are  dependent  upon  the 
location  of  the  abscess.  Optic  neuritis  is  much  less  frequent  than  in  brain 
tumor  and  in  meningitis,  and  even  when  present  is  rarely  severe.  It  is  some- 
Avhat  more  frequent  in  abscesses  of  the  frontal  and  spheno-temporal  lobes  and 
cerebellum  than  in  abscesses  elsewhere.  Great  physical  prostration  and  rapid 
emaciation  often  accompany  the  other  symptoms.  Tache  cerebrale  is  noted 
in  some  cases  just  as  in  meningitis.  In  others,  again,  tenderness  or  pain  upon 
percussion  directly  over  the  spot  where  an  abscess  exists  is  sometimes  present. 
Too  much  reliance  should  not,  however,  be  placed  upon  this  symptom. 

Special  Symptoms.  The  second  group  of  symptoms,  namely,  those 
which  depend  upon  the  location  and  mode  of  origin  of  the  abscess,  neces- 
sitate the  consideration  of  the  various  kinds  of  abscesses  separately.  The 
latter  may  be  roughly  grouped  :  first,  into  those  due  to  trauma  ;  secondly, 
those  occurring  in  cases  of  general  pyaemia,  purulent  lung  affections,  ulcera- 
tive endocarditis,  and  various  infectious  diseases ;  and  thirdly,  those  having 
their  origin  in  infection  from  various  suppurating  cavities  about  the  head, 
such  as  the  middle  ear,  the  frontal  sinuses,  the  orbits,  etc. 

Traumatic  abscesses  consist,  first,  of  those  with  actual  wound  of  the  skull, 


376  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

brain  membranes,  and  perhaps  brain  tissue  itself ;  and,  secondly,  those  in 
which  no  such  wound  can  be  detected.  In  the  first,  rigors  such  as  are  com- 
mon to  purulent  infection  elsewhere,  fever,  localized  and  general  headache, 
together  with  focal  symptoms  dependent  upon  the  part  of  the  brain  injured, 
are  apt  to  be  present.  Among  the  latter  are  localized  palsies  or  convulsions 
affecting  the  opposite  side  of  the  body.  These  abscesses  are  prone  to  be 
complicated  by  purulent  meningitis,  and  it  is  probable  that  the  delirium, 
convulsions  and  coma  often  present  in  these  cases,  are  due  to  this  cause. 
Optic  neuritis  may  or  may  not  exisist.  As  a  matter  of  experience,  these 
abscesses  are  found  more  frequently  in  the  parietal  and  frontal  regions.  In  the 
second  variety  of  abscess  due  to  trauma,  that  is,  those  in  which  no  lesions  of  the 
cranium  or  of  the  membranes  exists,  and  in  which  the  abscess  appears  to  be 
due  to  an  acute  suppurative  encephalitis,  the  symptoms  may  be  very  vague 
and  ill-defined.  Thus  in  cases  in  which  frontal  abscess  results  from  a  blow 
upon  the  occiput,  no  signs  may  be  present  save  somnolence,  stupor  and  other 
symptoms  referable  to  simple  destruction  of  the  frontal  lobes.  If  such  an  ab- 
scess occur  in  the  tips  of  the  temporal  lobes,  as  is  every  now  and  then  the 
case,  the  symptoms  may  be  so  poorly  defined  that  the  abscess  may  run  its 
course  without  detection. 

Abscesses  due  to  pyaemia,  suppurative  lung  troubles  and  infectious  pro- 
cesses are  less  apt  to  present  the  general  symptoms  of  brain  abscess  in  a 
marked  degree.  Usually  the  patient  is  already  so  ill  that  headache,  vomit- 
ing and  mental  disturbances  lose  much  of  their  significance.  These  ab- 
scesses may  occur  in  almost  any  situation,  though  they  are  more  frequently 
met  with  in  the  occipital  lobes.  Not  uncommonly  they  are  found  in  the 
distribution  of  the  middle  cerebral  artery,  and,  indeed,  more  frequently  upon 
the  left  side  than  upon  the  right^.  The  clinical  picture,  as  in  tumor  of  the 
brain,  depends  largely  upon  the  focal  symptoms  produced.  Thus  in  abscesses 
of  the  occipital  lobe  various  disturbances  of  vision,  especially  hemianopsia,  are 
usually  present ;  monocular  diplopia  was  observed  in  one  case.*  In  abscesses 
in  or  beneath  the  motor  area,  cortical  epilepsy  is  rarely  absent.  For  the 
same  reason  localized  palsies  may  exist  upon  the  opposite  side  of  the  body. 
Abscesses  due  to  general  infectious  processes  are  most  frequently  multiple  ; 
this  fact  may  also  influence  the  symptomatology. 

The  third  group  of  abscesses,  those  having  their  origin  in  otitis  media  and 
disease  of  the  frontal  sinuses,  orbits,  etc.,  are  next  to  be  considered.  Most 
important  are  those  due  to  diseases  of  the  ear,  the  so-called  otitic  abscesses. 
A  history  of  chronic  otorrhoea  is  usually  present.  The  discharge  which  has 
continued  without  special  symptoms  for  months,  and  perhaps  for  years,  sud- 
denly ceases.  Often  this  cessation  is  attributed  to  cold  or  to  a  blow  upon 
the  head.  Pain  in  the  ear  and  side  of  the  head,  sometimes  of  frightiul 
severity,  now  sets  in.  At  the  same  time,  the  patient  may  suffer  from  a 
chill.  This  is  soon  followed  by  fever,  generally  moderate  in  degree,  and 
by  slightly  increased  frequency  of  the  pulse.  Vomiting  also  is  present,  and 
bears  no  relation  whatever  to  the  presence  or  absence  of  food  in  the  stom- 
ach. The  pain  in  the  head  is  not  characteristic,  and  does  not  differ  from 
that  which  may  be  met  with  in  ordinary  acute  otitis  media,  but  its  occur- 
rence in  a  chronic  case  is  of  the  utmost  significance.  After  a  variable 
period,  twenty-four,  forty-eight  hours  or  more,  the  pain  diminishes,  and  in 
the  course  of  a  few  days  the  patient  passes  into  the  condition  of  indifference 
and   apathy  already  described    in  considering   the   symptoms   in    general. 

1  Martins:  Beitrage  z.  Lehre  vom  Hirnabscess,  VercefFentlichungen  ueber  Krankengeschichten 
und  Leichenbefunde  aus  den  Garnisonlazaretten,  vii,  Berlin. 

2  Abercrombie :    Trans,  of  the  Ophthalmological  section  of  tbe  American  Medical  Assoc,  1891, 
p.  217. 


GENERAL  DISEASES  OF  THE  BRAIN.  377 

About  this  time,  also,  such  febrile  rise  as  may  have  been  present  at  first 
disappears,  and  the  temperature  becomes  normal  or  subnormal,  and  the 
pulse  markedly  slow.  Otitic  abscess  may  be  situated  either  in  the  spheno- 
temporal  lobe,  the  cerebellum,  or,  less  often,  in  the  pons  or  cerebellar 
peduncle.  The  detailed  symptoms,  therefore,  vary  according  to  the  loca- 
tion. If  the  abscess  be  in  the  temporal  lobe  and  be  sufficiently  extensive  it 
may,  by  pressure  upon  the  basal  ganglia  and  capsules,  give  rise  to  paresis  of 
the  arm  and  leg  of  the  opposite  side,  and  other  symptoms,  such  as  spasms 
or  convulsions.  However,  the  capsule  itself  is  rarely  directly  involved. 
Hemiansesthesia  and  other  sensory  disturbances  have  not  been  reported. 
If  the  abscess  presses  forward  and  outward  it  may  act  upon  the  various 
centres  of  the  motor  area,  more  especially  upon  the  centres  nearest  to  it, 
such  as  the  facial  centre.  Paresis  or  spasms  of  the  face  of  the  opposite 
side  are  occasionally  observed.  If  the  abscess  be  upon  the  left  side,  motor 
aphasia  may  result  either  directly,  by  extension  of  the  abscess,  or  indirectly, 
by  pressure  on  the  third  frontal  convolution.  Most  firequently  this  motor 
aphasia  is  not  complete.  Word-deafness  and  psychic  blindness,  due  to 
disturbance  of  the  first  temporal  convolution  and  angular  gyrus  have 
also  been  recorded.  (Macewen.')  In  a  spheno-temporal  abscess  various 
cranial  nerves  are  also  apt  to  be  involved,  especially  the  oculo-motor.  Com- 
plete oculo-motor  palsy  is  not  infrequently  observed  ;  ptosis,  dilated  pupil  and 
external  strabismus  are  then  present  on  the  side  of  the  abscess.  The  abdu- 
cent nerve  also  occasionally  suffers,  and  in  rare  instances  the  trigeminal  may 
be  involved.     The  pathetic  nerve,  for  some  reason,  escapes. 

Optic  neuritis,  present  in  some  cases  and  absent  in  others,  will  not  enable 
us  to  distinguish  between  a  cerebellar  and  spheno-temporal  abscess,  nor  will 
it  aid  us  in  determining  the  side  upon  which  the  abscess  is  situated.  It  is, 
when  present,  sometimes  more  marked  upon  the  side  opposite  to  that  of  the 
abscess. 

If  abscess  be  present  in  the  cerebellum,  special  symptoms  may  be  alto- 
gether wanting.  However,  vomiting  is  apt  to  be  more  marked,  and  rigid- 
ity of  the  muscles  of  the  back  of  the  neck  is  frequently  present.  The 
headache  is  usually  occipital,  but  may  be  frontal.  Symptoms  of  inter- 
ference with  the  vermiform  process,  titubation,  and  ataxia  are  rarely,  if 
ever,  noted,  due,  doubtless,  to  the  fact  that  the  abscess  is  almost  always 
limited  to  the  lateral  lobe.''  Sometimes,  however,  the  speech  is  syllabic  and 
jerky,  such  as  is  seen  in  cerebellar  tumor.  Mace  wen  has  noted  especially 
rigidity  of  the  masseter  muscles.  Optic  neuritis  may  be  present,  but  is 
of  no  more  significance  than  in  abscess  of  the  temporal  lobe.  Due,  doubt- 
less, to  a  remote  effect  of  pressure,  dilated  pupils  and  general  oculo-motor 
paresis  is  sometimes  observed.  It  is  not  limited  to  the  side  of  the  abscess. 
Hemiparesis,  with  rigidity  of  the  muscles  of  the  same  or  opposite  side,  is 
occasionally  noted.  Mastoid  tenderness  is  not  usually  present,  unless  there 
be  a  complicating  thrombosis  of  the  lateral  sinus. 

If  the  abscess  be  in  the  pons,  special  symptoms  may  be  w^anting  unless  the 
abscess  be  large.  In  the  latter  instance,  crossed  hemiplegia,  double  hemi- 
plegia, or  other  lateral,  bilateral,  or  shifting  palsies  may  be  present.  Oculo- 
motor symptoms  may  also  be  observed. 

Abscesses  of  the  frontal  lobe  usually  present  a  significant  history.  Either 
they  are  caused  by  trauma,  or  there  is  more  or  less  marked  disease  of  the 
frontal  sinus.  The  symptoms  consist  of  somnolence,  frontal  headache,  and 
stupor,  preceded,  perhaps,  by  an  initial  chill.     The  temperature  pursues  a 

1  Maeewen :    Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal  Cord,  New  York,  1893,  case 
xxxvii. 

2  Koerner:  Loc  clt.,  pp.  105  and  106. 


378  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

course  similar  to  that  in  otitic  abscesses.  If  the  abscess  be  large,  it  may  pass 
sufficiently  far  back  to  interfere  with  the  motor  area,  and  thus  give  rise  to 
convulsions  and  hemiplegia.  If  it  exist  upon  the  left  side,  motor  aphasia 
may  be  one  of  the  symptoms  presented,  with  or  without  right  hemiplegia. 
According  to  Paget,  there  is  also  voracious  appetite  and  extreme  thirst.^ 

The  Course  of  Beain  Abscess.  The  course  of  brain  abscess  varies 
greatly  in  different  cases.  An  abscess  may  terminate  within  a  few  weeks, 
or  may  extend  over  many  months,  or  even  years.  In  some  cases  the  abscess, 
even  after  being  encapsulated,  may  become  permanently  quiescent.  Death 
ensues  in  inoperable  or  neglected  cases  either  from  profound  exhaustion, 
which  is,  perhaps,  the  most  common  termination,  or  from  the  rupture  of  the 
abscess  upon  the  surface  of  the  brain  or  into  the  ventricles,  or  by  its  encroach- 
ment upon  important  centres,  such  as  exist  in  the  medulla.  In  those  cases 
in  which  a  complicating  sinus  thrombosis  sets  in  death  may  result  from  gen- 
eral systemic  infection.  In  studying  cases  of  suspected  brain  abscess,  we 
should  always  bear  in  mind  that  departures  from  the  average  symptoma- 
tology are  not  uncommon.  This  is  due  not  only  to  such  frequent  complica- 
tions as  meningitis  and  sinus  thrombosis,  but  also  to  the  fact  that  the 
symptoms  are  often  but  slightly  pronounced,  or  that  they  are  at  times  alto- 
gether wanting.  Cases  in  which  an  abscess  has  pursued  an  entirely  symp- 
tomless course  from  beginning  to  end  are  recorded. 

Pathology.  Brain  abscesses  are  micro-organismal  in  origin.  This  is  true 
of  them  all.'''  The  pathogenic  organisms  most  frequently  found  are  the 
streptococcus  pyogenes  and  the  staphylococcus  pyogenes  aureus,  though  there 
may  be  an  admixture  of  other  forms.^  In  a  few  cases  the  oidium  albicans  has 
been  noted.  Among  rare  causes  of  brain  abscess  we  should  mention  actino- 
mycosis, a  few  cases  of  which  have  been  reported.  Tuberculous  disease  of  the 
middle  ear  or  of  the  cranial  bones  is  also  among  the  less  frequent  causes, 
the  membranes  being  more  likely  to  suffer  in  such  cases  than  the  brain  tissue. 
Primary  abscess  due  to  the  direct  localization  of  organisms  of  infectious 
fevers  is  rare.  These  lead  more  commonly  to  a  purulent  meningitis  or 
meningo-encephalitis.  Isolated  brain  abscesses  may,  however,  be  caused  by 
peculiar  localization  of  the  poison  of  cerebro-spinal  meningitis  or  erysipelas. 
The  pus  of  cerebral  abscess  is  greenish  or  greenish-yellow  in  color,  and  fetid. 

An  abscess  having  once  made  its  appearance,  it  steadily  increases  in  size, 
and  gradually  encroaches  uj)on  the  surrounding  brain  tissue.  In  a  large 
number  of  cases  this  surrounding  brain  tissue  forms  a  defensive  wall  about 
the  abscess  in  the  shape  of  a  capsule  or  pyogenic  membrane.  This  cap- 
sule is  generally  quite  soft  and  fragile  ;  rarely  it  is  firm.  The  capsule  does 
not  bring  about  a  cessation  in  the  formation  of  pus,  and  the  abscess  may 
finally  burst  and  infiltrate  the  surrounding  tissue,  or  discharge  into  the  meshes 
of  the  pia  arachnoid,  the  surface  of  the  brain,  or  into  the  lateral  ventricles. 
At  times,  if  the  rupture  extend  into  the  white  matter  only,  a  second  capsule 
may  form,  and  at  the  autoi^sy  one  encapsulated  abscess  may  be  found  inside 
of  another.  On  the  other  hand,  an  abscess  may,  by  the  formation  of  a 
capsule,  remain  quiescent  for  a  long  period  of  time,  or  may  even  become 
permanently  encysted.  Abscesses  are  much  more  frequently  met  with  in 
the  cerebrum  than  in  the  cerebellum,  and  are  quite  rare  in  the  pons  and 
medulla.  Further,  they  occur  more  frequently  in  the  right  hemisphere  than 
in  the  left,  though  metastatic  abscesses  appear  to  form  an  exception  to  this 
rule.     When  due  to  pyaemia  or  to  infection  from  distant  organs,  such  as  the 

1  Paget:  Trans.  Clinic.  Society,  1891,  xxiv.  p.  192. 

-  Martins,  loc.  cit. ;   also  Macewen,   Proceedings  of  Eleventh  International  Medical  Congress, 
Medical  News,  April  28,  1894,  d.  464. 
i"  Macewen,  loc.  cit. 


GENERAL  DISEASES  OF  THE  BBAIX.  379 

lungs,  they  are  generally  multiple.  When  secondary  to  disease  of  the  ear, 
of  the  frontal  sinuses,  of  the  orbits,  naso-pharynx,  etc.,  they  are  generally 
single.     This  is  also  the  case  when  they  are  due  to  trauma. 

Otitic  abscesses  are  found  in  the  spheno-temporal  lobe  about  twice  as  fre- 
quently as  in  the  cerebellum.  This  is  especially  true  in  children.  In  adults 
the  disproportion  is  not  so  great. 

The  more  frequent  complications  of  otitic  abscess  are  purulent  lepto-menin- 
gitis  and  sinus  thrombosis.  Judging  from  the  statistics  of  Hessler,^  in  about 
one-third  of  the  cases,  one  or  the  other  of  these  complications  exists.  Thus, 
of  106  cerebral  abscesses,  26  were  complicated  by  a  meningitis  and  13  by  a 
sinus  phlebitis — that  is,  in  spheno-temporal  abscess  meningitis  as  a  compli- 
cation occurs  about  twice  as  often  as  sinus  thrombosis.  Of  59  cerebellar 
abscesses,  only  6  were  complicated  by  meningitis  and  10  by  disease  of  the 
sinus.  In  spheno-temporal  abscess,  meningitis  occurs  in  one-fourth  the  num- 
ber of  cases,  in  cerebellar  abscesses  in  one-ninth.  In  the  former,  again,  sinus 
thrombosis  occurs  in  but  one-eighth,  Avhile  in  cerebellar  abscess  it  occurs  in 
one-sixth. 

It  should  also  be  borne  in  mind  that  external  purulent  pachymeningitis 
— i.  e.,  extia-dural  abscess — in  rare  cases  complicates  otitic  abscess. 

Diagnosis.  In  the  majority  of  cases  of  brain  abscess  the  symptoms  are 
such  as  suggest  organic  intra-cranial  disease.  The  headache,  the  vomiting, 
and  the  mental  condition  are  significant,  especially  when  taken  in  connec- 
tion with  the  history  of  the  case.  The  history  of  a  trauma,  of  the  sudden 
suppression  of  a  chronic  discharge  from  the  ear,  or,  it  may  be,  of  general 
septic  infection,  is  of  the  utmost  importance.  Many  of  the  symptoms  are 
common  to  both  tumor  and  meningitis ;  bvit  a  history  of  rigors,  irregular 
fever,  and  especially  of  subnormal  temperature,  points  to  abscess.  We 
should  bear  in  mind  that  optic  neuritis  is  either  not  present  at  all,  or,  if 
present,  is  rarely  as  marked  as  in  tumor.  Differentiation  from  menin- 
gitis depends  upon  the  fact  that  the  symptoms  are  rarely  as  generalized  as 
in  difilise  inflammation  of  the  membranes  of  the  base  or  vertex.  Diflferen- 
tiation  from  a  local  meningitis  is,  however,  not  always  possible,  inasmuch  as 
such  a  meningitis  is  often  present  as  a  complication. 

In  addition  to  the  history,  the  symptoms  of  most  value  in  enabling  us  to 
make  a  dilferential  diagnosis  are  those  arising  from  the  location  of  the 
abscess.  As  a  rule,  they  are  not  difiicult  of  recognition.  Thus,  in  abscess 
of  the  temporal  lobe  we  have  not  only  such  general  symptoms  as  headache, 
vomiting,  mental  disturbance,  and,  perhaps,  subnormal  temperature,  but  also, 
if  the  abscess  be  large,  various  local  phenomena  produced  by  its  destructive 
influence  and  pressure  upon  neighboring  structures,  e.  g.,  oculo-motor  and 
pupillary  changes,  weakness  and  convulsions  of  the  opposite  side  of  the  body, 
perhaps  various  forms  of  aphasia,  and,  it  may  be,  optic  neuritis. 

In  cerebellar  abscess  we  may  have  as  focal  symptoms  excessive  vomiting, 
rigidity  of  the  back  of  the  neck,  "  cerebellar  speech,"  and,  perhaps,  rigidity 
of  the  masseters,  as  pointed  out  in  the  section  on  Symptomatology.  On  the 
other  hand,  frontal  abscess  is  characterized  by  such  symptoms  as  stupor, 
coma,  and,  perhaps,  voracious  appetite,  convulsions,  and  aphasia.  The 
characteristics  of  pyemic  and  other  abscesses  have  also  been  pointed  out  in 
detail  in  considering  the  symptoms.  They  may  be  situated  in  the  occipital 
lobes,  giving  rise  to  certain  visual  symptoms,  or  in  the  motor  areas  and 
tracts,  giving  rise  to  focal  convulsions  and  palsies. 

In  order  to  assist  in  the  diagnosis  of  a  cranial  abscess,  INIacewen  has 
studied  the  differential  cranial  percussion  note.     "The  percussion  note  is 

1  Quoted  by  Koerner,  loc.  cit.,  p.  110. 


380  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

obtained  by  the  cranial  walls  vibrating  when  struck,  the  note  being  modified 
by  the  consistency  and  volume  of  the  contents  and  their  relative  position  to 
the  bone."^  The  test  is  applicable  especially  to  children.  The  percussion 
note  in  a  healthy  child  is  dull,  and  nearly  equally  distributed  over  the 
vault  of  the  skull.  Any  increase  of  density  or  of  tension  of  the  cranial  con- 
tents beneath  the  point  percussed  makes  the  note  clearer. 

The  possibility  of  the  existence  of  a  complicating  sinus  thrombosis  should 
always  be  borne  in  mind,  especially  in  cerebellar  abscess,  and  the  character- 
istic symptoms  should  be  sought  for.     (See  p.  366.) 

Prognosis  The  prognosis  of  brain  abscess  is  always  serious.  Unless  sur- 
gical interference  is  possible,  a  fatal  termination  sooner  or  later  supervenes 
in  the  vast  majority  of  cases.  Brain  surgery,  however,  has  made  such  enor- 
mous strides  that  when  the  diagnosis  is  made  sufficiently  early,  and  the 
abscess  is  surgically  accessible,  the  condition  constitutes,  in  the  words  of 
Macewen,  "one  of  the  most  hopeful  of  all  cerebral  affections."  Many 
instances  are  on  record  in  which  trephining  has  been  successililly  performed, 
the  abscess  evacuated  and  drained,  the  operation  being  followed  by  excellent 
recovery. 

Treatment.  The  treatment  of  brain  abscess  is  a  surgical  one  only.  Every- 
thing depends  upon  the  promptness  and  accuracy  of  the  diagnosis.  As  soon 
as  an  abscess  is  diagnosed,  or,  in  fact,  even  suspected,  provided  localizing 
symptoms  present  themselves,  exploratory  trephining  should  be  undertaken. 
For  the  detailed  procedure  in  these  cases,  as  well  as  the  after-treatment,  the 
reader  is  referred  to  the  section  on  Surgery. 

'  1  Macewen,  loc.  cit.,  p.  146. 


CHAPTER  XIV. 

THE  ANATOMY  OF  THE  CEREBRAL  CORTEX  AND  THE 
LOCALIZATION  OF  ITS  FUNCTIONS. 

By  CHARLES  K.  MILLS,  M.D. 


The  surface  of  the  cerebrum  is  a  convoluted  arrangement  of  gray  matter 
known  as  the  cortex,  the  depth  of  which  varies  considerably  with  age,  sex, 
and  in  different  regions  of  the  same  hemisphere,  and  also  in  different  indi- 
viduals, in  accordance  with  development  or  disease.  Its  variations  are  usually 
given  as  between  two  and  three  millimetres,  but  exceptionally  it  may  be  as 
thin  as  one-and-one-fifth  millimetres,  or  as  thick  as  four.  It  varies  much 
less  among  women  than  among  men  at  different  periods.  The  maximum 
depth  is  at  the  crest  of  the  convolutions,  the  minimum  near  the  occipital 
pole.  According  to  Obersteiner,'  its  maximum  depth  regionally  is  attained 
in  the  paracentral  lobe,  its  minimum  near  the  occipital  pole.  Conti'^  found 
that  from  the  postcentral  gyrus  caudad  to  the  occipital  lobe  the  thickness  of 
the  cortex  diminished,  and  that  it  was  at  its  minimum  in  the  region  of  Mey- 
nert's  calcarine  type  of  eight  layers,  the  diminution  being  so  rapid  as  to  be 
perceptible  in  sections  one  centimetre  apart.  The  thickness  of  the  cortex  of 
the  parietal  lobe  is  greater  on  the  mesal  than  on  the  lateral  surface. 

Donaldson^  compared  the  cortex  of  the  brain  of  the  blind  deaf-mute, 
Laura  Dewey  Bridgman,  with  nine  normal  brains,  and  concluded  that  no 
figures  can  be  given  for  the  average  thickness  of  the  fresh  normal  cortex. 
Other  conclusions  by  him  were  that  persons  with  an  acquired  defect  of  the 
central  nervous  system  have  a  cortex  thinner  than  normal ;  that  females 
have  a  slightly  thinner  cortex  than  males ;  that  normally  the  right  hemi- 
sphere has  a  cortex  slightly  less  in  thickness  than  the  left,  the  maximum 
difference  being  seven  per  cent.  Laura  Bridgman's  cortex  was  abnormally 
thin,  having  but  eighty-nine  per  cent,  of  the  thickness  of  the  controls,  and 
containing  an  abnormally  large  number  of  small  nerve  cells.  His  conclu- 
sions with  reference  to  special  areas  of  the  cortex  will  be  referred  to  later. 

The  amount  of  gray  matter  in  the  surface  of  the  brain  has  interested  a 
number  of  investigators,  and  it  may  be  of  practical  value,  among  other 
things,  to  determine,  as  was  done  by  Donaldson,  whether  portions  of  the 
cortex  suspected  to  be  defective,  and  which  belong  to  one  hemisj^here,  will 
prove  to  have  a  less  area  when  the  two  hemispheres  are  compared  with  one 
another.  Donaldson,  besides  the  report  of  his  own  important  investigations, 
has  given  a  summary  of  the  work  done  by  others. 

The  older  attempts  to  estimate  the  relative  extent  of  different  regions  of 

1  H.  Obersteiner  :  The  Anatomy  of  the  Central  Nervous  Organs.  Translated  by  Alex.  Hill,  Phila- 
delphia, 1890,  p.  350. 

2  Alfredo  Conti :  Sur  I'Epaisseur  de  I'Ecorce  du  Cerveau  Humain.  Cited  by  Jules  Soury  in  Les 
Fonctions  du  Cerveau,  Paris,  1892,  p.  334. 

3  Henry  H.  Donaldson  :  Anatomical  Observations  on  the  Brain  and  Several  Sense  Organs  of  the 
Blind  Deaf-mute,  Laura  Dewey  Bridgman.  The  American  Journal  of  Psychology,  September,  1890, 
vol.  iii.  No.  3,  p.  293,  and  December,  1891,  vol.  iv.  No.  2,  p.  248. 


382 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  cerebral  cortex  were  mostly  made  with  a  view  of  determining  the  rela- 
tions of  certain  areas  of  the  brain  to  the  degrees  of  intelligence.  R.  and  H. 
Wagner/  for  example,  endeavored  to  make  accurate  comparisons  in  this  way 
between  the  brains  of  individuals  of  acknowledged  mental  ability  and  those 
of  persons  of  ordinary  or  inferior  capacity.  In  the  following  table  are 
given  comparative  measurements  of  the  extent  of  the  surface  of  the  convo- 
lutions of  two  men  of  acknowledged  eminence  and  ability,  and  of  two  others 
of  ordinary  capacity : 

Comparative  Measurement  of  the  Extent  of  Surface  of  Cerebral 

Convolutions. 


Surface  of  each  lobe  separately. 

Free  and  deep 

surfaces  of 
convolutions. 

Whole 
surface 

Frontal. 

Parietal. 

Occipital. 

Temporal 

Central. 

Free  sur- 
face. 

Deep  sur- 
face, in- 
cluding 
surface 

of  insula. 

of 
cere- 
brum. 

1.  Gauss    .    .    . 

2.  Fuchs    .    .    . 

3.  Woman .    .    . 

4.  Workman  .    . 

89,545 
92,380 
84,318 
72,890 

45,493 

44,783 
41,838 
40,142 

38,286 
37,927 
32,851 
32,490 

44,062 
43,468 
42,982 
39,880 

2,252 
2,447 
2,126 
2,270 

72,650 
72,100 
68,900 
62,750 

146,988 
148,905 
135,215 
124,922 

219,638 
221,005 
204,115 
187,672 

The  methods  of  making  these  determinations  are  necessarily  tedious  and 
troublesome,  but  by  such  measurements  either  new  views  or  corroboration  of 
old  ones  as  to  cerebral  localization  may  sometimes  be  obtained.  Various 
methods  have  been  adopted  by  different  investigators.  In  the  Bridgman 
case  thin  sheets  of  flexible  gelatine  were  laid  on  the  surface,  and  outlines  of 
the  gyri  were  traced  with  India  ink.  Copies  were  taken  on  tracing  paper, 
and  numbered.  The  length  and  depth  of  the  sulci  were  also  taken,  and 
calculations  of  the  sunken  surface  were  made. 

The  specific  weight  of  the  gray  substance,  whether  cortical  or  ganglionic, 
is  less  than  that  of  the  white.  The  latter  attains  its  maximum  from  the 
fiftieth  to  the  sixtieth  year,  the  former  from  the  fortieth  to  the  fiftieth  year. 
The  gray  matter  is  in  larger  quantity  in  man  than  in  woman ;  the  white 
substance  is  more  abundant  in  woman  than  in  man.  The  cortex  may  man- 
ifestly diminish  in  old  age.  The  preponderance  in  weight  of  the  white 
substance  does  not  indicate  that  it  has  higher  functions  than  the  gray, 
but  this  superiority  is  apparently  dependent  upon  the  abundance  of  its 
neuroglia. 

The  following  is  a  table  by  Baistrocchi^  of  the  mean  specific  weight  of  the 
brain  and  spinal  cord  : 

Males.  Females. 

White  substance  of  the  hemispheres 1.0273  1.0289 

Gray  substance 1.0206  1.0239 

Entire  brain 1.0265  1.033S 

Mantle  or  cortex 1.0278  1.0286 

striatum  and  thalamus 1.0453  1.0446 

Midbrain  and  cerebellum 1.0479  1.0584 

Spinal  cord 1.0387  1.0318 


1  H.  Wagner :  Maasbestimmungen  der  Oberflache  des  grossen  Gehirns,  Inaug.  Diss.  Gottingen, 
1864.    Cited  in  Quain's  Anatomy,  1893,  vol.  iii.  part  i.  p.  177. 

"  E.  Baislrocchi :  Sul  peso  specifico  dell'  encefalo  umano,  sue  parti  e  del  midollo  spinale  e  sulla 
determinazione  quantitiva  della  sostanze  bianca  e  della  grigia.  Rive,  speriment.  di  fren.,  1884,  vol. 
X.  p.  193.    Cited  by  Soury,  p.  336. 


ANATOMY  OF  THE  CEREBRAL  CORTEX. 


38^ 


The  cerebral  cortex  should  be  studied  from  the  points  of  view  of  its  gross 
anatomy,  hemispherical,  lobar,  fissural,  and  gyral ;  of  its  minute  anatomy, 
including  the  nature  and  arrangements  of  the  elements  of  the  cortex,  and  its 
methods  of  lamination ;  of  its  circulation,  especially  its  arterial  supply,  and 
the  independence  of  various  distributions ;  and  of  the  embryological,  physio- 
logical, and  clinicopathological  facts  that  indicate  its  functional  subdivisions. 

Fig.  8C. 


Lobes  of  the  cerebrum ;  lateral  aspect. 
Fig.  81. 


Lobes  of  the  cerebrum ;  mesal  aspect. 


As  the  circulation  of  the  brain  will  be  considered  in  another  chapter,  it  Avill 
only  be  incidentally  referred  to  here. 

The  cerebrum  is  divided  into  two  hemispheres  or  hemicerebrums  by  the 
longitudinal  fissure,  and  each  hemisphere  is  subdivided  into  lobes,  the  special 


384 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


method  of  subdivision  varying  somewhat  with  different  authors.  The  okl 
lobar  subdivision  is  into  an  anterior  or  frontal,  a  middle  or  parietal,  a  pos- 
terior or  occipital,  and  an  inferior  temporal  or  temporo-sphenoidal ;  and  for 
the  lateral  surface  of  the  cerebrum  this  subdivision  continues  to  be  the  one 
commonly  used  by  anatomists ;  but  on  the  median  surface  a  limbic  lobe  has 
been  suggested  by  Broca,  and  a  falciform  lobe  by  Schwalbe.  The  falciform 
lobe  consists  of  that  portion  of  the  cerebrum  which  surrounds  the  callosum, 
and,  in  addition,  the  fascia  dentata,  fornix,  and  septum  lucidum,  which  are 
not  visible  to  external  inspection  of  the  cortex.  The  terms  falciform  lobe 
and  limbic  lobe  are  sometimes  used  synonymously ;  but  the  limbic  lobe  of 
Broca  is  only  the  outer  segment  of  the  falciform  lobe,  the  part  formed  by 
the  callosal  convolution  or  gyrus  fornicatus  and  the  uncinate  convolution. 

Fig.  82. 


Diagram  of  the  falciform  lobe  of  Schwalbe ;  limbic  lobe  of  Schafer. 

ATiatomy.) 


(ScHAEFER,  in  Quain's 


In  Figs.  80  and  81  are  shown  the  subdivisions  of  the  lateral  and  mesal 
surfaces  of  the  cerebrum  into  lobes.  The  frontal  lobe  on  its  mesal  aspect  is 
sometimes  subdivided  in  the  marginal  and  paracentral  lobule  as  indicated. 
Fig.  82  is  a  diagram  from  Quain's  Anatomy  of  the  falciform,  or,  as  it  has 
been  called,  the  limbic  lobe.  To  the  parts  included  by  Schwalbe,  as  men- 
tioned above,  are  added  the  supercallosal  gyrus,  represented  in  man  by  the 
longitudinal  striae  of  the  callosum,  the  peduncles  of  the  callosum,  and  an- 
other rudimentary  gyrus  underneath  the  callosum  called  the  gyrus  infracal- 
losus  or  gyrus  fornicis. 

Instead  of  this  subdivision  into  anatomical  lobes,  the  cortex,  in  accordance 
with  its  functions  so  far  as  they  are  known,  may  be  conveniently  subdivided 
into  physiological  lobes — motor,  sensory,  visual,  auditory,  olfactory,  gusta- 
tory, and  for  the  higher  psychical  functions — a  subdivision  which  will  l)e 
more  fully  indicated  when  enumerating  special  zones  and  centres. 

A  distinction  is  often  made  between  fissures  and  sulci,  but  it  is  best,  fol- 


ANAT03fY  OF  THE  CEBEBBAL  CORTEX.  385 

lowing  Wilder,  to  designate  all  cerebral  depressions  as  fissures,  using  "  sulci " 
simply  as  a  synonym.  The  main  guide  to  the  study  of  the  most  usual  ar- 
rangement of  fissures  and  gyres  of  the  brain  surface  has  been  for  many  years 
the  diagrams  of  Ecker,'  which,  with  modifications  and  improvements  sug- 
gested by  Wilder,^  Eberstaller,"  Cunningham,*  and  others  are  still  reliable 
for  teaching  purposes. 

Certain  fissures  have  ental  correlatives  or  colliculi,  that  is,  internal  parts 
corresponding  to  them,  and  these  are  designated  as  total  fissures.  They  are 
given  by  Wilder  as  follows  : 

Fissures.  Colliculi. 

1.  Calcarine    ....    Calcar. 


2.  Callosal 

3.  Collateral    . 

4.  Hippocampal 

5.  Occipital 


Callosal  eminence  (in  the  fcBtus  only).  (?) 

Collateral  eminence. 

Hippocamp. 

Occipital  eminence  in  the  fcetus,  lamboidal  suture  in  the  adult. 


Other  fissures  are  called  partial,  and  these  fissures  may  be  either  constant 
or  inconstant,  that  is,  invariably  present  or  sometimes  present  and  sometimes 
absent  (Wilder). 

Deeply  placed  within  the  Sylvian  fissure,  and,  as  a  rule,  only  visible  when 
its  lips  are  pulled  apart,  is  the  insula  or  island  of  Reil,  which  is  not  as  com- 
pletely covered  in  the  negro  as  in  the  white  brain,  and  is  more  or  less  exposed 
in  arrested  and  aberrant  brains.  Operculum,  which  means  lid  or  cover,  is  in 
common  use  as  a  general  descriptive  term  for  each  of  the  gyres  which  over- 
lap the  insula.  According  to  Wilder,  the  insula  is  a  subgyre,  having  been 
gradually  covered  more  or  less  by  the  converging  folds  of  adjacent  regions. 
The  operculum,  preoperculum,  suboperculum,  and  postoperculum,  parts  over- 
lapping it  on  all  sides,  are  supergyres. 

The  insula  may  be  regarded  as  a  true  cerebral  lobe,  and  is  sometimes  de- 
scribed as  the  central  lobe.  Embryologically,  it  corresponds  to  the  floor  of 
the  Sylvian  fossa.  It  is  overlapped  above  by  the  operculum  and  below  by 
the  temporal  lobe.  It  is  roughly  triangular,  with  the  base  upward  and  inter- 
nal, and  is  grooved  somewhat  like  an  open  fan  with  a  series  of  nearly  straight 
gyres,  usually  four  or  six  in  number,  called  the  gyri  operti,  or  concealed 
gyres.  A  curved  farrow  nearly  surrounds  the  insula.  One  of  the  insular 
fissures,  known  as  the  central  fissure  of  the  insula,  is  large  and  very  constant, 
running  in  the  same  general  direction  as  the  central  fissure  of  the  hemisphere. 
This  divides  the  island  into  two  parts,  an  anterior  or  cephalic,  and  a  posterior 
or  caudal  portion,  the  latter  being  the  smaller  of  the  two.  Eberstaller,  Cun- 
ningham, and  others  have  shown  a  close  coi"resj)ondence  between  the  gyres 
and  sulci  of  the  insula  and  those  on  the  lateral  surface  of  the  hemispheres. 
They  believe  its  two  central  gyres  correspond  with  the  two  central  convolu- 
tions which  bound  the  fissure  of  Rolando,  and  that  its  three  fissures  are  com- 
parable with  the  precentral,  central,  and  retrocentral  fissures  of  the  brain 
mantle ;  and  not  infrequently  something  which  approaches  very  nearly  to  a 
continuity  of  these  fissures  is  observed.  Variations  of  the  gyres  of  the  insula 
go  hand-in-hand  with  variations  in  the  fronto-parietal  region.  Fig.  83  is  a 
view,  after  Eberstaller,  of  the  fissures  and  gyres  of  the  insula.  The  postei'ior 
portion  of  the  insula  is  seen  at  4  and  5.     This  part  is  usually  termed  the  pars 

1  Alexander  Ecker  :  On  the  Convolutions  of  the  Human  Brain.  Translated  by  John  C.  Galton, 
London.  1873. 

-  Burt  G.  Wilder  :  Brain  ;  Gross  or  Macroscopic  Anatomy.  Reference  Handbook  of  the  Medical 
Sciences,  vol.  viii,  1889,  pp.  107-164.  Supplement,  vol.  ix.  pp.  99-111.  American  Reports  upon  Ana- 
tomical Nomenclature,  1889, 1890.  Extract  from  the  Proceedings  of  the  American  Association  for 
the  Advancement  of  Science,  vol.  xxxviii.  1889,  p  26.  The  Fundamental  Principles  of  Anatomictil 
Nomenclature,  Medical  News,  Philadelphia,  December  19,  1891,  vol.  lix.  p.  708. 

■■'  Oscar  Eberstaller  :  Das  Stirnhirn.    Vienna  and  Leipzig,  1890. 

■*  D.  J.  Cunningham  :  Manual  of  Practical  Anatomy,  Edinburgh  and  London,  1894.  Contribution 
to  the  Surface  Anatomy  of  the  Cerebral  Hemispheres.    Dublin,  1892. 

25 


386 


NERVOUS  DISEASES  ANB  THEIR  TREATMENT. 


temporo-parietalis,  but,  according  to  Cunuiugham,  a  study  of  the  develop- 
ment of  this  part  of  the  island  has  shown  "that  it  is  connected  with  the 
falciform  lobe,  and  not  with  the  temporal,  and  he  suggests  to  call  it  the  pars 
parietofalciformis. 


Fig.  83. 


s.R.s. 


sBa 


g.tr.l. %_ 


Fissures  and  gyri  on  the  surface  of  the  insula  :  1,  2,  and  3.  Three  short  gyri  on  the  frontal  part  of 
the  insula.  4  and  5.  Two  gyri  on  parietolimbic  part.  s.R.a.  Anterior  limiting  sulcus.  s.R.s.  Superior 
limiting  sulcus.  s.JJ.p.  Inferior  limiting  sulcus.  Z.  Limen  insula.  P.  Pole  of  the  insula,  i^.  Orbital 
operculum  (for  the  most  part  removed).  3\.  First  temporal  gyrus.  T^,.  Second  temporal  gyrus. 
X,  y.  Gyri  of  Heschl.  sc.  Sulcus  centralis  insulee.  m.  Gyri  on  deep  surface  of  temporal  pole. 
(Ebeestallee.) 


Fig.  84. 


Brain  showing  cross-formation  of  the  supertemporal  gyre,  and  confluence  between  the  cephalic 
half  of  the  supertemporal  fissure  and  the  fissure  separating  the  most  cephalic  of  the  retroinsular 
convolutions.  The  other  retroinsular  gyres  blend  with  the  caudal  portion  of  the  supertemporal 
convolution. 

Caudad  of  the  insula,  at  .v  and  y,  are  seen  two  convolutions,  or  parts  of  two 
convolutions,  crossing  the  Sylvian  fossa,  and  uniting  the  temporal  with  the 
parietal  lobes.  These  have  been  designated  as  the  retromsular  or  tempero- 
parietal  convolutions,  or  the  transverse  convolutions  of  Heschl.  In  a  number 
of  human  brains  I  have  observed  cross-fissuration  of  the  first  temporal  con- 
volution,'indicating  a  tendency  to  confluence  between  the  anterior  portion  of 
the  supertemporal  fissure  and  the  fissure  which  separates  the  two  most  anterior 
retroinsular  convolutions.    Fig.  84  shows  this  relationship.    The  parts  played 


ANAT03IY  OF  THE  CEREBRAL  CORTEX. 


387 


by  the  insula  and  the  retroinsular  convokitions  are  still  obscure  and  are  to 
be  solved  in  all  probability  as  much  by  embryological  study  as  by  clinical 
and  pathological  observation. 

The  study  of  the  anatomy  of  the  cerebral  surface  has  been  made  more 
difficult  by  the  different  names  Avhich  have  been  given  to  the  same  fissures 
and  gyres,  and  also  by  the  differences  of  opinion  between  authorities  appar- 
ently equally  competent  regarding  the  multiplication  of  fissural  integers. 
One  includes  in  his  schemes  and  diagrams  more  secondary  fissures  than 
others ;  one  describes  a  principal  fissure  as  single ;  another  as  if  usually 
divided  into  two  parts  ;  and  still  another  as  if  it  consisted  of  three  parts. 

A  close  study  of  diagrams  and  legends  of  Ecker,  Wilder,  and  Cunningham 
will  show  these  differences,  but  it  may  be  well  to  emphasize  and  summarize 
a  few  of  the  most  important  features.  Both  Wilder  and  Eberstaller  recog- 
nize fissural  integers  not  accepted  by  Ecker,  and  in  some  cases  divide  fissures 
and  gyres,  regarded  by  the  latter  as  single,  into  two  or  more  components. 
Wilder  makes  of  the  precentral  fissures  a  supercentral  and  a  precentral ;  he 

Fig  85. 


Olfactory  f. 
,     Basisylvicui  f. 

Lateral  aspect  of  the  left  hemicerebrum  :  A.  Angular  gyrus.  M.  Marginal  (or  supramarginal) 
gyrus,  f.  Fissure,  g.  Gyrus,  preop.,  preoperculum.  2.  Subcentral  fissure.  The  Interrogation 
points  near  the  caudal  end  indicate  Professor  Wilder's  doubts  as  to  the  existence  of  constant  fissures 
In  these  places,  or  as  to  what  they  should  be  called  if  they  do  exist,    (Wilder.) 


subdivides  the  second  frontal  convolution  into  two  parts,  and  submits  the  in- 
terparietal fissures  to  the  same  process  of  subdivision.  Ebertstaller  has  car- 
ried the  multiplication  of  fissural  integers  to  even  a  greater  length,  and  yet 
anyone  familiar  with  human  brains,  from  actual  study,  will  be  willing  to 
concede  that  his  anatomical  scheme  has  been  constructed  from  actual  obser- 
vation. Let  me  call  attention  to  a  few  of  the  special  features  in  Eber- 
staller's  diagram.  Instead  of  the  single  precentral  fissure  of  Ecker,  he 
figures  an  inferior,  a  superior,  and  a  median  precentral  sulcus ;  the  single 
interparietal  fissure  of  Ecker  is  divided  by  him  into  three  parts,  which  he 
names  respectively  the  inferior  retrocentral  sulcus,  the  interparietal  sulcus, 
and  the  anterior  occipital  or  outer  perpendicular  fissure,  giving  also  a 
superior  retrocentral  and  a  transverse  retrocentral  sulcus.  In  the  lateral 
prefrontal  region  are  given  a  superior  and  inferior  frontal  sulcus  after  the 


388 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


manner  of  Ecker,  and,  in  addition,  a  median  frontal  sulcus,  in  this  respect 
following  Wilder ;  he  also  figures  a  diagonal  opercular  sulcus  and  a  radiating 
frontal  sulcus,  and  subdivides  the  frontomarginal  or  orbitomarginal  sulcus 
into  three  parts.  The  subdivision  of  the  second  frontal  convolution  into  a 
median  and  lateral  layer,  and  of  the  third  frontal  into  a  basal  ascending 
and  triangular  portion  are  also  peculiar  to  his  diagram,  and,  judging  from 
my  own  observations,  in  accordance  with  what  is  usually  found  in  Nature. 
Instead  of  a  transverse  occipital  and  inferior  longitudinal  occipital  sulcus,  he 
has  as  an  anterior  outer  perpendicular  or  ape  fissure,  and  a  lateral  occipital 
fissure.  These  additions  of  Eberstaller  will  prove  useful  in  recording  autop- 
sies and  in  making  histological  examinations  of  particular  regions  of  the 
brain. 

Fig.  86. 


Amygdaline  f. 


Mesal  aspect  of  the  right  hemicerebrum  :  g.  Gyrus.  /.  Fissure,  ocde.  f.  Occalcarine  fissure  for 
oecipito-calearine,  the  common  stem  of  the  fissures  demarcating  the  cuneus.  3.  Cuneolus ;  the  fissure 
cephalad  of  it  is  the  adoccipital.    (Wildee.) 


The  inflected  fissure  (see  Figs.  85  and  86),  first  described  by  Lussana  and 
Lemoigne,  is  a  short  fissure  or  indentation  cutting  the  median  edge  of  the 
hemisphere  a  little  cephalad  of  the  precentral  fissure.  It  is  very  seldom 
absent  in  the  adult  human  brain ;  in  a  large  number  of  human  brains  ex- 
amined by  me  it  has  always  been  present.  Wilder  says  that  at  first  glance 
it  suggests  the  cruciate  fissure  of  the  carnivora,  but  he  is  not  willing  to 
admit  this  homology  without  further  investigation.  The  confusion  caused 
by  a  multitude  of  names  is  well  illustrated  in  considering  this  fissure ;  it  was 
"  first  described  by  Lussana  as  solco  inflesso,  which  was  anglicized  by  Wilder 
as  inflected  fissure;  by  Broca  it  Avas  called  incisure  py^eovalarie,  and  by 
Schwalbe  sulcus  paracentralis ;  while  Eberstaller  calls  it  sulcus  medialis" 
(Wilder).  The  callosal  fissure,  as  already  described,  is  the  space  between 
the  dorsal  aspect  of  the  callosum  and  the  overhanging  cortex.  The  precu- 
neal fissure  is  a  small  right-angled  or  T-shaped  fissure  in  the  central  portion 
of  the  precuneus.  The  medifrontal  fissure,  first  named  by  Owen,  is  an  in- 
consistent fissure  which  sometimes  divides  the  second  frontal  convolution 
into  two  parts.  It  is  figured  by  Wilder,  but  is  not  always  present,  or  at  least 
is  not  always  distinctive.     Benedikt  holds  that  the  three-fissure  or  four- 


ANATOMY  OF  THE  CEREBRAL  CORTEX. 


389 


convolution  type  of  the  frontal  lobe  is  a  peculiarity  of  the  brains  of  many 
criminals. 

The  amygdaline  fissure  (see  Figs.  85  and  86),  which  is  usually  distinct  but 
small,  appears  upon  the  mesoventral  aspect  of  the  temporal  lobe,  near  its  tip, 
extending  caudad  for  ^  cm.  from  the  horizontal  portion  of  the  Sylvan  fissure, 
between  the  ventrocephalic  ends  of  the  hippocampal  and  collateral  fissures 
(Wilder).  Owen  and  Broca  recognized  this  fissure,  the  former  calling  it 
basirhinal.  Wilder's  name  was  postrhinal,  but  believing  it  might  have  a 
constant  ental  part,  the  amygdala,  he  later  suggested  amygdaline. 


Fig.  87. 


-^-P 


View  of  the  brain  from  above :  F.  Frontal  lobe.  P.  Parietal  lobe.  0.  Occipital  lobe.  S.  End  of 
the  horizontal  branch  of  the  fissura  Sylvii.  C.  Central  fissure  or  fissure  of  Rolando.  A.  Anterior 
central  or  ascending  frontal  convolution.  B.  Posterior  central  or  ascending  parietal  convolution. 
J'l.  Upper.  F.,.  Middle.  F-i-  Lower  frontal  convolution,  /i.  Superior  frontal  sulcus,  f...  Inferior 
frontal  sulcus,  /a.  Vertical  fissure  (sulcus  prajcentralis).  Pi.  Upper  or  posteroparietal  lobule.  Po. 
Lower  parietal  lobule,  constituted  by  Po,  gyrus  supramarginalis.  Po'.  Gyrus  anguiaris.  ip.  Inter- 
parietal sulcus,  cm.  Callosomarginal  sulcus,  po.  Parieto-occipital  fissure,  h.  Upper  temporal 
fissure.  Oi.  First  occipital  convolution.  Oj.  Second  occipital  convolution,  o.  Sulcus  occipitalis 
transversus.  (Ecker). 

The  subtemporal  fissure  is  an  inconstant  fissure  sometimes  placed  between 
the  third  or  subtemporal  convolution  and  the  fourth  (subcollateral  or  fusi- 
form). Unfortunately,  Eberstaller  has  applied  this  name  to  a  figuration 
on  the  mesal  aspect  of  the  cerebrum.  The  exoccipital  fissure  of  Wilder  (see 
Fig.  85)  is  an  independent  fissure  l)etween  the  occipital  and  temporal  regions 
on  the  lateral  aspect  of  the  hemisphere ;  when  present  it  is  nearly  vertical, 


390  NEBVO  US  DISEASES  AXD  THEIR  TREATMENT. 

and  has  been  described  by  Benedikt  as  AYernicke's  fissure.  It  is  also  known 
as  the  ape-fissure,  because  it  is  homologous  with  the  inferior  portion  of  the 
external  perpendicular  fissure  of  the  ape.  The  late  A.  J.  Parker  proposed 
for  it  the  name  occipito-temporal  fissure.  It  is  best  defined  in  low-type 
human  brains — those  which  approach  ape-like  conformations.  In  the  brain 
of  a  criminal  paranoiac  I  have  seen  it  almost  as  well  defined  as  in  the  ape. 

Fissures  universally  admitted  to  be  of  the  first  importance  are  the  fissure 
of  Sylvius,  the  central  fissure  or  the  fissure  of  Rolando,  the  parieto-occipital 
fissure  (occipital  of  ^Yilder),  and  the  calcarine  fissure.  These,  with  the  cal- 
losal,  the  supercallosal  or  callosomargiual,  and  the  collateral  fissures  are  the 
boundaries  of  the  lobes.  The  Sylvian  fissure  has  a  well-defined  course  both 
at  the  base  and  on  the  lateral  aspect  of  the  brain.  At  the  base,  passing 
toward  the  lateral  convexity,  it  separates  the  cephalic  extremity  of  the  tem- 
poral lobe  from  the  orbital  surface  of  the  frontal,  and  on  the  lateral  con- 
vexity divides  into  an  anterior  ascending  limb,  Avhich  is  usually  short,  and 
into  a  longer  and  more  horizontal  posterior  limb,  which  forms  a  boundary 
between  the  temporal  and  portions  of  both  the  frontal  and  parietal  lobes. 

The  central  fissure,  or  fissure  of  Rolando,  is  usually  deep  and  una- 
bridged, running  from  above  downward  and  a  little  forward,  nearly  midway 
between  the  cej)halic  and  caudal  extremities  of  the  cerebrum,  as  a  rule, 
beginning  close  to  the  longitudinal  and  extending  nearly  to  the  Sylvian 
fissure.  Sometimes  it  really  or  apparently  passes  into  the  longitudinal 
fissure,  but  usually  the  confluence  is  apparent,  bridging  fibres  being  present 
below  the  crests  of  the  bounding  convolutions.  In  rare  instances  it  runs 
into  the  Sylvian  fissure,  and  it  may  be  duplicated,  but  this  is  a  very  rare 
occurrence.  As  both  the  precentral  and  the  retrocentral  fissures  are  some- 
times nearly  as  large  as  the  central,  either  of  these  may,  to  one  not  versed 
in  cerebral  anatomy,  appear  to  be  a  duplicated  central  fissure.  This  dupli- 
cation sometimes  really  occurs.  At  the  meeting  of  the  American  Neuro- 
logical Association  in  1894,  Professor  Wilder  exhibited  a  brain  in  which 
apparently  two  central  fissures  were  present  on  each  side ;  and  other  in- 
stances of  this  have  been  recorded  by  Giacomini,  Calori,  and  Debierre. 

The  parieto-occipital  fissure  of  Ecker  (occipital  of  Wilder)  is  seen  from 
the  lateral  aspect  of  the  cerebrum  in  the  median  edge  of  the  hemisphere, 
about  half-way  between  the  upper  extremity  of  the  central  fissure  and  the 
occipital  pole.  It  extends  as  a  deep  and  well-defined  fissure  on  the  mesal 
surface,  and  serves  as  the  main  demarcation  between  the  j^arietal  and  occipi- 
tal lobes. 

The  calcarine  fissure,  one  of  the  most  important  cerebral  fissures,  corre- 
sponds in  position  in  its  anterior  j)art  to  the  postcornu,  and  has  for  its  ental 
correlative  the  calcar  or  hippocampus  minor.  It  unites  with  the  parieto- 
occipital fissure  to  form  a  Y-shaped  figure,  which  includes  the  gyral  mass 
knoAvn  as  the  cuneus  or  wedge.  At  its  posterior  extremity  it  is  usually 
forked,  but  this  extremity  is  sometimes  independent  of  the  main  fissure,  and 
has  been  termed  the  sulcus  extremis  by  Schwalbe.  The  stem  of  the  Y,  which 
is  the  common  stem  of  the  calcarine  and  the  parieto-occipital  fissure,  is  gen- 
erally considered  an  extensiou  of  the  former.  Wilder  designates  it  as  the 
occalcarine  fissure.  Occasionally  it  runs  into  the  hippocamjDal  fissure.  In 
the  brain  of  a  paranoiac  criminal  examined  by  me  this  confluence  was 
nearly  complete.     I  have  also  seen  the  calcarine  fissure  bridged. 

The  callosal  fissure  is  the  space  between  the  dorsal  aspect  of  the  callosum 
and  the  overhanging  cortex.  The  callosomargiual,  or  supercallosal  fissure  of 
Wilder,  extends  ft'om  before  backward  along  the  mesal  surface  of  the  hemi- 
sphere, for  the  most  of  its  length  parallel  with  the  callosum  and  nearly  mid- 
way between  it  and  the  edge  of  the  hemisphere.     Caudad  it  turns  upward 


ANATOMY  OF  THE  CEREBRAL  CORTEX. 


391 


until  it  reaches  the  edge  of  the  hemisphere,  and  cephalad  it  follows  the 
curve  of  the  knee  of  the  callosum.  It  is  occasionally  divided  into  two  or 
even  three  parts.  Its  caudal  curve  forms  the  posterior  boundary  of  the  para- 
central lobule.  The  collateral  fissure,  commonly  described  as  the  fourth 
temporal  fissure,  separates  the  temporal  from  the  limbic  or  falciform  lobe. 

Besides  these  fissures  others  of  less,  but  still  of  considerable,  importance 
subdivide  the  lobes  of  the  brain  into  gyres,  or  convolutions. 


Fig.  88. 


Outer  surface  of  the  left  hemisphere  :  i^.  Frontal  lobe.  P.  Parietal  lobe.  0.  Occipital  lobe.  T. 
Temporo-sphenoidal  lobe.  S.  Fissure  of  Sylvius.  S'.  Horizontal.  S".  Ascending  ramus  of  the  same, 
c.  Sulcus  centralis  or  fissure  of  Rolando.  A.  Anterior  central  or  ascending  frontal  convolution.  B. 
Posterior  central  or  ascending  parietal  convolution.  Jl.  Superior,  F.,.  Middle,  and  Fo.  Inferior 
frontal  convolutions,  /j.  Superior,  and  f.i,  inferior  frontal  sulcus,  f-j.  Sulcus  prsecentralis.  Pi.  Su- 
perior parietal  or  iposteroparietal  lobule.  Pj.  Inferior  parietal  lobule,  viz.:  Po.  Gyrus  supramargin- 
alis.  P'2-  Gyrus  angularis.  ip.  Sulcus  intraparietalis.  era.  Termination  of  the  callosomarginal 
fissure.  Oi,  first ;  Oo,  second;  O3,  third  occipital  convolutions,  po.  Parietooccipital  fissure.  Oj.  Sul- 
cus occipitalis  transversus.  Oo.  Sulcus  occipitalis  longitudinalis  inferior.  7i.  First.  T2.  Second. 
73.  Temporo-sphenoidal  convolutions,    ^j.  First,    t,- Second  temporo-sphenoidal  fissures.    (Ecker). 

On  the  lateral  surface  of  the  pi-efrontal  region  two  fore  and  aft  fissures 
are  uniformly  present,  and  are  commonly  spoken  of  as  the  fir.st,  or  super- 
frontal,  and  the  second,  or  .subfrontal  fissures.  A  short  distance  cephalad  of 
the  central  fissure,  and  more  or  less  parallel  with  it,  is  a  fis.?ure  called  the 
precentral,  or  vertical  frontal,  which  is  not  infrequently  subdivided  into  two 
parts,  and  when  this  ls  the  case  the  lower  one  can  be  regarded  as  the  precen- 
tral and  the  upper  as  the  supercentral.  By  means  of  these  fissures,  and  the 
Sylvian  and  central  fis.sures,  the  frontal  lobe  is  subdivided  into  four  convo- 
lutions, namely,  the  superfrontal,  medifrontal  (or  the  first,  second,  and  third 
frontal),  and  the  precentral,  or  ascending  ft-ontal,  which  lies  just  in  front  of 
the  central  fissure. 

Arching  over  the  lateral  aspect  of  the  parietal  lobe  is  a  fissure,  usually 


392 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


long  and  well  defined,  which  has  been  designated  as  the  intraparietal  (Tur- 
ner), interparietal  (Ecker),  or  parietal  (Wilder)  fissure.  It  may  be  sub- 
divided into  two  parts,  and  its  more  caudal  portion  is  regarded  by  Wilder  as 
a  fissural  integer,  which  he  has  named  the  paroccipital  fissure,  because  it 
environs  more  or  less  completely  his  occipital  (parieto-occipital)  fissure. 
The  parietal  lobe  is  subdivided  by  this  fissure  into  a  superior  and  inferior 
portion. 

Pig.  89. 


View  of  the  brain  from  below  :  JFi.  First  frontal  convolution  or  gyrus  rectus.  F2.  Middle  or  sec- 
ond frontal.  Fg.  Inferior  or^third  frontal  convolution,  /j.  Sulcus  olfactorius.  f^.  Sulcus  orbitalis. 
T2.  Second  or  middle  temporo-sphenoidal  convolution.  Tg.  Tiiird  or  inferior  temporo-sphenoidal 
convolution.  T^.  Gyrus  occipito-temporalis  lateralis  (lobulus  fusiformis).  T^.  Gyrus occipito-tem- 
poralis  medialis  (lobulus  lingualis).  ^4.  Sulcus  occipito-temporalis  inferior.  4.  Sulcus  temporo- 
sphenoidalis  inferior  or  third  temporal  fissure .  t-o.  Sulcus  temporo-sphenoidalis  medialis  or  second 
temporal  fissure,  po.  Parieto-occipital  fissure,  oc.  Calcarine  fissure.  B.  Gyrus  hippocampi.  U. 
Gyrus  uncinatus.  Ch.  Optic  chiasma.  cc.  Corpora  albicantia.  KK.  Crura  cerebri.  C.  Corpus  cal- 
losum.    (Ecker). 

In  order  to  understand  the  fissures  and  gyres  of  the  temporal  lobe,  it  is 
necessary  to  remember  that  it  has  a  ventral,  or  ventromesal,  as  Avell  as  a 
lateral  aspect.  Passing  from  the  horizontal  branch  of  the  Sylvian  fissure 
ventrad,  and  then  mesad,  four  fissures  and  five  gyres  are  recognizable,  which 
are  enumerated  by  Ecker  in  oi'der  as  the  first,  second,  third,  and  fourth  tem- 
poral fissures,  and  the  first,  second,  third,  fourth,  and  fifth  temporal  convolu- 
tions.    The  first  two  of  these  fissures  are  described  by  Wilder  as  the  super- 


ANAT03IY  OF  THE  CEREBRAL  CORTEX. 


393 


temporal  and  subtemporal,  and  the  first  three  convolutions  as  the  supertem- 
poral,  meditemjjoral,  and  subtemporal  gyres.  The  ventromesal  fissures  and 
convolutions  have  other  special  names.  The  fiaurth  temporal  fissure  is 
commonly  described  as  the  collateral,  and  the  fiaurth  temporal  convolution, 
because  of  its  shape,  the  fusifi^rm.  The  fifth  gyre  has  been  given  the  name 
of  lingual,  because  of  its  supposed  resemblance  to  the  tongue.  As  shown  in 
the  diagrams,  these  are  occipito-temporal,  rather  than  temporal  convolutions. 
The  fifth  temporal  convolution  is  subdivided  into  two  parts,  an  anterior, 
known  as  the  uncus  or  uncinate  gyre,  and  a  posterior,  the  hippocampal.  The 
hippocampal  fissure  is  situated  to  the  inner  side  of  these  gyres,  and  is  con- 
cealed from  view  on  ordinary  inspection  of  the  brain ;  but  by  pulling  aside 
the  edge  of  the  temporal  lobe  the  fissure  can  be  seen,  and  traversing  the 
bottom  of  it  a  serrated  ridge  of  gray,  the  fascia  dentata,  or  dentate  gyre. 
The  latter  is,  properly  speaking,  a  part  of  the  cortex,  although  largely  con- 
cealed within  the  fissure,  which  it  follows  cephalad  toward  the  splenium  of 
the  callosum,  and  there  becomes  continuous  with  another  smooth,  gray  layer, 
the  fasciola  cinerea. 


Fig.  90. 


c  B 


Inner  surface  of  right  hemisphere  :  CC.  Corpus  callosum  longitudinally  divided.  Gf.  Gyrus  for- 
nlcatus.  H.  Gyrus  hippocampi,  h.  Sulcus  hippocampi  or  dentate  fissure.  U-  Uncinate  gyrus,  cm. 
Sulcus  calloso-marginalis.  Fi.  Median  aspect  of  the  first  frontal  convolution,  c.  Terminal  portion 
of  the  sulcus  centralis  or  fissure  of  Rolando.  A.  Ascending  frontal.  B.  Ascending  parietal  convo- 
lution. Pi".  Precuneus.  Oz.  Cuneus.  Po.  Parieto -occipital  fissure,  o.  Sulcus  occipitalis  trans- 
versus.  oe.  Calcarine  fissure,  oc'.  Superior,  oc".  Inferior  ramus  of  the  same.  D.  Gyrus  descend- 
ens.  74.  Gyrus  occipito  temporalis  lateralis  (lobulus  fusiformis).  Ti,.  Gyrus  occipito-temporalis 
medialis  (lobulus  hngualis).    cf.  Collateral  or  occipito-temporal  fissure.    (Ecker.) 

The  fissures  and  gyres  of  the  occipital  lobe  do  not  always  follow  a  well- 
defined  plan  in  the  human  brain ;  but  it  is  usual,  following  Ecker,  to  recog- 
nize on  the  lateral  aspect  of  the  cerebrum  a  superior  and  inferior,  or  a  first 
and  second  occipital  fissure,  and  a  superior,  middle,  and  inferior  occipital 
convolution.  The  fissure  described  by  Ecker  as  the  transverse  occipital 
fissure  is  present  in  the  anterior  portion  of  the  lateral  aspect  of  the  occipital 
lobe.     It  is  called  the  anterior  occipital  by  Eberstaller  and  Schiifer,  while 


394 


NERVOUS  DISEASES  AI^D  THEIR  TREATMENT. 


Wilder  regards  it  as  the  caudal  portion  of  the  paroccipital.  It  is  usually  a 
separate  fissure  in  the  foetus,  but  in  most  adult  brains  it  is  joined  to]|the 
caudal  extremity  of  the  interj^arietal.  On  the  mesal  aspect  of  the  hemi- 
cerebrum  the  occipital  lobe  is  sharply  demarcated  by  the  parieto-occipital 
and  the  calcarine  fissures,  between  which  is  the  lobule,  or  gyre,  known  as  the 


Diagrammatic  representation  of  the  outer  surface  of  the  normal  brain  : 
S.  Truncus  flssura  Sylvii  (trunk  of  the  Sylvian  Assure).  S^.  Fissura  Sylvii  (outer  portion  of  the 
Sylvian  fissure  ;  including  Si  asc.  ramus  posterior  ascendens  (posterior  terminal  branch) ;  So.  ramus 
anterior  ascendens  (anterior  ascending  branch),  c.  Fissura  centralis  (central  fissure) ;  including  ctr- 
(inferior  transverse  sulcus),  pci.  Sulcus  prsecentralis  inferior  (inferior  precentral  sulcus),  pes.  Sulcus 
preecentralis  superior  (superior  precentral  sulcus),  pcm.  Sulcus  prtecentralis  medialis  (median  pre- 
central sulcus),  rtc.  i.  Sulcus  retrocentralis  inferior  (inferior  retrocentral  sulcus),  rtc.  s.  Sulcus 
retrocentralis  superior  (superior  retrocentral  sulcus),  rtc.  tr.  Sulcus  retrocentralis  transversus  (trans- 
verse retrocentral  sulcus),  s/r.  Fissura  subfrontalis  (median  marginal  fissure),  /i.  Sulcus  frontalis 
superior  (superior  frontal  sulcus),  f-j.  Sulcus  frontalis  inferior  (inferior  frontal  sulcus),  /s.  Sulcus 
frontalis  medius  (median  frontal  sulcus),  d.  Sulcus  diagonalis  (diagonal  opercular  sulcus),  r.  Sulcus 
radiatus  (radiating  frontal  sulcus),  fm^,  fmo,  fm^.  Sulcus  frontomarginalis  (parts  of  orbital  marginal 
sulcus),  ip.  Sulcus  interparietalis  (interparietal  sulcus),  po.  Fissura  parieto-occipitalis  (inner  per- 
pendicular fissure),  occ.  ant.  Fissura  occipitalis  anterior  (outer  perpendicular,  or  ape  fissure.) 
occ.  lat.  Fissura  occipitalis  lateralis  (lateral  occipital  fissure),  ti.  Sulcus  temporalis  primus  (first 
temporal  sulcus,  or  parallel  fissure) ;  including <i  asc,  ramus  ascendens  (ascending  ramus).  ^3.  Sulcus 
temporalis  secundus  (second  temporal  sulcus) ;  including  to  asc,  ramus  ascendens  (ascending 
branch).  A.  Gyrus  centralis  anterior  (anterior  central  convolution).  B.  Gyrus  centralis  posterior 
(posterior  lateral  convolution).  Fi.  Gyrus  frontalis  superior  s.  primus  (superior,  or  first  frontal  con- 
volution). Fo.  Gyrus  frontalis  medius  s.  secundus  (median  frontal  convolution) ;  including  F^  7ned.t 
median  layer ;  F2  lat.,  lateral  layer.  F^.  Gyrus  frontalis  inferior  s.  tertius  (inferior,  or  third  frontal 
convolution) ;  including  p.  has.,  pars  basilaris  (basal  part  of  opercular  portion) ;  p.  asc,  pars  ascen- 
dens (ascending  portion  of  the  opercular  portion)  ;  p.  triang.,  pars  triangularis  (triangular  portion) ; 
p.  orb.,  pars  orbitalis  (orbital  portion).  1.  Lateral  root  of  the  siiperior  frontal  convolution.  2.  Lateral 
root  of  the  median  frontal  convolution.  Pi.  Lobulus  parietalis  superior  (superior  parietal  lobe).  Po- 
Lobulus  parietalis  inferior  (inferior  parietal  lobe) ;  including  G.  sjmi.,  gyrus  supramarginalis  (supra- 
marginal  convolution)  ;  G.  ang.,  gyrus  angularis  (angular  convolution);  0.  par.  post.,  gyrus  parie- 
talis posterior  (posterior  parietal  convolution).  0.  Lobus  occipitalis  (occipital  lobe).  Jj.  Gyrus 
temporalis  primus  s.  parallelus  (first  temporal,  or  parallel  convolution).  To.  Gyrus  temporalis  secun- 
dus (second  temporal  convolution).  T^.  Gyrus  temporalis  tertius  (third  temporal  convolution). 
(Ebeestallek.) 


ANATOMY  OF  THE  CEREBRAL  CORTEX.  395 

cuneus,  or  wedge,  which  is  almost  invariably  of  distinctive  appearance. 
Ventrad  of  the  calcarine  fissures  the  occipital  and  temporal  lobes  merge 
more  or  less. 

The  convolution  just  above  the  Sylvian  fissure  is  sometimes  designated  as 
the  supramarginal,  and  the  one  below  it  the  inframarginal,  the  former  corre- 
sponding to  the  lower  extremity  of  the  postcentral  and  the  anterior  extremity 
of  the  subparietal  convolution,  and  the  latter  to  the  supertemporal  convolu- 
tion. Marginal  is  used  by  some  authors  to  describe  the  lobule,  or  convo- 
lution, between  the  supercallosal  fissure  and  the  edge  of  the  hemisphere. 
Others  regard  this  area  as  simply  constituting  portions  of  the  mesal  aspects 
of  the  frontal  and  parietal  lobes.  It  is  unfortunate  that  the  term  marginal 
is  applied  to  one  region  bordering  the  edge  of  the  hemisphere,  while  supra- 
marginal  and  inframarginal  are  used  to  describe  remotely  situated  convolu- 
tions which  border  the  Sylvian  fissure.  Within  the  marginal  convolutions 
another,  called  the  paracentral  gyre  or  lobule,  is  sometimes  located.  It 
unites  the  precentral  and  the  postcentral  convolutions,  and,  therefore,  passes 
around  the  uj)j)er  extremity  of  the  central  fissure ;  hence  its  name,  para- 
central. 

The  angular  gyre  or  convolution  is  one  to  which  frequent  reference  is 
made,  and,  as  the  term  is  used  with  somewhat  different  meanings,  it  may  be 
best  here  to  enter  into  an  explanation.  Huxley  employed  the  term  to  describe 
the  convolution  which  curves  around  the  posterior  extremity  of  the  fissure  of 
Sylvius,  and  Gratiolet  applied  the  term  ^;/?'  courhe,  which  has  a  similar 
meaning,  to  the  homologous  gyre  in  the  brain  of  the  ape,  in  which  it  is 
limited  caudad  by  the  parieto-occipital  fissure.  In  descriptions  of  the  human 
brain  "  angular  "  is  more  commonly  applied  to  the  convolution  which  curves 
around  the  extremity  of  the  supertemporal  or  j)arallel  fissure,  which  is  in 
accordance  with  Gratiolet's  recommendation  to  restrict  for  the  brain  of  man 
the  term  to  the  region  between  the  Sylvian  fissure  and  the  occipital  lobe,  so 
that,  ordinarily,  the  angular  gyre  w^ill  be  constituted  by  the  arch  composed 
of  the  posterior  uniting  portions  of  the  subparietal  and  supertemporal  con- 
volutions ;  the  supertemporal  fissure,  however,  terminates  most  frequently  in 
the  parietal  lobe,  but  sometimes  reaches  into  the  occipital,  and  I  have  known 
it  to  extend  without  bridging  over  the  median  edge  of  the  hemisphere ;  and 
a  description  will  not  hold  good  if  the  extremity  of  the  fissure  reaches  into 
the  occijjital  lobe,  or  elsewhere  than  its  usual  position.  The  difficulties  arise 
largely  from  the  term  having  been  first  used  to  describe  appearances  present 
in  the  brain  of  an  ajie,  whereas  the  human  brain  had  developed  into  a  more 
complex  region.  It  is  best  to  understand  that  it  describes  that  convolutional 
area  on  the  lateral  aspect  of  the  hemicerebrum  where  the  parietal,  occipital, 
and  temporal  lobes  come  together,  no  matter  what  relations  this  area  may 
bear  to  fissures,  although  in  the  majority  of  human  brains  this  gyre  will 
curve  around  the  end  of  the  supertemporal  fissure. 


THE  MINUTE  ANATOMY  OP  THE  CEREBRAL  CORTEX. 

It  has  been  held  that  differences  in  the  function  are  indicated  by  the  shape, 
size,  prolongations,  or  other  peculiarities  of  the  nerve  cells  in  different  regions 
of  the  cortex.  In  some  regions  certain  types  of  cells  are  pi'ominent,  leaving 
no  room  for  doubt  as  to  their  special  significance.  The  motor  zone  ha.s  been 
thoroughly  studied,  and  for  it,  for  the  cerebellar  cortex,  and  to  a  less  extent 
for  the  regions  assigned  to  the  special  senses,  and  to  common  sensation,  dis- 
tinctive histological  features  have  been  determined. 

The  views  formerly  held,  and  to  some  extent  yet  maintained,  are  those 


396  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

given  in  the  works  of  Charcot,  Ferrier,  and  Bevan  Lewis.  Among  the  most 
distinctive  of  the  special  elements  of  the  cortex  are  pyramidal  cells,  compar- 
able in  every  way  to  the  motor  cells  of  the  ventral  horns  of  the  spinal  cord. 
These  are  variable  in  their  dimensions  and  have  been  placed  in  three  classes 
according  to  their  size.  The  largest  or  giant  pyramidal  cells  were  first  care- 
fully studied  by  Betz  and  Mierzejewski. 

The  pyramidal  cells  abound  especially  in  the  motor  cortex,  although  Golgi 
and  others  have  demonstrated  that  they  exist  everywhere  in  the  gray  matter. 
They  may  reach  dimensions  of  from  -^-^  to  -g^-Q  of  an  inch  in  breadth,  and 
may  be  four  or  five  times  as  long  as  they  are  broad.  They  often  deserve  the 
name  which  has  been  given  them  of  "giant  cells."  These  cells  are  furnished 
with  prolongations  and  processes.  Some  of  them  are  of  great  length  and  of 
great  complexity.  From  their  apices  processes  pass  upward  to  the  superfi- 
cial layers  of  the  cortical  cinerea,  there  to  terminate  in  a  tree-like  panicle. 
Long  axis  cylinder  processes  reach  dowuAvard  to  become  constituents  of  the 
white  fibres  of  the  brain.  Numerous  small  so-called  protoplasmic  processes 
spring  from  the  sides  of  the  body  of  the  cell. 

While  a  general  agreement  exists  among  authors  as  to  the  laminal  arrange- 
ment of  the  cortex,  the  number  of  layers  given  differs  somewhat  according 
to  the  point  of  view  taken,  and  also  according  to  the  region  of  the  brain. 
Baillarger  maintained  it  was  composed  of  six  layers,  arranged  from  without 
inward  in  alternations  of  gray  and  white  as  follows:  1,  white;  2,  gray;  3, 
white  ;  4,  gray  ;  5,  white  ;  6,  gray.  The  four  internal  layers  are  often  con- 
founded in  a  single  yellowish-red  layer,  by  some  authorities  described  as  a 
special  layer.  Duval  admitted  either  five  or  six,  according  as  the  fifth  and 
sixth  are  counted  as  one  or  two. 

With  reference  to  different  regions  of  the  brain,  Meynert  enumerated  five 
types  of  cortical  lamination  as  distinctive  in  the  brain  of  mammals  as  fol- 
lows:  1,  a  common  type;  2,  the  occipital  type;  3,  the  Sylvian  type;  4,  the 
type  of  the  cornu  ammonis ;  5,  the  type  of  the  olfactory  bulb.  '  Bevan  Lewis 
differs  from  Meynert  both  as  regards  his  types  of  lamination  of  the  cortex  in 
different  regions,  and  in  some  cases  as  regards  his  description  of  the  charac- 
teristic types,  holding  to  eight  distinct  t}^es  of  cortex,  not  mere  fanciful  dis- 
tinctions based  upon  trivial  peculiarities,  but  abrupt  transitions  from  one 
kind  of  cortex  to  another,  especially  to  be  seen  in  small  mammalian  brains. 

In  the  motor  area,  which  has  received  the  most  attention,  usually  five  or 
six  layers  have  been  enumerated  by  different  authorities,  as  Meynert,  Betz, 
Mierzejewski,  Bevan  Lewis,  and  Clark  ;  but  sometimes  the  layers  of  the  motor 
cortex  are  described  as  only  four  in  number.  Five  are  made  by  a  subdivision 
of  the  fourth,  and  six  by  a  subdivision  of  the  third  and  fourth.  In  the  occi- 
pital region  a  larger  number  of  separate  layers  are  usually  enumerated,  as 
many  as  eight  by  Meynert.  In  other  regions,  as  in  the  parietal  and  in  the 
limbic  lobe,  the  stratification  of  the  cortex  is  apparently  different. 

The  most  commonly  accepted  lamination  of  the  motor  cortex  has  been 
that  of  Meynert  into  five  layers :  1,  a  very  thin  external  layer,  formed  almost 
exclusively  of  amorphous  substance  containing  a  few  if  any  nerve  cells  ;  2,  a 
layer  almost  entirely  composed  of  numerous  small  pyramidal  cells ;  3,  a 
layer,  also  composed  of  pyramidal  cells,  but  most  of  these  of  larger  size  than 
the  preceding  (the  most  internal  portion  of  this  lamina  containing  the  largest 
cells  is  sometimes  described  as  a  separate  layer)  ;  4,  a  layer  chiefly  composed 
of  myelocytes ;  5,  a  layer  of  reddish-yellow  color  composed  of  fusiform  and 
irregular  cells.  Lewis  holds  to  five  typical  lamina  for  the  motor  cortex  (Fig. 
92)  subdividing  the  third  layer  of  the  four  type  layers.  These  are :  1,  an 
extremely  delicate  pale  zone,  devoid  of  nerve  cells,  which  limits  the  cortex 
externally,  and  presents  the  features  described  as  peculiar  to  the  cortical 


ANATOMY  OF  THE  CEREBRAL  CORTEX. 


397 


neuroglia ;  2,  a  narrow  belt  of  very 
closely  aggregated  nerve  cells  of  ir- 
regular marginal  contour,  oval,  pyr- 
amidal or  angular,  with  a  proportion- 
ately large  nucleus ;  these  cells  vary 
much  in  size,  and  are  much  more  richly 
developed  in  some  than  in  other  regions 
of  the  brain  ;  3,  a  deep  belt  of  nerve 
cells  subjacent  to  the  above  elements, 
which  are  characterized  by  their  more 
or  less  elongated  contour  and  by  the 
tendency  to  gradual  increase  in  their 
size,  as  they  lie  deeper  in  the  cortex  ; 
4,  a  layer  which  presents  us  with  highly 
characteristic  nerve  elements,  usually 
large  pyramidal  cells,  which  Lewis  has 
described  as  "motor  cells,"  elements 
which  are  found  modified  in  different 
cortical  regions ;  5,  a  layer  represented 
by  a  series  of  spindle  cells,  which  be- 
neath the  summit  of  a  convolution  are 
disposed  radially  to  the  surface  in  regu- 
lar columns,  separated  by  bundles  of 
medullated  fasciculi  ascending  from 
the  core  of  the  gyrus. 

Golgi  found  everywhere  in  the  cor- 
tex three  great  types  of  cells,  the  pyr- 
amidal, the  fusiform,  and  the  globular 
or  polygonal,  but  he  did  not,  like 
others,  recognize  them  as  existing  in 
sharply  isolated  strata.  Globular  cells 
were  found  every  where  in  the  thickness 
of  the  cortex,  as  were  also  pyramidal 
cells,  but  the  former  are  met  with  most 
abundantly  near  masses  of  fusiform 
cells,  which  are  commonly  found  al- 
most entirely  in  the  deepest  layers, 
while  the  pyramidal  mainly  occupy 
the  superficial  and  middle  lamina. 
Golgi  therefore  divides  the  cortex 
into  only  three  layers,  a  superficial, 
middle,  and  deep.  He  does  this  not 
only  for  the  motor  area,  but  for  the 
first  occipital  convolution,  instead  of 
the  six  of  Lewis,  or  the  eight  of  Mey- 
nert,  Clark,  and  others. 

It  has  been  supposed  that  lamination 
of  the  cortex  and  the  peculiar  consti- 
tution of  the  lamina  in  different  corti- 
cal areas  were  dependent  on  the  function 
subserved,  in  one  region  motor  cells,  in 
another  sensorial  abounding  ;  also  that 
cells  and  their  processes  are  large  or 
small  or  have  special  traits  according 
to  their  functions.  Golgi  maintains 
that  the  cells  should  be  subdivided 
according;  to  their  histological  charac- 


FiG.  92. 


Lamina  of  the  cortex  from  the  modified 
upper  limbic  type  in  the  brain  ol  the  rabhit. 
(Bevan  Lewis.) 


398 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


teristics  into  motor  and  sensory  cells,  as  everywhere  in  the  brain  and  spinal 
cord  these  two  types  are  found. 

Recent  opinion  favors  a  general  type  of  four  layers.  Ramon  y  Cajal,  who 
has  examined  the  cortex  aspecially  in  small  mammals,  such  as  rabbits  and 
cats,  enumerates  :  1,  a  molecular  layer ;  2,  a  layer  of  small  pyramidal  cells  ; 
3,  a  layer  of  large  pyramidal  cells ;  and,  4,  a  layer  of  polymorj^hic  cells. 
Fig.  93  shows  a  section  of  the  cerebral  cortex  as  described  by  him. 


Fig.  93. 


Fig.  94. 


Fig.  93.— Section  of  the  cerebral  cortex  from  the  supraventricular  region  of  a  young  mouse: 
A.  Molecular  layer.  B.  Small  pyramidal  layer.  C.  Large  pyramidal  layer.  D.  Layer  of  polymorphic 
cells  or  irregular  corpuscles.  E.  White  matter,  a.  Panicles  of  the  pyramids,  b.  Smallest  and  most 
superficial  of  the  pyramids-  c.  Axis  cylinder  from  a  small  pyramid,  d.  Large  pyramid,  e.  Its  axis 
cylinder.  /.  Cell  with  ascending  axis  cylinder,  g.  Similar  but  smaller  cells,  h.  Cells  found  in  the 
white  matter,  i.  Rounded  cell  that  sends  its  axis  cylinder  toward  the  white  substance,  j.  Cell  with 
short  axis  cylinder  process.    (Ramon  y  Cajal.) 

Fig.  94.— Cortex  of  the  human  brain,  showing  the  nerve-flbre  systems  and  plexuses  (combined 
Weigert's  and  Golgi's  methods):  c-z.  Clear  zone  (free  of  nerve-fibre).  M.P.  Molecular  plexus 
(Exner's),  in  the  molecular  layer.  A.  str.  Ambiguous  cell-stratum.  Stibm.  P.  Submolecular  plexus. 
Gt.  P.P.  Great  pyramidal  plexus-  Pol.  P.  Polymorphic  plexus.    W.  White  substance.    (Andeiezen.) 


Andriezen  speaks  of  the  second  of  these  layers  as  the  ambiguous  layer, 
because  of  the  indefinite  shape  of  many  of  its  cells.  At  least  eight  types  of 
cells  are  now  recognized  in  the  cortex  ;  and  with  the  new  methods  of  staining 
and  investigating,  the  different  cortical  layers  have  been  largely  unravelled. 


ANAT03IY  OF  THE  CEREBRAL  CORTEX.  399 

Many  structures,  for  example,  have  been  determined  as  entering  into  the 
molecular  or  outermost  layer.  In  the  most  superficial  portion  of  this  layer 
is  a  system  of  neuroglia  fibre-cells  which  form  a  fine  feltwork,  and  under- 
neath this  system  in  the  same  layer  are  certain  neuroprotoplasmic  structures, 
more  than  a  dozen  of  which  have  been  difierentiated  by  recent  methods  of 
research.  The  ambiguous,  the  large  pyramidal,  and  polymorphic  layers 
have  also  been  made  to  reveal  numerous  structures  hitherto  unknown. 
Seven  cell  types  are  described  for  the  polymorphic  layer.  The  intricate 
nerve-fibre  systems  of  the  cortex  are  well  shown  in  Fig.  94.  We  are  begin- 
ning to  get  new  light  on  the  functions  both  of  the  different  regions  of  the 
cortex,  and  of  its  difterent  layers,  through  these  microscopic  revelations. 
According  to  Andriezen,  the  sensory  excitations  which  reach  the  cortex  by 
the  different  systems  of  sensory  projection  fibres  are  distributed  mainly  in  the 
molecular  and  submolecular  regions,  their  terminal  processes  coming  in  con- 
tact with  the  apical  processes  of  the  ambiguous  and  great  pyramidal  cells, 
chiefly  in  that  part  of  the  molecular  layer  which  is  known  as  Exner's  plexus. 


CEREBRAL    LOCALIZATION. 

The  literature  of  cerebral  localization  has  attained  such  vast  proportions 
that  even  to  summarize  it  would  be  a  vain  task.  Since  the  publication,  in 
1888,  of  my  monograph  on  Cerebral  Localization  in  its  Practical  Relations,^  few 
important  additions  to  our  knowledge  of  this  subject  have  been  furnished 
by  physiology  and  clinico-pathology,  although  much  of  the  earlier  work  has 
been  reviewed,  new  points  of  departure  have  been  taken,  and  new  methods  of 
regarding  phenomena  have  been  suggested.  Souiy'^  in  1892  devoted  more 
than  four  hundred  pages,  which  proved  scarcely  sufficient,  to  a  critical  and 
historical  review  of  the  literatvire  of  the  functions  of  the  brain.  Recent  work 
which  promises  most  for  the  solution  of  the  problems  of  cortical  function  is 
based  upon  microscopical  investigation.  Golgi's  method  of  silver  staining 
has  revealed  a  new  world  to  the  neuro-histologist,  and  the  work  inaugurated 
by  him  and  carried  forward  by  his  pupils,  and  by  Ramon  y  Cajal,  Van 
Gehuchten,  Koelliker,  and  others,  bids  fair  to  place  upon  a  firm  foundation 
the  whole  subject  of  brain  flinctions.  It  has  become  possible  by  this  method, 
and  other  methods  wdiich  are  its  natural  outcome,  to  trace  in  a  manner  never 
before  possible  the  processes  of  nerve  cells. 

Whatever  views  may  be  held  as  to  the  nature  of  localization,  for  the 
practical  purposes  of  the  physician  and  surgeon  the  cerebral  cortex  can  be 
divided  into  a  series  of  physiological  lobes,  and  these  lobes  into  more  or  less 
numerous  subareas  and  centres.  The  lobes  are  regions  for  motion,  common 
sensation,  vision,  hearing,  naming,  smell  and  taste,  and  for  the  higher  mental 
faculties. 

MOTOR   LOCALIZATION. 

As  would  be  anticipated,  the  subject  of  motor  representation  has  been 
more  fully  developed  than  any  other  branch  of  cortical  localization,  having 
become,  for  most  specialized  movements,  an  exact  science.  As  the  proper 
interpretation  of  localizing  phenomena  has  been  much  disputed  it  may  he 
well  first  to  briefly  consider  some  of  the  differing  views. 

1  Read  before  the  Conarress  of  American  Physicians  and  Surgeons,  Washington,  D.  C,  September, 
19, 1888.    This  paper  has  been  used  freely  in  the  preparation  of  this  chapter. 

2  Jules  Soury  :  Les  Fonctions  du  Cerveau,  Doctrines  de  I'Ecole  de  Strasbourg,  Doctrines  de  I'Ecole 
Italienne.  Paris,  1892. 


400  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Franck^  summarizes  the  explanations  of  the  action  of  the  excitable  regions 
of  the  cortex  under  several  heads,  as  follows  :  (1 )  they  are  true  motor 
centres,  (2)  they  are  sensory  centres  (reflex  theory),  (3)  they  are  at  the  same 
time  motor  and  sensory,  (4)  they  are  places  of  confluence  and  passage  of 
excitations  originating  elsewhere,  (5)  they  are  simj^ly  places  which  receive 
and  transmit  excitations  to  the  regions  of  movement  below. 

Ferrier'^  believes  that  the  motor  zone  contains  psycho-motor  centres,  or 
centres  for  movements  which  involve  conscious  discrimination  ;  movements 
which  are  automatic,  instinctive,  or  responsive  are  more  or  less  distinctly 
organized  below  the  cortex.  He  adheres  in  his  latest  work  to  separate  sensory 
localization.  The  motor  centres,  he  holds,  although  functionally  and  organ- 
ically connected,  are  anatomically  difierentiated  from  the  centres  of  sensation, 
general  as  well  as  special.  The  functional  connection  between  sensory  and 
motor  centres  is  necessary  to  be  borne  in  mind.  Ferrier  admits  that  the 
motor  centres  are  not  independent  centres  of  action,  but  respond  only  to 
stimuli  which  pass  from  the  sensory  centres  by  way  of  associating  fibres. 
Marique's  experiments,  which  have  been  confirmed  by  Exner  and  Paneth, 
show  that  when  the  motor  centres  have  been  completely  isolated,  by  section 
of  the  fibres  which  associate  them  with  the  sensory  centres  of  the  cortex, 
paralysis  results  of  precisely  the  same  character  as  that  which  occurs  when 
they  are  actually  extirpated  ;  also  that  the  same  contractions  were  obtainable 
on  electrical  irritation  of  the  respective  centres  after,  as  before,  isolation, 
showing  that  they  still  retain  their  excitability  and  connection  with  the 
pyramidal  tracts. 

Charcot's  views  were  practically  those  of  Ferrier,  namely,  that  these 
centres  were  the  cortical  substrata  of  motor  activities.  Exner  originated  the 
theory  of  absolute  and  relative  centres,  according  to  which  lesions  which  cause 
affections  of  particular  parts,  as  of  the  upper  extremities  or  of  the  face,  are 
chiefly  grouped  in  definite  localities,  but  nevertheless  the  same  effects  may 
result  from  lesions  of  almost  any  part  of  the  cerebral  convexity.  Absolute 
centres  are  those  destruction  of  which  always  causes  certain  symptoms; 
while  lesion  of  relative  centres  frequently,  but  not  invariably,  induce  these 
phenomena. 

According  to  Bastian,  the  Rolandic  centres  are  kinesthetic  ;  he  refers  the 
movements  to  their  sensory  or  centripetal  antecedents,  believing  the  only 
true  motor  centres  are  bulbar  and  spinal ;  but,  as  Waller  points  out,  all  that 
he  really  denies  is  that  these  centres  are  spontaneously  motor. 

Both  Hitzig  and  Nothnagel  looked  upon  the  Rolandic  region  as  related  to 
the  so-called  musclar  sense.  Nothnagel  regarded  this  area  as  containing 
centres  of  muscular  consciousness,  or  centres  wherein  conceptions  of  the 
normal  progress  of  movement  were  formed.  Schiff"  held  that  these  Rolandic 
centres  were  tactile,  destructive  lesions,  causing  ataxia  and  irritation,  resulting 
in  movements  of  a  reflex  nature. 

Munk  regards  the  cortical  Rolandic  region  as  the  sensory  area,  or  Fuhl- 
sphdre,  believing  that  it  stands  in  the  same  relation  to  common  sensation, 
meaning  sensation  of  the  whole  body,  as  the  cortex  of  the  occipital  lobe  does 
to  vision,  and  that  of  the  temporal  lobe  to  hearing.  Tripler,  Goltz,  Luciani 
and  Seppili,  Starr,  Dana,  and  others  also  hold  that  aflTections  resuhing  from 
destruction  of  the  so-called  motor  zone  are  in  some  way  related  to  disorders 
of  sensibility  in  the  limbs  affected. 

According  to  Horsley,^  in  the  so-called  motor  region  three  functions_  are 
clearly  represented,  as  s'hown  in  the  diagram.  Fig.  95.     They  are,  1,  slight 

1  Francois  Pranck  ;  Ler-ons  sur  les  Fonctions  Motrices  du  Cerveau,  Paris,  1887,  p.  362. 

2  David  Ferrier  :  Croonian  Lectures  on  Cerebral  Localization,  London.  Smith,  Elder  &  Co.,  1890. 

3  Victor  Horsley:  Trans.  Cong.  Amer.  Phys.  and  Surgs.,  1888,  Washington,©.  C,  p.  341. 


CEREBRAL  LOCALIZATION.  401 

representation  of  the  tactile  sensation ;     2,  representation  of  the  so-called 

muscular  sense;  and,  3,  great  representation  of  movement.     "These  three 

functions  are  wrapped  up  closely  together,  and  in  every  particle  of  gray 

surface  there  is  represented  this  triune  function  for  a  single  segment  of  the 

body." 

Fig.  95. 

O 

Slight  tactile  sense  A 

Muscle  sense  A 


Motor 


Horsley's  view  of  sensorimotor  representation  in  the  motor  cortex. 

According  to  Waller,  who  has  given  close  attention  to  both  the  psychical 
and  physical  sides  of  the  subject  of  localization,  the  main  drift  of  develop- 
ment is  from  undifferentiation  toward  specialization.  Secondary  connections 
may  become  established,  but  the  main  and  primary  movement  is  disconnec- 
tion. Localization  is  the  law  of  all  organization,  and  it  would  be  marvel- 
lous if  the  cerebrum  presented  an  exception.  He  contends  that  every  centre 
must  be  a  point  to  which,  as  well  as  from  which,  an  impulse  goes.  He 
pictures  one  undivided  change  taking  place  in  any  centre,  resulting  in  im- 
pulses both  to  it  and  from  it ;  he  avoids  the  term  motor,  because  it  may 
imply  spontaneous  origination  of  force.  He  speaks  of  his  two  laboratories, 
in  one  of  which  he  learns,  and  the  other  where  he  teaches,  comparing  the 
first  to  a  sensory  and  the  other  to  a  motor  region,  and  the  highway  by  which 
he  travels  from  one  to  the  other  he  compares  to  the  internuncial  tract  Jbetween 
them;  but  he  argues  the  laboratories  themselves  are  neither  sensory  nor 
motor;  they  are  places  in  which  sensation  and  motion  are  produced.  "The 
truism  that  by  a  sensory  centre,  or  motor  centre,  we  cannot  mean  a  centre 
which  feels  or  which  causes  motion,  but  at  most  a  place  where  sensation 
occurs  or  a  motor  impulse  is  elaborated,  is  worth  Avhile  making  particularly 
clear,  if  only  as  a  matter  of  definition." 

The  view  expressed  in  the  latter  part  of  the  preceding  sentence  is  the  only 
one  that  need  to  be  accepted  by  the  practical  physician ;  he  simply  needs  to 
know  that  something  occurs  in  a  so-called  sensory  region,  on  the  one  hand, 
or  in  a  motor,  on  the  other — something  which  gives  rise  in  each  case  to  clin- 
ical manifestations  of  a  special  character. 

In  reality,  the  special  functions  of  different  cerebral  zones  are  determined 
by  the  fibres  which  go  to  them  from  the  periphery.  We  are  gradually 
reaching  more  scientific  and  more  sensible  ideas  of  cerebral  structures  and 
function,  having  been  handicapped  too  long  by  erroneous  views  as  to  the 
nature  of  cell  action.  It  has  been  too  much  the  fashion  to  speak  of  the 
cell  as  the  citadel  of  nervous  energy ;  to  regard  it  as  the  true  source  of 
power,  and  to  believe  that  it  has  spontaneity.  The  supposed  necessity  of 
structural  continuity  from  centre  to  periphery  has  also  held  us  back.  Wundt, 
Forel,  and  Nansen  (admirably  summarized  by  Soury)  have  shown  the  fallacy 
of  these  views.  Forel  first  saw  that  it  was  only  necessary  for  the  nerve 
fibrils  to  be  in  contact  in  order  that  nervous  impulses  should  be  conveyed, 

26 


402  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

nerve  transmissions  being  in  this  way  comparable  to  the  method  of  electrical 
transmission.  He  protested  against  speaking  of  motor  cells  and  sensory 
cells,  the  only  differences  between  motor  and  sensory  cells  being  that  the  cell 
body  is  central  for  the  former  and  peripheral  for  the  latter.  The  iibres  from 
both  terminate  in  arborescent  ramifications,  the  motor  nerves  in  the  muscles, 
the  sensory  in  the  cortical  cinerea.  The  nerve  processes,  according  to  Nan- 
sen,  are  of  two  kinds — nerve  fibres  proper,  and  protoplasmic  processes.  The 
former  pass  toward  the  periphery  from  the  cortex  ;  they  do  not  anastomose 
with  nerve  cells  by  means  of  these  prolongations.  The  true  nerve  cells  have 
processes  always  single,  but  with  lateral  branches.  They  directly  become 
nerve  tubes,  or  lose  their  individuality,  and  give  birth  to  nerve  trees  in  the 
network  of  the  cortex.  The  main  point  of  Hansen's  view  is  that  nerve 
impulses  may  be  transmitted  to  or  from  the  higher  centres  Avithout  passing 
directly  to  the  nerve  cells — that  is,  by  the  cell  bodies ;  also  that  a  reflex  can 
be  constituted  through  the  ramifications  of  the  cells.  Impulses  are  conveyed 
from  processes  to  processes  through  an  entire  reflex  arc ;  through  the  entire 
length  of  a  cortico-efferent,  or  a  cortico-afierent,  projection  system.  The 
function  of  the  nerve-cell  body  is  trophic ;  its  nuclei  and  nucleoli  preside 
over  the  nutrition  of  the  long  or  short  fibres  which  pass  out  of  or  grow  into 
them.  CelLs  are  of  enormous  bulk,  in  order  that  they  may  be  able  to  sustain 
these  processes.  The  aggregation  of  gray  matter  at  various  levels  of  the 
nervous  system  are  watering  and  feeding  places,  not  places  for  renewing 
nerve  activity.  In  the  central  fibrillary  network  of  the  cortex  the  degree  of 
development  of  intelligence  will  be  proportioned  directly  to  the  complexity 
of  this  reticulum. 

The  acceptance  of  views  such  as  these  does  not  call  for  an  abandonment 
of  the  doctrine  of  localization,  even  as  held  by  its  most  advanced  advocates  ; 
at  the  most  it  simply  requires  the  subject  to  be  looked  at  from  a  difierent 
point  of  view,  or  to  be  explained  in  different  terms.  At  certain  levels,  and 
in  certain  areas  of  given  levels,  in  the  great  sensorimotor  path  or  arc  occur 
or  can  be  elicited  certain  phenomena,  which  only  show  themselves  out- 
wardly in  the  one  case  by  the  sensory  and  in  the  other  by  motor  manifesta- 
tions. 

James  compares  the  motor  area  to  the  mouth  of  a  funnel,  from  which 
pour  out  impulses  caused  by  incoming  impulses. 

According  to  Brown-Sequard,^  the  most  persistent  and  constant  opponent 
of  modern  localization,  numerous  contradictory  facts  show  that  nerve  cells 
possessed  of  definite  functions,  instead  of  being  united  in  a  certain  cerebral 
territory,  are  dispersed  throughout  the  encephalic  mass,  and  are  joined  in 
some  way  one  to  the  other,  so  as  to  form  a  functional  solidarity ;  also,  that 
all  symptomatic  manifestations  of  cerebral  origin  arise  exclusively  from  an 
irritation,  which  acts  either  by  arresting  or  exaggerating  the  activity  of  the 
encephalon.  Dupuy,^  who  also  believes  that  the  doctrine  of  localization  as 
generally  understood  cannot  be  accepted,  holds  that  as  no  agent  but  electric- 
ity produces  movements  from  application  to  the  motor  cortex,  when  a  current 
of  minimum  strength  applied  to  certain  spots  in  the  cortex  produces  certain 
motor  effects,  it  only  shows  that  these  points  are  situated  in  the  line  of  the 
least  resistance.  He  criticises  the  flap  experiments  of  Putnam,  and  the  cir- 
cumvallation,  freezing,  and  other  experiments  of  Franck,  and  reproduces 
the  old  cases  and  the  old  arguments  regarding  destructive  lesions,  which 
have  not  produced  paralysis  or  aphasia,  and  also  the  well-known  facts  that 
the  cortex  is  not  absolutely  necessary  for  the  production  of  epileptic  convul- 

1  Brown-Sequard  :  Ai-chives  de  Physiologie,  January,  1890. 

2  Eugene  Dupuy  :  The  Rolandic  Area  Cortex.    Brain,  1892,  vol.  sv.  p.  190. 


CEREBRAL  LOCALIZATION.  403 

sions.  His  most  interesting  argument  is  drawn  from  the  teachings  of  Golgi 
and  Nansen,  that  the  cells  are  trophic  elements,  and  that  motion  and  sensa- 
tion are  the  attributes  of  the  peripheric  elements  alone,  the  central  gray 
matter  simply  reacting  according  to  the  nature  of  the  impulse. 

Goltz  has  ridiculed  those  who  consider  the  brain  a  mosaic  of  little  brains, 
and  yet  he  acknowledges  that  the  functions  of  the  forepart  of  the  cerebrum 
of  the  dog  are  not  the  same  as  those  of  the  hindpaxt,  and  he  has  never 
denied  the  possibility  of  the  existence  of  different  cortical  territories  related 
to  diverse  functions  ;  but  he  affirms  that  the  most  important  functions  of  the 
brain — those  which  indicate  the  passions,  the  emotions,  and  the  instincts — do 
not  depend  upon  such  circumscribed  areas  (Soury).  He  would  seem  to  hold 
that  the  phenomena  usually  attributed  to  the  ablation  or  irritation  of  isolated 
cortical  centres  or  areas  are  due  to  inhibition  or  interference  with  lower 
centres,  admitting  only  loss  of  j)erception  of  a  general  character. 

Mott,^  who  believes  in  the  sensorimotor  ftinctions  of  the  central  convolu- 
tions, in  summarizing  the  evidence  in  favor  of  this  doctrine,  cites  the  embry- 
ological  work  of  Flechsig  and  Hosel,  which  he  believes  shows  that  afferent 
channels  connect  the  nuclei  of  the  posterior  columns,  and  the  sensory  nuclei 
of  the  fifth  nerve,  with  the  opposite  Rolandic  area  either  directly  by  the 
fillet,  or  indirectly  by  the  fillet  and  thalamus.  The  real  claim  made  by 
Flechsig  is  that  the  sensory  fibres  terminate  in  the  region  behind  the  central 
fissure  ;  and  it  is  not  quite  sound  to  argue  that  because  fibres  run  from  behind 
forward  these  embryological  facts  teach  that  sensory  fibres  terminate  in  the 
motor  cortex. 

SUBDIVISIONS  OP  THE    MOTOR  AREA. 

The  motor  zone  is  divided  horizontally  on  the  lateral  aspect  of  the  hemi- 
spheres into  three  great  regions  for  the  face,  arm,  and  leg,  which  correspond 
nearly,  but  not  exactly,  with  the  imaginary  extensions  caudad  of  the  super- 
frontal  and  subfrontal  fissures.  Instead  of  subdividing  the  Rolandic  region 
from  above  downward  into  thirds,  as  is  often  done,  it  is  better  to  divide  it 
into  fifths,  placing  the  area  of  representation  for  the  lower  extremity  in  the 
upper  fifth,  and  that  for  the  upper  extremity  in  the  middle  two-fifths,  and 
that  for  the  face  in  the  lower  two-fifths. 

The  anterior  branch  of  the  Sylvian  fissure,  and  an  imaginary  line  extend- 
ing from  it  to  the  longitudinal  fissure,  may  be  regarded  as  the  cephalic  or 
anterior  boundary  of  the  motor  area ;  the  retrocentral  fissure  may  be  con- 
sidered its  caudal  or  posterior  boundary,  the  posteroparietal  region  being- 
concerned,  in  part  at  least,  with  sensation.  The  horizontal  branch  of  the 
fissure  of  Sylvius  is  its  ventral  or  inferior  boundary.  For  a  long  time  the 
longitudinal  fissure  was  regarded  as  the  superior  boundary  of  the  motor 
area,  but  Hoi'sley  and  Schafer,  and  others  since  them,  have  shown  that  this 
area  extends  over  the  edge  of  the  hemicerebrum.  They  found  that  the 
application  of  the  electrodes  at  successive  points  from  before  backward  in 
the  marginal  convolutions  produced  :  (1)  movements  of  the  head  ;  (2)  of  the 
forearm  and  hand  ;  (3)  of  the  arm  at  the  shoulder ;  (4)  of  the  upper  (dorsal) 
part  of  the  trunk ;  (5)  of  the  lower  (pelvic)  part  of  the  trunk  ;  (6)  of  the 
leg  at  the  hip ;  (7)  of  the  lower  leg  at  the  knee ;  (8)  of  the  foot  and  toes. 
These  primary  movements  are  almost  invariably  complicated  by  secondary 
movements,  produced  by  excitation  of  the  adjacent  parts.  The  paracentral 
lobule  is  the  convolution  of  the  mesal  surface  of  the  cerebrum,  chiefly  con- 
cerned with  the  movements  of  the  leg  and  foot. 

1  F.  W.  Mott :  Jour.  Physiol..  1894,  vol.  xv.  pp.  464-487. 


404 


XERVOUS  DISEASES  AND  THEIR  TREATMENT. 


The  sulDclivision  of  tlie  motor  area  on  the  lateral  aspect  of  the  hemicere- 
bruni  into  subareas  for  speech,  the  head  and  eves,  the  face,  arm,  leg,  and 


Lateral  surface  of  brain  of  monkey.     (Hoesley  and  Sch'afee.) 


Fig.  97. 


Median  surface  of  brain  of  monkey.     (Horsley  and  Schafer.) 


CEREBRAL  LOCALIZATION. 


405 


trunk,  and  the  further  division  of  these  subareas  into  a  few  centres  for  cer- 
tain specialized  movements  of  the  face,  arm,  and  leg,  are  represented  in  Fig. 
96.  The  motor  area  of  the  lateral  surface  of  the  hemisphere  is  made  to 
include  the  caudal  portions  of  the  three  frontal  and  both  central  convolu- 
tions, but  not  to  reach  backward  so  as  to  take  in  the  superior  and  inferior 
parietal  convolutions.  The  areas  for  the  arm  extend  cephalad  and  mesad  to 
the  edge  of  the  hemisphere.  The  subdivision  of  the  head,  arm,  trunk,  and 
leg  areas  in  the  marginal  lobule  on  the  mesal  surface  of  the  hemisphere  are 
shown  in  Fig.  97. 

Area  for  the  Movements  of  the  Head  and  Eyes.  Ferrier  found  that  irri- 
tation at  the  base  of  the  superior  and  middle  frontal  convolutions  gave 
rise  to  lateral  movements  to  the  opposite  sides  with  dilatation  of  the  pupils, 
the  expression  assumed  by  the  monkey  being  that  of  attention  and  surprise ; 
but  the  same  movement  occurs  with  other  special  reactions,  on  stimulation  of 
the  angular  g}Tus,  and  more  especially  of  the  superior  temporal  convolution. 
With  the  latter  Ls  associated  pricking  of  the  ear  from  stimulation  of  the 
auditory  centre ;  but  Ferrier  argues  that  these  are  simply  attention  move- 
ments, the  same  as  would  result  from  stimulation  of  the  motor  centres  for 
these  movements.  Destruction  of  the  oculo-motor  centres  of  Ferrier,  accord- 
ing to  some  experiments,  causes  conjugate  deviation  toward  the  side  of  the 
lesion.  Bilateral  destruction  of  the  centres  at  first  caused  inability  to  turn 
the  head  and  eyes,  but  the  animal  recovered. 

A  minute  physiological  study  of  the  representation  of  the  head  and  eyes 
was  made  by  Beevor  and  Horsley,^  who  studied  the  following  list  of  move- 
ments :  "I.  Movements  of  the  Head.  The  head  moves  in  one  of  the  following 
modes  or  in  combination  of  the  same :  (a)  simple  horizontal  rotation  to  the 
opposite  side ;  (h)  rotation  with  elevation  of  the  muzzle;  (c)  rotation  with 

Fig.  98. 


Areas  of  representation  of  the  movements  of  the  head  and  eyes  (oblique  shading),  of  the  upper  limb 
(vercical  shading),  and  of  the  lower  limb  (horizontal  shading).    (Beevor  and  Horsley.) 

adduction  of  the  head  to  the  (opposite)  shoulder.  II.  Movements  of  the 
Eyes,  (a)  Both  eyes  open  ;  (b)  both  eyes  turn  horizontally  to  the  opposite 
side  and  upward ;  (d)  both  eyes  turn  to  opposite  side  and  downward  ; 
(e)  both  eyes  turn  to  middle  line  (from  the  side  stimulated),  or  turn  only 
through  a  few  degrees.  III.  Movements  of  the  Pupils,  (a)  Contraction ; 
{h)  dilatation." 


1  Beevor  and  Horsley:  Phil.  Trans,  of  Royal  Soc.  Lond.,  (lSS-8),  vol.  clxxix.  B.  pp.  205-256. 


406 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


The  area  determined  as  representing  the  movements  of  the  head  and  eyes 
is  indicated  in  Fig.  98  by  the  oblique  shading.  They  found  it  to  be  a  very 
extensive  region,  reaching  from  the  longitudinal  fissure  above  almost  to  the 
Sylvian  fissure  below.  The  turning  of  the  head  to  the  opposite  side — so  that 
the  face  looks  away  from  the  hemisphere  stimulated — has  a  much  larger  area 
of  representation  than  the  synchronous  conjugate  deviation  of  the  eyes.  The 
area  in  man  is  probably  much  the  same.  Beevor  and  Horsley  found  that 
simple  horizontal  rotation  to  the  opposite  side  occurred  most  markedly  from 
irritation  of  the  cortex  just  above  the  horizontal  branch  of  the  precentral 
fissure.  Rotation  Avith  elevation  of  the  muzzle,  as  in  the  movement  when 
the  head  is  tilted  backward,  so  that  the  face  looks  upward  as  well  as  out- 
ward, was  also  observed  above  this  fissure.  Rotation  with  adduction  of  the 
head  to  the  opposite  shoulder  is  rarely  a  primary  movement,  but  was  observed 
occasionally  from  iriitation  along  the  lower  border  of  the  horizontal  limb  of 
the  precentral  fissure.  The  movement  of  opening  both  eyes  was  represented 
just  above  but  close  to  this  fissure,  and  that  of  turning  both  eyes  horizontally 
best  in  front  of  the  precentral  fissure,  but  to  a  less  degree  loehind  it.  The 
movements  of  the  eyes  in  other  directions  mentioned  occurred  at  various 
points  near  the  transverse  limb  of  the  precentral  fissure.     Dilatation  of  the 

Fig.  99. 


Cortical  foci  of  representation  of  movements  of  small  segments  of  the  body. 
(Beevor  and  Horsley.) 

pupils,  when  it  occurred,  which  was  but  rarely,  appeared  to  be  represented 
around  the  horizontal  limb  of  the  precentral  sulcus.  In  Fig.  99,  which 
indicates  the  foci  of  representation  of  movements  of  all  the  small  segments 
of  the  body,  are  shown  the  areas  for  the  movements  of  the  head  and  e^-es 
together,  of  the  eyes  to  the  opposite  side,  and  of  opening  the  eyelids. 

Area  for  Associated  Eye  Movements,  according  to  Mott.  Mott,^  as  the  result 
of  recent  researches  on  associated  movements  produced  by  unilateral  and 
bilateral  cortical  faradization  of  the  monkey's  brain,  concluded :  (1)  That 
the  area  of  the  cortex  of  the  frontal  lobe,  which,  when  stimulated,  gives  rise 
to  associated  eye  movements,  can  be  divided  into  three  zones — (a)  a  middle 
zone  immediately  below  the  horizontal  part  of  the  precentral  sulcus,  faradiza- 


1  F.  W.  Mott :  Brit.  Med.  Journ.,  vol.  i.  June  21, 1S90,  p.  1419. 


CEREBRAL  LOCALIZATION. 


407 


tion  of  which  is  followed  by  simple  lateral  deviation  of  the  opposite  side ; 
(6)  an  upper  zone  immediately  above  this,  which  may  extend  to  and  include 
part  of  the  marginal  gyrus  ;  this  gives,  on  faradization  downward,  inclination 
combined  with  lateral  deviation ;  (c)  a  motor  zone  immediately  below  the 
middle  one,  and  sometimes  extending  nearly  down  to  the  margin  of  the 
hemisphere  ;  this  gives  upward  inclination,  usually  combined  with  lateral 
deviation.  (2)  That  similtaneous  bilateral  faradization  of  the  frontal 
cortex  at  identical  points  invariably  brings  the  eyes  into  position  of  looking 
straight  forward.  (3)  Bilateral  faradization  of  identical  points  in  the  visual 
area  produces  similar  results  to  those  obtained  in  the  frontal  area.  (4)  Weak 
stimulation  of  the  frontal  area  sufficed  to  overcome  one  of  the  occipital 
visual  area. 

These  areas  are  shown  in  Fig.  100,  and  in  one  of  my  own  cases  in  which  a 
trephine  opening  presumably  uncovered  the  lower  halves  of  the  two  central, 


Fig.  100. 


Cortical  areas  for  associated  eye  movements,  according  to  Mott. 

the  posterior  extremity  of  the  second  frontal,  and  the  posterior  superior 
corner  of  the  third  frontal  convolutions,  a  careful  application  of  a  weak 
faradic  current  to  the  cortex,  at  a  point  which  corresponded  to  the  posterior 
extremity  of  the  second  frontal  convolution,  caused  distinct  deviation  of  the 
head  to  the  opposite  side. 

In  one  of  Horsley's  cases,  in  which  operation  was  performed  at  the  point 
of  meeting  of  the  areas  for  the  movement  of  the  trunk,  protrusion  of  the 
upper  limb,  and  turning  of  the  head  and  eyes,  the  aura  was  contraction  of 
the  abdominal  muscles  followed  by  turning  of  the  head  and  eyes  to  the 
opposite  side.  Other  cases  have  been  reported  in  which  turning  of  the  head 
was  the  starting-point  of  the  spasm.  In  some  cases  at  least,  when  the  aura 
or  signal  symptoms  can  be  most  certainly  shown  to  be  turning  of  the  head 
and  eyes  to  the  side  opposite  the  lesion,  the  probabilities  are  that  the  focus 
or  primary  seat  of  the  irritation  is  from  a  lesion  in  this  oculomotor  region. 
The  fact  that  the  cortical  oculomotor  palsies  are  not  present  as  a  persistent 
condition,  even  when  we  have  definite  lesions  of  the  second  frontal  gyre,  is 
not  an  argument  of  weight  against  the  existence  here  of  oculomotor  centres. 
Such  persistent  oculomotor  paralysis  Avas  not  present  in   one  of  the  best 


408  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

defined  cases  of  lesion  in  the  second  frontal  gyre  ever  reported,  a  case 
occurring  in  my  wards  of  the  Philadelphia  Hospital,  Such  symptoms  do 
not  persist,  because  of  the  automatic  nuclear  mechanism  of  the  cranial  nerves 
related  to  these  centres. 

Conjugate  deviation  of  the  head  and  eyes,  when  a  persistent  or  permanent 
symptom,  is  most  likely  to  arise  from  lesions  of  the  pons,  cerebellum,  or 
cerebellar  peduncles. 

Fraenkel'  has  reported  a  case  in  which  there  was  excessive  rigidity  of  the 
neck  muscles,  which  would  seem  to  bear  out  this  conclusion,  as  examination 
showed  the  existence  of  a  large  clot  covering  the  foot  of  the  second  and  the 
adjacent  part  of  the  third  left  frontal  convolution,  immediately  in  front  of 
the  anterior  central  convolution. 

Centre  for  Elevation  of  the  Upjoer  Eyelids  (Action  of  the  Levator  Paljyebrce 
Superioris).  The  experiments  of  Ferrier,  of  Beevor  and  Horsley,  and  of 
Mott  indicate  the  existence  of  a  centre  for  elevation  of  the  upper  eyelid  in 
the  caudal  portion  of  the  second  frontal  convolution,  which  would  be  its 
most  probable  position,  because  this  movement  is  usually  associated  with 
movements  of  the  eyes  and  head,  which  are  represented  in  this  and  adjoin- 
ing gyres.  Landouzy,  Grasset,  Rendu,  and  others  have  recorded  isolated 
cases  of  paralysis  of  the  upper  eyelid  with  cortical  lesions  in  or  near  the 
angular  gyre ;  but  although  a  stimulation  of  this  region  or  an  area  nearby 
sometimes  causes  elevation  of  the  eyelid  with  other  phenomena,  this  reponse 
is  to  be  regarded  rather  as  a  reflex  from  sensory  stimulation,  than  as  due  to 
excitation  of  a  motor  centre.  An  animal  when  appealed  to  through  the 
sense  of  sight  and  hearing  elevates  its  eyelids  as  a  sign  of  attention.  De- 
struction of  the  angular  gyre  in  animals  does  not  cause  j)aralysis  of  any 
kind,  and  many  cases  of  lesion  of  this  region  without  ptosis  or  any  other 
paralysis  have  been  reported  by  competent  observers. 

Centre  for  Laryngeal  Movements.  In  1877,  Seguin^  reported  a  case  of  left 
hemiparesis,  with  impairment  of  speech,  and  also  of  phonation,  the  patient 
after  an  attack  being  never  able  to  control  the  pitch  of  the  voice,  apparently 
from  lack  of  projDcr  action  of  the  muscles  of  the  pharynx  and  larynx. 
Autopsy  showed  the  surface  of  the  right  third  frontal  convolution  degen- 
erated, being  yellow,  tough  and  elastic,  and  the  same  change  to  a  less  extent 
was  found  in  the  same  location  on  the  left  side.  A  motor  centre  for  laryn- 
geal movements  has  therefore  been  assigned  to  the  posterior  extremity  of 
the  third  or  subfrontal  and  the  anterior  extremity  of  the  precentral  convo- 
lutions, and  this  is  supposed  to  be  better  differentiated  in  the  right  than  on 
the  left  side.  Krause,^  in  1883,  on  excitation  of  the  cortex,  noticed  rise  of 
the  larynx  and  movement  of  the  vocal  bands  to  a  position  midway  between 
expiration  and  phonation,  lifting  of  the  palate,  contraction  of  the  constrictor 
pharyngis,  and  movements  at  the  base  of  the  tongue.  With  extirpation 
experiments  he  found  that  eight  dogs  had  lost  the  power  of  barking,  on 
attempting  which  they  only  uttered  a  hoarse  whiue  or  sound.  Garel*  has 
reported  a  case  of  vocal  paralysis  in  which  the  inferior  portion  of  the  pre- 
central gyre  on  the  right  side  was  slightly  adherent  to  the  meninges,  and  the 
membranes  being  stripped  from  the  surface  beneath  presented  a  light  yellow 
discoloration ;  so  at  the  foot  of  the  third  frontal  gyre  Avere  two  red  points  of 
softening.  Semon^  and  Horsley  found  that  excitation  of  the  lower  end  of 
the  precentral  gyre  at  its  most  cephalic  part  brought  about  phonatory  closure 

1  Fraenkel :  Charite  Annalen,  1886,  cited  by  Gowers  in  Diseases  of  the  Nervous  System,  1893, 
vol.  ii.  2d  ed. 

2  E.  C.  Segiiin  :    Referred  to  by  Delevan  in  Med.  Rec,  N.  Y.,  Feb.  14,  1885. 

3  Hermann  Krause  :    Cited  by  Horsley  and  Schafer  and  Delavan. 

*  Garel  :    Annales  des  Maladies  de  I'Oreille  et  du  Langue,  1886,  tome  xii.  p.  218. 
5  Felix  Semon  and  V.  Horsley  :    Phil.  Trans.  Roj'al  Soc,  1888,  vol.  clxxix. 


CEREBRAL  LOCALIZATION.  409 

of  the  vocal  chords,  and  a  fair  amount  of  other  evidence  has  been  collected 
to  show  the  existence  of  a  cortical  centre  for  laryngeal  movements.  Masini 
reproduced  the  experiments  of  Krause,  and  found  that  the  laryngeal  centre 
had  its  principal  focus,  as  indicated  by  Krause,  at  the  foot  of  the  precrucial 
convolution  of  the  dog ;  and  yet,  according  to  Masini,  the  unexcitable  areas 
of  the  larynx  embraced  nearly  all  of  the  motor  zone.  To  cause  paresis  of 
the  muscles  of  the  larynx,  he  found  it  necessary  to  practice  bilateral  extirpa- 
tion of  the  entire  cerebral  mass  in  front  of  the  crucial  fissure. 

Centre  for  Movements  of  the  Jatu.  The  movements  of  the  jaw  are  proba- 
bly represented  in  the  immediate  vicinity  of  the  centres  for  the  larynx,  throat, 
tongue,  lijDS,  and  face.  In  the  course  of  an  operation  Horsley  found  that 
electrical  excitation  of  the  precentral  convolution,  at  the  junction  of  the 
middle  and  upper  thirds  of  the  area  for  the  face,  caused  lateral  movement 
of  the  jaw,  as  well  as  of  the  angle  of  the  mouth,  such  as  might  be  produced 
by  the  conjoint  action  of  the  platysma  and  the  pterygoid  muscles.  In 
Horsley's  diagram.  Fig.  99,  of  the  cortical  foci  or  representation  of  move- 
ments of  small  segments,  centres  for  laryngeal,  pharyngeal,  and  masticatory 
movements  are  placed  one  behind  the  other,  between  the  presylvian  or  as- 
cending branch  of  the  Sylvian  fissure  and  the  foot  of  the  precentral  fissure. 

The  movements  just  considered — those  of  the  larynx,  pharynx,  and  jaws 
— are  among  those  which  have  a  bilateral  representation  of  the  cortex  ;  they 
are  movements  performed  by  muscles  which  usually  act  together  on  the 
two  sides  of  the  body.  The  cortical  centre  on  either  side  is  sufficient  for 
the  representation  of  movements  of  both  sides.  What  is  ordinarily  termed 
a  hemiplegia  is  never  a  complete  hemiplegia ;  the  movements  of  the  trunk, 
of  the  neck,  of  inspiration,  and  some  of  the  movements  of  the  face,  par- 
ticularly those  of  the  jaw,  and  of  the  orbicularis  palpebrarum  and  the  leva- 
tor palpebrse  muscles,  are  not  affected  at  all,  or  only  slightly.  The  double 
representation  of  the  cortex  is  more  or  less  complete,  according  to  the  de- 
gree of  the  association  of  the  two  halves  of  the  body.  The  orbiculo-palpe- 
bral  movement  is,  to  a  certain  extent,  and  particularly  in  some  individuals 
under  the  control  of  the  will,  and  in  such  cases  will  have  a  distinct  unilat- 
teral  representation  in  the  cortex.  This  is  sometimes  greater  for  one  side 
than  the  other,  as  is  illustrated  by  the  fact  that  the  individual  can  wink  with 
one  eye  voluntarily  better  than  with  the  other.  It  is  necessary  to  have  dou- 
ble lesions  in  order  to  produce  complete  paralysis  of  these  bilaterally  repre- 
sented movements. 

The  Face  Area.  The  face  area  is  subdivided  into  an  upper  and  a  lower 
subarea.  In  three  cases  during  operation  I  have  observed  faradization  of 
the  anterior  superior  portion  of  this  face  area  produce  contraction  of  the 
opposite  angle  of  the  mouth  and  face.  It  is  probable  that  in  the  extreme 
upper  anterior  portion  of  this  area  is  a  subcentre  for  such  movements  of  the 
upper  face  as  contraction  of  the  frontalis  and  obicularis  palpebrarum  mus- 
cles, although  as  these  movements  are,  as  as  a  rule,  bilaterally  associated, 
such  a  centre  does  not  seem  to  come  out  clearly  as  the  result,  either  of  phys- 
iological investigation  or  the  expermients  of  disease.  Berkeley  fixed  the 
cortical  centre  for  the  movements  of  the  angle  of  the  mouth  in  this  upper 
subarea  for  the  face,  but  probably  lower  than  the  centre  for  orbicular  move- 
ments. While  it  is  not  usual,  paralysis  in  the  upper  distribution  of  the 
facial  nerve  sometimes  takes  place  as  the  result  of  a  cortical  lesion. 

Orolingual,  or  lip  and  tongue,  centres  are  situated  in  the  anterior  portion 
of  the  lower  subarea  of  the  face,  a  little  behind  the  centres  for  the  throat 
and  larynx.  In  a  case  of  typical  orolingual  paralysis,  recorded  by  me,  the 
patient  had  distinct  facial  paralysis  in  the  muscles  supplied  by  the  lower 
distribution  of  the  seventh  nerve,  and  also  lingual  paresis ;  probably  also 


410  XEBVOUS  DISEASES  AXD  THEIR  TREATMENT. 

slight  want  of  control  over  the  right  orbicularis  palpebrarum.  He  had  some 
power  over  the  nasal  dilator,  and  good  control  of  masseter,  pterygoid,  and 
temporal  movements.  Articulation  was  distinctly  involved  because  of  oro- 
lingual  monoparesis.  He  could  talk,  but  pronounced  certain  words  indis- 
tinctly. He  had  no  difficulty  in  propositionizing.  A  focus  of  strictly  corti- 
cal yellowish  softening  was  found  involving  the  lower  extremities  of  both 
central  convolutions  (Fig.  101),  both  on  their  external  and  Sylvian  surfaces, 
and  a  soft  one,  half-inch  in  diameter,  about  the  middle  of  the  internal  por- 
tion of  the  insula.  The  softening  reached  into  the  central  fissure,  thus 
taking  in  a  posterior,  inferior  strip  of  the  second  frontal  convolution.  Its 
greatest  height  was  one  and  one-half  inches  upward  fi'om  the  Sylvian  fissure, 
its  width  along  this  fissure  one  and  one-fourth  inches.  The  anterior  limit  of 
the  lesion  was  one-fourth  of  an  inch  caudad  of  the  presylvian  fissure. 

Fig.  101. 


Softening  of  face  area. 

A  more  recent  report  locating  the  facial  centre,  is  by  Brissaud.^  The 
patient  was  a  woman  aged  eighty  years,  with  cardiac  disease  and  catarrhal 
emphysema.  She  had  right-sided  hemiplegia  and  aj^hasia,  which  greatly 
improved.  For  two  years,  subsequently,  she  was  found  to  have  right  facial 
paralysis,  with  some  muscular  atrophy  on  the  right  side,  with  hypersesthesia, 
and  with  right  ptosis  and  dilatation  of  the  pupil.  Her  face  was  absolutely 
asymmetrical,  the  mouth  deviating  to  the  right,  the  right  nostril  was  drawn 
upward,  the  arch  of  the  nose  on  this  side  completely  immobile,  and  the 
angles  of  the  cheek  effaced.  The  brain  showed  a  focus  of  yellow  softening 
occupying  the  inferior  quarter  of  the  left  postcentral  convolution.  The  gyral 
conformations  j)resented  some  peculiarities,  the  foot  of  the  subfrontal  convo- 
lution being  situated  much  in  advance  of  the  inferior  extremity  of  the 
Eolandic  fissure. 

Centre  for  Retraction  of  the  Angle  of  the  Mouth  (Action  of  the  Flatysma 
Myoides.)  Ferrier  found  that  electrical  irritation  of  the  lower  extremity  of 
the  postcentral  convolution  of  the  monkey  caused  retraction  of  the  angle  of 
the  mouth,  stronger  excitation  causing  the  head  to  draw  slightly  to  one  side. 
A  similar  effect  was  produced  1)y  excitation  of  the  frontal  division  of  the  third 
external  or  supersylvian  convolution  of  the  dog ;  and,  occasionally,  the  angle 
of  the  mouth  was  retracted  on  both  sides  and  the  ear  drawn  forward.  Similar 
results  were  obtained  by  experiments  on  jackals.  A  limited  number  of  clin- 
ical cases  have  corroborated  this  experimental  result,  as  one  case  reported  by 

1  Brissaud  :  Le  Progres  Medical,  vol.  xix.  2d  ed.  (S.  Paris,  Dec.  1893.) 


CEREBRAL  LOCALIZATION. 


411 


BramwelP  of  a  woman  who  ireqnently  had  convulsions  which  always  began 
in  the  right  platysma,  and  often  were  almost  entirely  confined  to  this  muscle, 
and  who  also  had  numbness  in  the  thumb  and  forefinger,  followed  by  jDaralysis 
of  the  right  arm  and  leg.  A  spicule  of  bone  was  found  irritating  the  inferior 
margin  of  the  postcentral  convolution. 

Area  for  the  Movements  of  the  Upper  Limb.  The  subdivision  of  the  area 
for  the  upper  limb  is  for  the  shoulder  in  the  upper  part,  the  elbow  next  below 
and  behind,  the  wrist  next  below  and  in  front,  the  thumb  lowest  and  behind. 
In  the  area  just  above  the  superfrontal  fissure  the  movements  of  the  lower 
and  upper  limb  are  absolutely  blended,  most  markedly  in  the  hinder  sixth  of 
the  superfrontal  gyre.  Sometimes  an  ej)ileptic  fit  from  a  lesion  centred  here 
begins  by  complicated  and  generalized  movements  of  both  extremities  on  one 
side.  Beevor  and  Horsley,^  a.s  one  of  the  results  of  an  elaborate  series  of 
experiments  by  stimulation  of  the  cerebral  cortex  of  the  monkey,  conclude 
that  "  the  most  intense  representation  of  the  movements  of  the  segments  of 
the  upper  limbs  is  arranged  in  a  most  perfect  graduation  from  below  upward. 
The  representation  of  the  thumb  occupies  the  lowest  j)art  of  the  upper-limb 
area,  i.  e.,  opposite  the  lowest  point  of  the  intraparietal  sulcus ;  the  fingers 
have  their  seat  of  greatest  intensity  immediately  above  that  of  the  thumb  ; 
the  representation  of  the  wrist  is  situated  just  above  that  for  the  fingers,  while 
the  elbow  is  represented  higher  up  than  the  wrist,  near  the  upper  limit  of  the 
area.  The  representation  of  the  shoulder  forms  the  upper  limit  of  the  upper- 
limb  area,  being  localized  rather  higher  up  than  that  for  the  elbow." 

Fig.  102. 


A.  Flexion  of  thumb,  fingers,  wrist,  elbow,  and  face  movements,     e.   Shoulder  retracted,  elbow 
fixed,    c.  Flexion  of  elbow  with  arm  raised ;  the  position  of  the  scar  is  shown  by  the  triangle. 

Some  of  the  experiments  and  observations  made  on  the  luiman  cortex 
during  operations  have  beautifully  isolated  the  subdivisions  of  the  areas  of 
the  U23j)er  and  lower  extremities,  and  of  the  face.  In  a  case  operated  upon 
for  me  recently  (October,  1894,)  by  Barton,  a  trephine  opening  was  made  in 
the  position  indicated  in  Fig.  102,  and  gentle  faradization  Avith  an  antiseptic 
bipolar  electrode  at  the  points  indicated  in  the  diagram  produced  the  follow- 
ing results :  At  A,  believed  to  be  just  cephalad  of  the  lower  part  of  the 
middle  third  of  the  central  fissure,  flexion  of  the  thumb,  fingers,  wrist,  and 


1  Byrom  Bramwell :  Brit.  Med.  Jour.,  August  28,  187.5. 

2  C.  E.  Beevor  and  V.  Horsley :  Phil.  Trans.  Royal  Society,  London,  vol.  clxxix. 


,  B,  pp.  205-256. 


412 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


elbow,  followed  by  movements  of  the  face  ;  at  b,  flexion  of  the  elbow  with 
raising  of  the  arm.  At  c,  retraction  of  the  shoulder  and  flexion  of  the 
elbow.  B  and  c  were  presumably  just  caudad  of  the  lower  part  of  the  middle 
third  of  the  precentral  convolution. 

In  one  of  Keen's'  operations,  on  touching  the  cortex  with  the  electrodes  at 
a  position  which  apparently  corresponded  to  the  anterior  portion  of  the  cen- 
tral convolution,  movements  of  the  wrist  and  fingers  were  produced.  The 
hand  moved  in  extension  in  the  mid-line  and  to  the  ulnar  side  at  diflferent 
touches,  the  fingers  being  extended  and  separated.  Above  the  region  in 
which  these  movements  were  obtained,  application  of  the  current  caused 
movement  of  the  left  elbow,  both  flexion  and  extension,  and  of  the  shoulder, 
which  was  raised  and  abducted.  Below  the  region  where  the  hand  move- 
ments were  excited,  the  application  of  the  current  produced  an  upward 
movement  of  the  whole  of  the  left  face.  In  a  case  trephined  by  Hearn  for 
the  writer,  the  exact  movements  described  by  Keen  were  produced.  These 
facts  of  experiments  on  man  would  seem  to  uphold  the  view  that  the  motor 
zone,  in  man  at  least,  is  much  more  extensive  in  front  of  than  behind  the 
fissure  of  Rolando.  Nancrede,  of  Philadelphia,  before  excision  of  the  cor- 
tex, fixed  the  position  of  the  thumb  centre  by  means  of  the  faradic  current. 
The  patient  suffered  from  convulsions  beginning  with  strong  flexion  of  the 
right  thumb.  The  current  was  applied  in  the  second  fourth  of  the  postcen- 
tral convolutions,  counting  from  below  upward. 

Fig.  103. 


Centres  for  the  thigh,  leg,  shoulder,  upper  arm,  elbow,  wrist,  and  hand,  as  determined  by- 
faradization  of  the  human  brain. 

In  another  case  operated  on  for  me  by  Keen,  the  centres  for  the  shoulder 
and  upper  arm  were  fixed  with  great  accuracy,  as  were  also  those  for  the 
elbow,  hand,  and  wrist.  After  the  removal  of  the  bone  and  dura  a  fissure 
corresponding  to  the  line  of  the  central  fissure  was  seen.  The  opening  was 
made  by  a  one  and  one-half  inch  trephine,  the  centre  pin  of  which  had  been 


1  W.  W.  Keen:  Trans.  Amer.  Surg.  Assoc,  vol.  vi.  1888;  also  American  Journal  of  the  Medical 
Sciences,  November,  1888. 


CEREBRAL  LOCALIZATION.  413 

inserted  in  the  line  of  the  central  fissure,  1.75  inches  from  the  median  line. 
Several  spots  were  selected,  as  shown  in  Fig.  103.  When  a  weak  faradic 
current  was  applied  to  the  spot  marked  1,  just  caudad  of  the  line  of  the 
central  fissure,  at  about  the  juncture  of  its  upper  and  middle  third,  the  first 
movement  which  at  once  resulted  was  protraction  and  moderate  adduction  of 
the  shouder  and  upper  arm.  This  was  soon  followed  by  a  series  of  jerks, 
involving  the  upper,  and  to  a  more  moderate  degree,  the  lower  arm.  No 
differentiated  movements  of  the  head  and  arm,  and  no  face  or  upper-leg  con- 
tractions were  observed.  The  left  toes  and  foot,  however,  slightly  flexed 
coincidently  with  the  shoulder  movement.  A  second  application  was  made 
at  the  point  marked  2,  the  effect  of  which  was  to  again  produce  decided 
shoulder  and  arm  movements,  with  greater  adduction  and  some  protraction 
of  the  entire  arm.  The  thigh  was  flexed  upon  the  pelvis  at  an  angle  of  about 
130°,  and  the  leg  upon  the  thigh  about  the  same,  with  adduction  of  the  thigh 
and  extension  of  the  foot  and  toes.  Excitation  at  the  point  marked  3,  flexed 
the  elbow,  hand,  and  wrist,  with  slight  shoulder  abduction,  protraction  closely 
following.  Excitation  at  4,  caused  primary  movements  of  abduction  and 
flexion  of  the  thigh  upon  the  pelvis,  and  the  leg  upon  the  thigh  at  an  angle 
of  135°  or  140.°  No  foot  movements  or  movements  of  the  upper  extremities 
occurred. 

Area  for  Movements  of  the  Lower  Limb.  The  movements  of  the  lower 
extremity  are  represented  in  the  upper  portion  of  the  motor  area  and  the 
adjoining  marginal  convolutions ;  probably  hip  and  thigh  movements  on  the 
lateral  and  mesal  aspects  of  the  hemisphere,  well  forward  in  the  area,  and 
movements  of  the  legs  and  toes  further  back  on  both  the  lateral  and  mesal 
aspects.  Beevor  and  Horsley'  described  the  whole  region  of  representation 
of  the  lower  limb  as  a  narrow  strip  running  along  and  forming  the  upper 
fifth  of  the  convex  outer  surface  of  the  excitable  region  of  the  hemisphere ; 
further,  that  the  middle  of  this  strip,  or,  more  strictly  speaking,  the  juncture 
of  its  middle  and  posterior  thirds,  is  essentially  the  seat  of  representation  of 
the  hallux,  while  each  extremity  is  essentially  the  seat  of  representation  of 
the  small  toes.  Horsley'''  has  described  a  case  of  traumatic  epilepsy,  the 
primary  movement  consisting  of  flexion  of  the  hallux,  followed  by  gradual 
flexion  of  the  rest  of  the  lower  limb,  and  that  followed  by  successive  invasion 
of  the  rest  of  the  lower  body  in  the  usual  order.  A  dense  and  cystic  cica- 
trix was  found  at  the  upper  end  of  the  precentral  gyrus.  In  another  case,  in 
which  a  tumor  was  removed  and  with  it  the  cortex  in  front  of  the  upper  end 
of  the  fissure  of  Rolando,  the  only  permanent  complete  paralysis  of  the  lower 
limb  was  that  of  the  hallux.  In  one  of  my  cases  in  which  a  small  gumma 
involved  the  upper  fourth  of  the  precentral  and  a  smaller  segment  of  the 
postcentral  convolution,  the  patient  had  severe  attacks  of  left-sided  spasm, 
beginning  with  twitchings  in  the  left  toe  and  foot ;  and  she  also  had  partial 
paralysis  of  the  left  leg  and  arm,  most  marked  in  the  leg.  The  leg  area, 
as  first  shown  by  Horsley  and  Schafer,  is  also  largely  situated  upon  the 
mesal  surface  of  the  hemispheres.  According  to  these  authors,  the  excitation 
takes  effect  chiefly  upon  the  ankles  and  digits,  producing  most  commonly 
flexion  of  the  foot  with  flexion  of  the  digits.  The  most  marked  movement 
in  front  of  the  upper  end  of  the  Rolandic  fissure  is  flexion  of  the  leg  at  the 
knee,  Avith  the  addition,  when  the  electrodes  Avere  applied  more  anteriorly,  of 
flexion  at  the  hip. 

Area  for  Movements  of  the  Trunk.  A  narrow  strip  of  the  anterior  portion 
of  the  leg  area  appears  both  from  the  results  of  experimentation  and  of 

1  Beevor  and  Horsley,  op.  cit. 

2  V.  Horsley  :  American  Journal  of  the  Medical  Sciences,  April,  1887. 


414 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


pathological  and  surgical  observation  to  be  a  trunk  area,  this  being  larger 
proportionally  on  the  mesal  than  on  the  lateral  aspect  of  the  hemisphere,  as 
represented  on  the  diagrams.  Horsley  and  Schafer  occasionally  obtained 
movements  of  the  trunk  when  the  electrodes  were  applied  to  the  lateral  sur- 
face near  the  margin  of  the  hemisphere.  On  the  adjoining  mesal  surface 
excitation  produced  rotation  and  arching  of  the  lower  spine  and  the  pelvis, 
and  extension  of  the  hip,  movement  of  the  tail  to  the  opposite  side,  and 
flexion  at  the  knee. 

The  study  of  motor  localization  shows  that  some  of  the  motor  areas  appar- 
ently overlap  each  other.  Ferrier  holds  that  the  various  centres  of  repre- 
sentation are  isolated  from  each  other,  but,  according  to  some  authors,  this 
overlapping  is  real.  The  views  of  Horsely'  are  given  in  the  following  quota- 
tion :  "  The  general  result  has  been  to  show  that  there  is  no  hard  and  fast  line 
limiting  the  representation  of  any  given  segment.  I  mean  to  say  that  there 
is  no  area  of  the  cortex,  over  which  any  particular  segment  is  equally  repre- 
sented throughout,  but  that  in  one  spot  especially  the  representation  is  con- 
centrated and  thence  diminishes  gradually  ;  thus  in  the  representation  of  the 


Fig.  104. 

^A      0      T      0 


R 


Cortical  centres  and  areas  of  representation  on  the  lateral  aspect  of  the  hemicerebrum. 

thumb,  we  find,  for  example,  that  there  is  a  focus,  but  that  the  thumb  is 
represented  over  a  great  deal  of  the  upper-limb  region,  and  that  this  repre- 
sentation diminishes  in  intensity  gradually  as  we  pass  from  the  focus  upward. 
To  give  one  more  example:  the  shoulder  and  the  thumb  form  the  two  great 
'  purposive '  parts  of  the  upper  limb,  and  we  find  that  the  shoulder  is  repre- 
sented in  exactly  the  opposite  part  of  the  upper-limb  region  to  that  of  the 
representation  of  the  thumb.  I  cannot  do  more  now  than  thus  indicate  the 
mode  in  which  we  believe  that  the  various  segments  of  the  body  are  repre- 
sented. I  have  here  a  diagram  (Fig.  99)  showing  the  various  foci  of  repre- 
sentation of  all  the  small  segments  of  the  body.    Professor  Ferrier  states  that 


1  V.  Horsley :  Trans.  Congress  Amer.  Phys.  and  Surg.,  1888,  vol.  i.  p.  342-345. 


CEREBRAL  LOCALIZATION. 


415 


these  areas  are  limited  by  hard  and  fast  lines,  that  no  one  area  ti*enches  upon 
the  other.  I  cannot  follow  my  honored  teacher  in  this  belief.  We  are  per- 
fectly sure  that  there  are  what  may  be  called  border  centres,  and  indeed  in 
one  portion  of  the  brain.  Professor  Ferrier  has  himself  called  attention  to  this 


^ 


Fir.  105. 

0      J      0 


Cortical  centres  and  areas  of  representation  on  the  mesal  aspect  of  the  hemicerebrum. 

fact.  There  are  border  centres,  and  the  area  of  representation  of  the  face 
merges  into  that  for  the  representation  of  the  ujDper  limb.  If  there  was  a 
focal  lesion  at  that  point  you  would  haye  the  moyements  of  these  two  parts 
starting  together.  You  haye  then  two  '  signal '  symptoms,  meaning  that  you 
haye  two  moyements  of  two  different  segments." 

SENSORY  LOCALIZATION   (Areas  for  Cutaneous  and 
Muscular    Sensations). 


The  remarks  already  made  regarding  the  different  theories  as  to  motor 
and  sensorimotor  localization  indicate  that  the  question  of  cortical  represen- 
tation of  the  cutaneous  sensations  of  touch  pain  and  temperature — and  other 
so-called  senses  embraced  under  the  designation  "  common  sensibility  " — is 
still  under  discussion.  As  we  haye  already  indicated,  it  is  only  necessary  for 
practical  purposes  to  admit  that  something  occurs  in  each  separate  area  of 
the  cortex  which  giyes  rise  to  manifestations  which  must  be  referred  to  this 
part.  In  order  that  a  certain  spot  in  the  brain  shall  constitute  a  centre  it  is 
only  necessary,  in  the  neurologist's  sense,  that  its  abolition  shall  cause  certain 
phenomena  to  disappear,  and  its  excitation  shall  cause  certain  phenomena  to 
be  present  or  to  be  intensified. 

In  1888  I  declared  that  the  conclusion  was  warranted  that  there  was  in  the, 
cerebrum  a  region  for  general  sensation,  including  touch,  pain,  temperature 
and  possibly  the  senses  of  pressure  and  of  the  location  of  a  limb,  which  could 
be  divided  into  special  subareas  for  the  yarious  distinct  portions  of  the  body. 


416  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  that  these  regions  lay  alongside  of  and  had  close  relation  with  correspond- 
ing motor  areas,  but  that  they  were  not  identical  with  them  ;  also  that  no  part 
of  the  brain  was  more  likely  to  contain  these  differentiated  areas  for  sensa- 
tion than  the  gyrus  fornicatus,  the  hippocampal  gyre,  the  precuneus,  and  the 
postparietal  convolutions.  I  see  no  reason  to  change  the  conclusions  ex- 
pressed in  this  paragraph,  but  the  use  of  the  term  "  centres  "  may,  as  just 
pointed  out,  be  misleading  in  this  connection.  Too  much  stress  is  laid  upon 
motor  celh  and  seiisory  cells.  The  great  function  of  all  cells  is  trophic.  Cells 
in  sensory  areas  do  not  feel,  nor  do  they  originate  sensation ;  neither  do 
motor  cells  spontaneously  generate  motion.  They  are  simply  bodies  placed 
in  the  great  sensorimotor  arc  to  administer  to  the  nutritive  functions  of  the 
fibres  which  convey  sensory  and  motor  impressions.  In  a  certain  practical 
sense  we  have  sensory  cells  and  motor  cells,  the  former  being  small  and 
having  short  neurons,  the  latter  large  with  long  axis-cylinder  processes ;  but 
these  cells  do  not  fundamentally  differ.  They  vary  in  size  according  to  the 
length  and  bulk  of  the  fibres  which  they  nourish. 

The  great  sensory  tract  or  path  is  constituted  of  nerve  cells  and  fibres 
which  originate  in  the  dorsal  spinal  ganglia  and  their  cranial  homologues. 
These  ganglia  send  out  prolongations  which  become  the  true  peripheral  nerve 
fibres  and  endings,  and  shorter  processes  which  penetrate  the  spinal  cord,  and 
there  bifurcate,  a  branch  descending  and  another  ascending.  Some  conflict 
still  exists  as  to  the  course  of  sensory  fibres  in  the  spinal  cord.  Ferrier^  holds 
that  the  evidence  is  in  favor  of  this  view — that  all  of  the  sensory  paths  pass  up 
the  opposite  side  of  the  spinal  cord,  and  that  they  are  not  contained  either  in 
the  postero-median  column  or  in  the  direct  cerebellar  tract,  or  in  the  antero- 
lateral tract ;  and  as  the  pyramidal  tract  may  be  entirely  sclerosed  without 
any  affection  of  sensation — he  is  led  by  a  process  of  exclusion  to  suppose 
that  the  sensory  tracts  ascend  in  immediate  relation  with  the  gray  central 
matter.  The  view  which  at  present  has  the  most  support  is  that  decussations 
of  the  fibres  which  constitute  the  great  sensory  pathway  take  place  both  in  the 
cord  and  oblongata,  (1)  by  crossings  in  the  spinal  commissures  at  all  levels,  of 
fibres  which  convey  pain  and  temperature  impulses,  which  ascend  in  Gowers's 
antero-lateral  tract  of  the  opposite  side ;  and  (2)  by  crossings  in  block  or 
mass  of  the  tactile  sensory  tracts  of  the  columns  of  Goll  and  Burdach,  just 
above  the  cuneate  and  clavate  nuclei  at  the  decussations  of  the  fillet,  or 
upper  sensory  decussation.  From  this  level  all  the  fasciculi  for  common 
sensation  pass  cephalad  together.  According  to  this  view  the  columns  of  Goll 
and  Burdach  constitute  a  direct  path,  conveying  to  the  clavate  and  cuneate 
nuclei,  by  long  axis-cylinder  processes,  the  tactile  impressions  received  from 
the  same  side  of  the  body.  The  cells  for  these  columns  are  chiefly  tauto- 
meral — cells  whose  axis  cylinders  pass  into  tracts  on  the  side  on  which  they 
originate.  The  antero-lateral  tract  of  Gowers  is  the  chief  path  for  pain  and 
temperature  impressions,  largely  constituted  by  processes  of  heteromeral 
cells,  whose  neurons  pass  by  the  way  of  the  anterior  commissure  to  the  white 
substance  of  the  opposite  side.  These  views  have  not  yet  received  full  accept- 
ance. One  of  the  strongest  arguments  in  their  favor  is  furnished  by  syringo- 
myelia. In  this  disease  destruction  of  the  spinal  decussations  accounts  for 
the  impairment  or  abolition  of  the  pain  and  temperature  senses,  the  tactile 
sense  remaining  intact  in  most  cases,  because  Goll's  columns  have  not  been 
invaded. 

However  views  may  differ  with  reference  to  the  spinal  sensory  paths  and 
the  cortical  representation  of  cutaneous  sensations,  they  are  in  general  accord 
with  regard  to  the  course  of  the  great  sensory  tract  in  the  fillet,  or  lemniscus 

1  David  Ferrier :  The  Croonian  Lectures  on  Cerebral  Localization,  London,  1890,  p.  99. 


CEREBRAL  LOCALIZATION.  417 

— in  the  oblongata,  pons,  and  mid-brain — and  its  continuation  in  the  posterior 
third  of  the  posterior  limb  of  the  internal  capsule. 

As  the  sensory  paths  are  differentiated  up  to  the  internal  capsule,  it  is  not 
probable  that  they  at  once  begin  to  blend  with  the  motor  and  other  fibres  of 
the  alba  immediately  after  emerging  from  the  capsule.  On  the  whole,  the 
weight  of  evidence  is  in  favor  of  a  separation  of  the  regions  especially  related 
to  common  sensibility  from  the  motor  and  other  areas  of  the  brain.  My 
own  views  on  this  subject  have  not  changed,  but  have  undergone  some  modifi- 
cation as  to  the  method  of  expressing  the  facts  regarding  this  localization. 
Indisputable  facts  of  experiment  and  pathology  show  that  the  callosal  gyre 
(gyrus  fornicatus)  and  hypocampal  region,  and  probably  also  the  postero- 
parietal  convolutions,  are  in  some  way  especially  concerned  with  the  represen- 
tation of  sensation,  or  with  some  cerebral  process  of  a  sensory  character  in 
the  great  sensorimotor  arc. 

After  sensory  fibres  have  passed  the  internal  capsule  they  soon  begin  to 
spread  outward,  but  still  hold  an  intermediate  place  betw^een  the  motor 
areas  and  the  areas  for  the  special  senses.  As  the  sensory  tract  approaches 
the  cortex  some  fibres  pass  to  neighboring  regions,  but  most  of  these  fibres 
reach  the  postero-parietal  region  and  the  falciform  lobe  before  sending  their 
branches  to  other  zones.  Sensory  cells — that  is,  cells  solely  concerned  with 
nourishing  fibres  which  are  still  responding  by  excitations  which  pertain  to 
the  afferent  side  of  the  nervous  system — are  found  in  the  limbic  lobe  and  post- 
parietal  region,  but  their  extensions  (processes)  must  form  various  thicknesses 
and  complications  of  fibres  and  cells  all  over  the  cerebrum. 

Cases  have  been  reported  by  Demeaux,  by  F.  Miiller,  by  the  writer,  and 
others  in  which  autopsies  have  shown  hemiansesthesia  from  lesion  of  the 
hinder  third  of  the  internal  capsule  or  adjoining  portions  of  the  corona 
radiata.  Veyssiere  produced  hemiansesthesia  on  the  opposite  side  of  the 
body  by  dividing  this  portion  of  the  capsule  in  animals.  The  fibres  of  the 
sensory  tract  are  probably  separated  from  the  motor  in  the  centrum  ovale 
until  the  cortex  is  reached  or  nearly  reached.  According  to  Flechsig,  the 
third  set  of  fibres  of  the  projection  system  included  those  which  lie  just  pos- 
terior to  the  motor  tract,  and  which  pass  inward  from  the  parietal  convolu- 
tions, and  these  take  a  similar  course  to  the  motor  tract,  and  fill  up  to  a  con- 
siderable extent  the  space  between  it  and  the  radiation  of  the  visual  tract, 
toward  the  occipital  lobe. 

Ferrier  in  his  earlier  experiments  found  that  lesions  involving  the  horn  of 
ammon  and  the  hippocampal  convolution  caused  impairment  or  abolition  of 
tactile  sensibility  on  the  opposite  side  of  the  body,  and  located  the  cortical 
centres  for  this  form  of  sensibility  in  the  hippocamj)al  region.  In  experi- 
ments on  monkeys,  with  Professor  Yeo,  he  established  that  tactile  sensibility 
was  in  every  case  temporarily  impaired  or  abolished,  according  to  the  amount 
of  destruction  of  the  hij^pocampal  and  temporo-sphenoidal  regions. 

Horsley  and  Schafer  found  that  hemiansesthesia,  partial  or  complete  and 
contralateral,  resulted  from  destructive  lesions  of  the  limbic  lobe.  They 
found  that  any  extensive  lesion  of  the  gyrus  fornicatus  was  followed  by 
hemiansesthesia  more  or  less  marked  or  persistent ;  sometimes  the  loss  of  sen- 
sation involved  almost  the  whole  of  the  opposite  side  of  the  body ;  some- 
times it  was  localized  either  to  the  upper  or  lower  limb,  or  to  a  particular 
part  of  the  trunk.  They  did  not,  however,  succeed  in  establishing  the  rela- 
tions between  special  regions  of  the  body  and  the  parts  of  the  convolutions 
which  had  been  destroyed.  Their  experiments  Avere  frequently,  but  by  no 
means  in  every  case,  complicated  by  the  presence  of  a  certain  amount  of 
motor  paralysis,  chiefly,  if  not  entirely,  affecting  the  muscles  of  the  leg,  and 
they  believe  that  this  condition  was  always  due  to  a  lesion  (accidentally  pro- 

27 


418  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

duced  during  the  operation  or  subsequently  as  the  result  of  interference  with 
the  circulation)  in  the  leg  area  of  the  marginal  convolution. 

Some  light  has  been  thrown  on  the  disputed  question  of  the  existence  of 
sensory  centres  in  the  motor  cortex  by  careful  examinations  of  patients  after 
operations,  particularly  when  definitely  determined  gyral  areas  haye  been 
cleanly  excised.  In  a  case  of  Lloyd  and  Deayer,  in  which  the  facial  and 
arm  centres  were  careflilly  excised,  I,  on  several  occasions,  with  Dr.  Lloyd, 
tested  the  conditions  as  to  motor  power  and  sensibility  and  the  reflexes  in 
this  patient,  with  the  results  which  have  been  reported  by  Dr.  Lloyd.  The 
patient  bbndfolded  could  instantly  recognize  the  slightest  touch  on  all  points 
on  the  affected  side ;  even  light  breathing  upon  his  hand  was  at  once  de- 
tected ;  pain  and  temperature  sense  were  normal,  and  he  could  discriminate 
between  weights.  If  objects  were  placed  in  his  paretic  hand  he  often  failed 
to  recognize  what  they  were,  but  apparently  because  he  was  not  able  to  grasp 
and  run  his  fingers  oyer  them  and  take  in  their  form  and  bulk. 

Bechterew^  who  believes  in  separate  sensory  areas,  maintains  that  the  loss 
of  sensation  in  animals  that  have  had  the  motor  area  of  the  convolutions  de- 
stroyed is  apparent  and  not  real ;  that  they  cannot  Avithdraw  the  irritated 
extremity,  though  they  feel  the  pain,  because  they  have  not  the  control  of 
the  muscles.  He  also  considers  the  loss  of  the  muscle  sense  only  apparent, 
because  if  the  animal's  paw  be  placed  in  an  uncomfortable  position  its  failure 
to  be  removed  is  due  rather  to  the  motor  inability  than  to  impaired  muscle 
sense. 

Starr,-  from  a  series  of  American  cases  of  cortical  lesion  of  the  brain,  and 
also  from  a  study  of  the  sensory  tracts,  concluded  that  the  various  sensory 
areas  lie  about  and  coincide  to  some  extent  with  the  various  motor  areas  for 
similar  parts  ;  that,  in  other  words,  the  Rolandic  region  is  a  sensorimotor 
region,  the  sensory  area,  however,  including  to  some  extent  the  gyres  of  the 
adjacent  postero-parietal  lobe.  Collections  of  cases  such  as  these  cannot,  how- 
ever, overcome  positive  evidence  of  decided  destructive  lesions  of  the  cortical 
motor  centres,  without  any  disturbance  of  touch,  pain,  or  temperature,  or 
even  of  muscular  sense. 

Dana^  collected  142  cases,  including  four  personal  observations,  and  con- 
cluded that  the  clinical  and  pathological  evidence  collected  by  him  showed 
that  the  motor  areas  of  the  cortex  contained  also  the  representation  for 
cutaneous  sensations. 

Both  Ransom*  and  Dana,^  in  advocacy  of  the  view  that  the  Rolandic 
areas  of  the  brain  are  centres  for  sensation  as  well  as  motion,  have  recently 
reported  cases  of  epilepsy  in  which  the  brain  was  exposed  through  an  open- 
ing made  to  relieve  the  epilepsy,  and  needle  electrodes  were  stuck  through 
a  cocainized  dura  to  the  depth  of  half  an  inch  ;  and  in  both  cases  subjective 
anaesthesia  of  the  limb  corresponding  to  the  area  experimented  upon  re- 
sulted. It  is  only  necessar}^  to  recall  a  criticism  already  made  on  one  of 
these  cases,  namely,  that  the  subjective  symptoms  of  an  epileptic,  confessedly 
of  weakened  intellect,  are  not  sufficiently  reliable  to  justify  any  conclusions 
whatever.  Subjective  perversion  of  sensation  means  nothing  for  the  deter- 
mination of  this  question.  Albertoui  and  Brigatti  report  a  case  of  epilepsy 
due  to  a  tumor,  which  was  removed  from  the  mid-Rolandic  region  by  opera- 
tion. The  epilepsy  ceased  as  a  result,  and  the  motor  paralysis  greatly  im- 
proved, but  tactile,  thermal,  painful,  and  muscular  sensations,  which  before 
the  operation  were  intact,  were  afterward  affected  in  an  appreciable  degree 

1  Bechterew  :  Neurol.  Centralbl.,  Leipzig,  1883,  ii.  pp.  409-414. 

2  M.  Allen  Starr :  Amer.  Journ.  Med.  Sei.,  Phila..  1884,  N.  S.,  Ixxxvii.  pp.  366-391. 

3  Dana  :  Journ.  Nerv.  and  Mental  Dis.,  vol.  xiii.  No.  9,  September,  1SS8,  p.  650-681. 

t  Ransom  :  Brain,  vol.  xv.  1892,  p.  437.  «  Dana  :  Medical  Record,  May  13,  1893. 


CEREBRAL  LOCALIZATION.  419 

over  the  entire  opposite  half  of  the  body.  This  case,  however,  proves  noth- 
ing conckisively,  because  of  the  large  mass  of  brain  substance  removed, 
which  probably  included  the  cortical  sensory  tracts. 

The  cases  reported  by  SavilP  are  confirmatory  of  the  doctrine  of  separate 
sensory  localization.  The  first  was  a  case  of  anaesthesia  and  trophic  changes 
consequent  on  lesions  of  the  gyrus  foruicatus.  The  lesion  was  strictly  local- 
ized, and  was  situated  precisely  beneath  the  parts  of  the  cortex  correspond- 
ing to  the  callosal  gyre  (gyrus  fornicatus),  and  part  of  the  marginal  convo- 
lution in  their  entire  extent,  and  also  beneath  the  anterior  half  of  the  quad- 
rate lobule  (precuneus).  The  cavity  stretched  from  before  backward  over 
the  roof  the  right  lateral  ventricle,  from  which  it  was  separated  in  places 
only  by  the  ependyma,  without  nerve  tissue.  Careful  details  are  given  of 
the  autopsy  and  subsequent  examination.  This  patient  had  completely  lost 
the  power  of  perceiving  when  the  left  side  of  the  body  was  touched  or  pricked 
seven  days  after  the  hemorrhage  which  Savill  believes  cut  off  all  communi- 
cation between  the  right  gyrus  fornicatus,  marginal  convolution,  and  the 
anterior  part  of  the  quadrate  lobule  with  the  part  beneath.  Sensation  was 
also  imperfect  in  portions  of  the  right  arm,  right  leg,  and  trunk,  which 
Savill  believed  was  due  to  pressure  on  the  corresponding  convolutions  of  the 
left  hemisphere.     Other  important  symptoms  were  present. 

Savill  concludes,  (1)  that  the  case  supports  the  experimental  evidence  that 
the  gyrus  fornicatus  is  the  centre  for  common  sensation  on  the  opposite  side  of 
the  body ;  (2)  that  this  loss  of  sensation  in  man  may  be  quickly  recovered 
from,  presumably  by  a  process  of  substitution  of  centres,  the  other  hemi- 
sphere taking  on  the  functions  of  the  parts  destroyed  ;  (3)  that  a  destructive 
lesion  of  the  gyrus  fornicatus  may  produce  loss  of  sensation  without  loss  of 
voluntary  motion,  at  any  rate  to  any  serious  extent ;  (4)  that  a  destructive 
lesion  in  the  same  position  is  also  attended  by  vasomotor  or  trophic  changes 
of  a  more  permanent  character  than  the  sensory  changes  in  the  skin  and  sub- 
cutaneous tissues  on  the  opposite  side  of  the  body ;  and,  therefore,  these  con- 
volutions may  possibly  be  centres  not  only  for  sensation,  but  also  for  trophic 
influences  transmitted  to  the  opposite  side  of  the  body. 

Savill's  second  case  seems  to  indicate  that  the  posterior  part  of  the  gyrus 
fornicatus  is  the  cerebral  centre  for  tactile  sensation  of  the  arm.  The  autopsy 
in  this  case  revealed  a  tumor  with  a  zone  of  softening,  which  corresponded 
to  the  paracentral  and  quadrate  lobules,  and  the  posterior  third  of  the  gyrus 
fornicatus,  also  projecting  into  the  posterior  and  superior  wall  of  the  lateral 
ventricle.  It  did  not  appear  on  the  vertex  of  the  brain,  but  the  posterior 
third  of  the  hemisphere  was  congested.  "  The  difRise  nature  of  the  anterior 
and  upper  parts  of  the  tumor  prevented  one  from  saying  very  precisely  which 
of  the  white  fibres  of  the  corona  radiata  were  destroyed  or  involved ;  but  it 
was  quite  certain  that  the  gray  matter  of  the  posterior  third  of  the  gyrus 
fornicatus,  the  greater  part  of  the  quadrate  lobule,  and  the  posterior  extrem- 
ity of  the  marginal  convolution,  was  considerably  disorganized,  and  its  com- 
munication with  the  parts  below  cut  off.  Indeed  the  tumor  fungated  out  on 
the  median  aspect  of  the  first-named  convolution,  which  was  the  chief  one 
involved. 

Savill  refers  to  a  case  of  hemiansesthesia  with  other  symptoms  published  by 
Dr.  Sharkey,^  and  believes  that  the  extent  of  the  lesion,  judging  from  the 
illustration,  was  such  as  to  involve  the  fibres  coming  from  the  gray  matter  on 
the  median  aspect  of  the  hemisphere. 

Luys,  largely  from  anatomical  studies,  made  the  thalamus  a  centre  of  sensi- 

1  Savill  :  Brain,  vol.  xiv.  1891,  p.  274 ;  and  vol.  xv.  1892,  p.  450. 

2  Sharkey  :  Med.  Chir.  Trans.,  1884,  p.  265. 


420  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

bility,  subdividing  it  into  four  special  centres,  olfactory,  optic,  acoustic,  and 
general  sensibility.  Ferrier  regards  the  thalamus  as  in  some  way  connected 
with  sensation,  but  believes  that  differentiated  areas  for  sensation  also  exist  in 
the  cortex.  The  experiments  of  Monakow  led  to  the  conclusion  that  different 
portions  of  the  thalamus  are  related  to  cortical  areas.     Fournier  believes  that 


Fig 


Savill's  case  of  tumor  with  zone  of  softening,  invading  the  paracentral  and  quadrate  lobules,  and 
the  posterior  third  of  the  gyrus  fornieatus.  The  white  central  spot  indicates  the  position  where  the 
tumor  protruded  from  the  surface.  The  white  line  around  indicates  a  zone  of  softening  and  conges- 
tion which  projected  above  the  level  of  the  median  surface. 

sensory  fibres  terminate  in  the  thalamus.  Crichton-Browne  regards  this 
ganglion  as  a  great  centre  of  general  sensibility ;  but  Flourens,  Longet, 
Schiff,  and  Tamburini,  among  others,  have  assigned  to  it  motor  functions. 
The  weight  of  evidence,  both  from  experiment  and  disease,  connects  the 
thalamus  with  various  forms  of  sensation,  but  it  is  not  the  sole  cerebral  region 
for  sensibility. 

VISUAL   LOCALIZATION. 

The  visual  area  is  represented  in  the  two  diagrams  as  taking  in  all  the  occi- 
pital lobe,  and,  on  the  lateral  aspect,  adjoining  portions  of  both  the  temporal 
and  parietal  lobes,  including  the  so-called  angular  gyre.  As  the  motor  zone 
has  been  subdivided  into  areas  of  representation,  not  only  for  the  leg,  trunk, 
and  arm,  face,  speech,  etc.,  but  also  into  areas  or  centres  for  parts  of  the  leg, 
arm,  face,  and  speech,  so  efforts  partly  successful  are  now  being  made  to  sub- 
divide the  visual  zone.  The  retina,  so  far  as  its  connection  with  the  central 
cortex  is  concerned,  can  be  subdivided  into  segments  probably  of  a  somewhat 
irregular  shape.  At  first,  studies  in  hemiopia  and  hemianopsia  seemed  to 
show  that  the  only  definite  connection  was  between  halves  of  the  retinse  and 
cortical  centres,  but  the  latest  observations  indicate  that  quadrants  and  prob- 
ably even  smaller  portions  of  the  retinal  expansion  are  related  to  separate 
areas  of  the  brain.  The  macular  region  certainly  has  its  special  cortical 
centre. 

Ferrier  has  modified  his  earlier  views  in  so  far  that  he  no  longer  localizes 
the  visual  centres  in  the  angular  gyre  to  the  exclusion  of  the  occipital  lobe, 
but  he  believes  now  that  the  visual  centres  embrace  not  only  the  angular  gyre, 
but  also  the  occipital  lobes,  which  together  he  terms  the  occipito-angular  re- 
gion. He  believes  that  the  angular  gyre  maintains  relations  with  the  retinal 
area  of  clear  central  vision,  and  especially  with  the  macula  lutese. 


CEREBRAL  LOCALIZATION.  421 

From  a  long  series  of  experiments  upon  the  monkey's  brain  in  which  he  was 
engaged  with  Horsley  during  more  than  two  years,  Schiifer  found  that  exten- 
sive lesions,  both  of  the  occi]3ital  lobe  and  of  the  temporal  lobe,  were  invari- 
ably followed  by  visual  disturbances,  taking  the  form,  when  the  operation  was 
confined  to  one  side  of  the  brain,  of  bilateral  homonymous  hemianopsia  ;  but 
in  nearly  every  case  the  hemianopsia  was  merely  temporary.  The  most 
marked  results  of  this  kind  were  obtained  when  the  occij)ital  lobes  were  the 
seat  of  operation,  extensive  unilateral  lesions  producing  amblyoj)ia ;  but  in 
neither  case  were  the  symptoms  permanent.  In  conjunction  with  Sanger- 
Brown,  Schafer  also  experimented  upon  the  angular  gyre  and  the  occipital 
lobes.  Destroying  one  angular  gyrus  as  completely  as  possible  with  the 
actual  cautery,  they  could  discover  no  defect  of  vision,  no  loss  of  the  move- 
ment of  the  eye  or  eyelids,  and  no  ansesthesia  of  the  corneal  conjunctiva.  A 
week  later  the  angular  gyre  of  the  opposite  side  was  destroyed,  also  with 
negative  results. 

With  reference  to  visual  localization,  the  importance  of  confirming  physio- 
logical experimentation  by  careful  clinico-j)athological  observations  cannot  be 
overestimated  ;  these  observations  are  even  here  of  more  importance  than  in 
motor  localization. 

A  few  well-reported  cases  of  hemianopsia  with  autopsies  by  Jastrowitz,^ 
Haab,''  Hueguenin,^  Monakow,*  Seguiu,"  Hun,®  Fere,  Keen  and  Thompson 
settled  beyond  doubt  the  connection  of  the  cuneus. 

Seguin  collected  forty  cases  with  autopsies,  and  five  traumatic  cases  with- 
out autopsies.  Eleven  of  these  were  cases  of  hemianopsia  due  to  lesions  of 
the  white  substance  of  the  occipital  lobe.  Sixteen  were  cases  of  cortical 
lesion,  or  of  lesion  limited  to  the  cortex  and  the  white  substance  immediately 
subjacent ;  and  four  of  the  sixteen  (those  of  Haab,  Hueguenin,  Fere,  and 
Seguin,  referred  to  above)  are  what  might  be  termed  conclusive  cases  as  to 
the  question  of  the  location  of  at  least  a  portion  of  the  cortical  visual  centre 
in  man,  as  in  them  the  lesion  was  circumscribed  and  occupied  nearly  the 
same  place  in  the  occipital  lobe.  In  one  of  his  tables  Seguin  has  included 
five  cases  of  traumatic  hemianopsia  due  to  injuries  of  the  occipital  region  of 
the  skull  and  lesion  of  the  subjacent  brain.  One  of  the  most  important 
cases  which  has  been  recorded  since  the  paper  of  Seguin  is  that  of  Hun,  in 
which  a  defect  in  the  fields  of  vision  involving  the  lower  left  quadrant  of 
each  eye  occurred  with  atrophy  of  the  lower  half  of  the  right  cuneus. 

r  have  recorded  an  account  of  the  brain  of  a  man  who  had  been  blind 
more  than  twenty-five  years — how  much  longer  could  not  be  positively  ascer- 
tained. Both  occipital  lobes  were  unquestionably  small.  The  cuneus  on 
each  side  was  small,  the  first  occipital  convolution  of  Ecker  (superior  exter- 
nal pli  de  passage  of  Gratiolet  and  paroccipital  of  Wilder)  showing  lack  or 
arrest  of  development.  The  second  and  third  occipital  convolutions  of 
Ecker,  especially  on  the  left,  pi-esented  a  dwindled  appearance.  In  another 
brain,  that  of  an  old  woman,  blind  for  at  least  thirty  years,  similar  gross  ap- 
pearances of  arrested  development  in  the  occipital  region  were  present. 

One  of  the  latest  reviews  on  the  subject  of  visual  localization  is  by  Hen- 
schen.®  His  conclusions  are  based  on  observations  of  lesions  of  the  visual 
paths  and  centres,  with  autopsies,  and  negative  cases  with  absence  of  visual 
defects  with  lesions  in  their  neighborhood,  he  having  collected  about  160 

1  Jastrowitz:  Centralbl.  fur  Prakt.  Augenheilk,  vol.  i.  Dec,  1879,  p.  254. 

2  Haab:  Klinischer  Monatsblatter  f.  Augenheilk,  xx.  141,  1882.  3  Hueguenin,  ibid. 
*  Monakow :  Arehiv.  f.  Psychiat.  u.  Nervenkrankheiten,  vol.  xvi.  S  166. 

5  Seguin  :  Journ.  Nerv.  and  Ment.  Dis.,  vol.  xiii.  No.  1,  Jan.,  1886, 1-38. 

s  Hun  :  American  .Tournal  of  the  Medical  Sciences,  vol.  xciii.  Jan.,  1887,  140-160. 

7  Mills  :  Univ.  Med.  Mag.,  Nov.,  1389,  vol.  ii.  p.  69. 

8  Heuschen  :  Brain,  Parts,  Ixi  and  Ixii,  1893,  vol.  xvi.  p.  170. 


422  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

cases  with  j)Ost-mortems.  He  divides  the  occipital  path  into  a  frontal,  mid- 
dle, and  occipital  portion.  The  frontal  includes  the  optic  nerves,  chiasm,  and 
tracts  ;  the  middle  is  mainly  the  pregeniculum  or  external  geniculate  body  ; 
the  occipital  path  is  in  the  occipital  lobe.  Nothnagel  is  quoted  as  believ- 
ing that  lesions  of  the  gemina  need  not  give  rise  to  visual  disturbances. 
Henschen  holds  that  destruction  of  the  pulvinar  is  not  always  accompanied 
with  hemianopsia  ;  also,  that  a  lesion  of  the  posterior  portion  of  the  internal 
capsule  does  not  cause  hemianopsia.  A  recent  observation  of  my  own  is 
conclusive  in  the  affirmative  to  both  of  these  propositions.  In  a  case  of  large 
lesion  of  the  thalamus  and  adjoining  internal  capsule,  involving  the  pul- 
vinar, but  not  the  external  geniculate  body,  hemianopsia  was  not  present. 
The  middle  path  of  the  optic  fibres  and  their  connection  with  the  central 
ganglia  has  not,  however,  been  thoroughly  investigated,  and  it  is  necessary, 
as  Henschen  points  out,  to  make  a  distinction  between  visual  fibres,  lesions 
of  which  produce  defects  in  the  visual  field,  and  optic  fibres  which  are  con- 
cerned with  reflexes.  With  reference  to  the  occipital  subdivision  of  the  visual 
path  an  analysis  of  all  cases  shows  that  it  is  situated  in  the  ventral  portion 
of  the  optic  radiation,  and  there  forms  a  bundle  less  than  a  centimetre  thick, 
which  lies  at  the  level  of  the  second  temporal  gyrus  and  second  temporal  sulcus. 
The  fibres  for  the  dorsal  retinal  quadrant  lie  dorsally ;  and  for  the  ventral 
retinal  quadrant  ventrally  ;  the  macular  fibres  have  a  more  median  situation. 

As  to  the  exact  position  of  the  retinal  centres  for  quadrant  or  half  vision, 
Henschen  is  very  definite.  He  holds  that  a  lesion  on  the  mesal  surface 
causes  hemianopsia  only  if  the  cortex  of  the  calcarine  fissure  or  the  fibres 
derived  from  it  are  affected ;  also,  that  a  lesion  limited  to  the  calcarine 
cortex  can  induce  a  complete  hemianopsia,  in  proof  of  which  he  regards  one 
of  his  own  cases  as  most  instructive.  It  was  stationary,  uncomplicated,  and 
the  clinical  examination,  as  well  as  the  post-mortem,  was  accurate.  The 
lesion  was  limited  to  the  cortex  in  the  depth  of  the  calcarine  fissure,  and  the 
hemianopsia  was  complete  and  absolute. 

Henschen  believes  the  elements  of  both  retinal  halves  are  represented  in 
the  calcarine  cortex  by  different  cells,  which  lie  beside  each  other.  After 
destruction  of  both  eyes  in  a  patient  suffering  from  leprosy,  complete  atrophy 
of  the  calcarine  cortex  ensued,  but  in  a  case  of  destruction  of  one  eye  only 
he  found  in  that  situation  a  number  of  pigment- charged  cells  alongside  of 
perfectly  normal  ones.  With  reference  to  the  position  of  the  macular  field 
Henschen  believes  it  lies  in  the  calcarine  cortex,  but  with  this  I  do  not  agree. 
According  to  Wilbrand,  the  macula  is  innervated  by  both  hemispheres  in  a 
variable  manner. 

Vialet^  has  published  a  monograph  on  the  cortical  centres  for  vision,  in 
which  he  reviews  the  work  of  previous  writers  and  contributes  a  valuable 
microscopical  research  of  several  cases  previously  recorded  by  Dejerine.  His 
conclusion  is  that  the  cortical  centre  for  vision  occupies  the  entire  internal 
face  of  the  occipital  lobe.  It  is  limited  in  front  by  the  internal  perpendicu- 
lar (parieto-occiptal  fissure),  above  by  the  superior  border  of  the  hemi- 
sphere, below  by  the  inferior  border  of  the  third  occipital  convolution,  and 
behind  by  the  occipital  pole.  He  believes  that  the  calcarine  fissure  plays 
an  important  special  part  in  this  localization  ;  that  it  certainly  forms  the 
centre  of  the  visual  sphere  in  man.  Wilbrand  has  advanced  the  h}^othesis  of 
the  existence  ot  three  distinct  centres — for  space,  for  light,  and  for  color,  l)e- 
lieving  that  these  centres  or  areas  are  superimposed  in  the  visual  zone. 
Vialet  does  not  believe  in  the  existence  of  these  secondary  centres,  and  the 
question  can  be  regarded  as  still  unsettled. 

1  Vialet :  Les  Centres  Cerebraux  de  la  Vision  et  I'Appareil,  8vo.  pp.  355,  Paris,  1893. 


CEREBRAL  LOCALIZATION.  423 


AUDITORY  LOCALIZATION. 

The  localizatiou  of  the  auditory  sphere  in  the  superior  temporal  gyres, 
clearly  established  by  the  experimental  work  of  Ferrier,  can  be  regarded  as 
settled,  although  this  view  is  still  antagonized.  The  most  imjDortant  physi- 
ological experiments  which  seem  to  contradict  this  position  are  those  of 
Schafer  and  Sanger  Brown,  Avho  in  six  monkeys  more  or  less  completely  de- 
stroyed the  supertemporal  convolution  on  both  sides,  and  claimed  that  in 
all  hearing  was  not  only  not  abolished,  but  was  not  permanently  affected. 
In  one  the  whole  temporal  lobe  of  one  side  was  removed,  and  yet  Schafer 
holds  that  the  animal  responded  to  all  impressions  of  all  senses,  but  ap- 
peared to  understand  very  imperfectly  their  meaning.  Sounds  even  slight 
in  intensity  were  heard.  He  believes  that  this  case  militated  strongly  against 
the  view  that  auditory  perception  is  localized  in  the  temporal  lobes.  Ferrier,^ 
however,  was  not  satisfied  that  the  evidence  of  the  existence  of  auditory 
percejrtion  in  these  animals  was  unequivocal.  His  previous  experiments  had 
all  pointed  in  another  direction,  but  as  an  unaccountable  discrepancy  seemed 
to  exist  between  Schafer's  results  and  those  of  Yeo  and  himself,  he  deter- 
mined to  reinvestigate  the  question.  In  one  monkey  on  which  he  performed 
the  operation  of  bilateral  extirpation  of  the  superior  temporal  gyre,  with  one 
month  interval  between  the  operations,  the  result  was  very  striking.  At 
first  the  animal  failed  absolutely  to  respond  to  any  of  the  tests  which  in- 
variably attracted  the  attention  of  normal  monkeys.  To  the  last,  with  the 
single  exception  of  the  door  of  the  laboratory,  from  which  it  was  always  ex- 
pecting something,  it  never  realized  the  origin  of  sounds  ;  it  was  altogether 
indifferent  to  sounds  which  formerly  were  full  of  significance  for  it,  and  all 
that  could  be  said  was  that  it  was  not  insensible  to  sonorous  vibrations, 
According  to  Munk,  the  auditory  area  is  at  a  position  corresponding  in  the 
monkey  and  in  man  to  about  the  meditemporal  gyre,  considerably  lower  in 
the  temporal  lobe  than  Ferrier's  localization.  In  the  posterior  portion  of 
the  supertemporal  convolution,  to  which  Ferrier  gives  the  preference  as  the 
location  of  the  auditory  centre,  Munk  places  the  area  for  sensibility  of  the 
auricle,  while  Luciani  includes  in  the  auditory  sphere  the  jDarts  which  cor- 
respond to  the  upper  temporal  gyres,  and  also  a  large  part  of  the  cortex 
which  is  concerned  with  other  functions. 

Confirmation  of  the  localization  of  the  auditory  centre  in  the  supertem- 
poral gyre  is  afforded  by  cases  of  auditory  discharges,  or  subjective  auditory 
sensations  in  connection  with  irritative  lesions  implicating  these  gyri,  of  which 
a  few  illustrations  have  been  recorded. 

A  few  cases  of  prolonged  deafness,  with  autoj)sies,  have  assisted  in  deter- 
mining the  position  of  the  cerebral  centres  for  hearing.  I  have  recorded  the 
case  of  a  man  deaf  for  thirty  years,'^  whose  brain  showed  atrophy  of  both 
supertemporal  convolutions,  and  particularly  of  the  left,  and  Broadbent 
reported  a  similar  case.  Manouvrier^  has  left  a  valuable  contribution  to  the 
subject  in  his  description  of  the  brain  of  Bertillon,  the  statistician.  This 
description  was  first  published  in  the  Bulletin  d'Anthropologie,  of  Paris,  in 
1878,  after  which  the  author  accidentally  learned  that  Bertillon  was  so  deaf 
in  the  left  ear  as  to  be  incapable  of  hearing  what  was  said  to  him  on  his  left 
side.  This  deafness  he  had  suflfered  since  infancy.  In  the  description  of  the 
brain  attention  has  been  drawn  to  the  large  size  of  the  left  supertemporal 

1  Ferrier  :  Brain,  April,  1888,  and  Croonian  Lectures,  p.  80. 
-  Mills :  Univ.  iled.  Mag..  November,  1889,  vol.  ii.  p.  69. 

3  Manouvrier :    Bulletin  de  la  Societe  de  Psvchologie  Physiologique.    T.  5.  .\bstract  by  James 
Taylor  in  Brain,  1890,  vol.  xiii.  p.  429. 


424  NERVOUS  BISEASES  AND  THEIR  TREATMENT. 

convolution  as  compared  Avith  the  right ;  the  difference  both  in  size  and  in 
the  amount  of  convolution  present  was  remarkable,  and  much  too  great  to 
be  accidental,  a  fact  which  goes  far  to  render  it  probable  that  in  man  hear- 
ing on  one  side  is  subserved  by  the  supertemporal  gyre  of  the  opposite  side, 
as  Ferrier  has  shown  to  be  the  case  in  apes.  The  part  of  Broca's  convolu- 
tion contiguous  to  the  supertemporal  gyre  was  much  better  developed  on  the 
right  than  on  the  left.  As  Bertillon  was  left-handed  in  his  youth,  it  is  sug- 
gested that,  so  far  as  speech  is  concerned,  he  was  right-brained,  and  the 
difference  in  the  development  of  the  auditory  and  speech  centres  on  the 
right  side  is  offered  as  an  explanation  of  the  difficulty  which  he  found  in 
expressing  himself  orally.  The  angular  gyre  was  much  more  developed  on 
the  right  side  of  the  brain  than  on  the  left,  and  the  explanation  is  offered 
that  there  was  a  hypertrophy  of  the  part  subserving  the  visual  sense  on  that 
side  to  compensate  for  the  auditory  deficiency.  The  postcentral  gyre  on  the 
left  side  was  found  to  have  quite  an  extraordinary  size,  which  the  author 
accounts  for  by  the  close  connection  which  must  exist  between  the  sensori- 
motor incitations  connected  with  the  limbs  and  the  sensory  phenomena  of 
auditory  origin. 

In  order  to  have  complete  cerebral  deafness,  it  is  necessary  that  the  lesions 
should  be  bilateral.  Such  bilateral  lesions  affecting  the  supertemporal  gyres 
of  both  sides  of  the  brain,  and  causing  deafness  in  persons  without  peripheral 
disease,  would  afford  conclusive  evidence  of  the  position  of  the  auditory 
centres  in  man.  Ferrier  speaks  of  the  extreme  rarity  of  bilateral  lesions  of 
the  superior  temporal  convolutions,  but  gives  two  important  cases  in  which 
these  double  lesions  simultaneously  or  successively  occurred.  One  case,  first 
recorded  by  Shaw,'  is  that  of  a  woman  who  suddenly  lost  power  in  the  right 
arm,  with  also  loss  of  speech  and  word-deafness.  The  loss  of  power  passed 
away,  but  she  became  incoherent  and  subject  to  delusions,  and  on  testing 
her  she  was  found  to  be  deaf  and  blind.  The  post-mortem  showed  atrophy 
of  both  the  angular  and  the  two  superior  convolutions  of  both  hemispheres. 
The  other  was  a  case  of  Wernicke  and  Friedlander,^  being  a  woman  who, 
after  apoplexy,  had  right  hemiplegia,  aphasia,  paraphasia,  and  word-deaf- 
ness. A  few  months  later  she  had  a  second  attack,  causing  paresis  of  the 
left  arm,  and  she  became  absolutely  deaf.  Extensive  lesions  were  found  in 
the  superior  temporal  convolutions  of  both  hemispheres. 

A  case  has  been  reported  by  the  writer,^  which  should  be  ranked  as  con- 
clusive in  the  decision  of  this  question  of  auditory  localization.  The  speci- 
mens showed  an  isolated  lesion  in  the  two  upper  temporal  gyres  of  the  left 
hemisphere,  which  caused  word-deafness,  and  also  a  later  lesion  of  the  two 
superior  temporals  of  the  other  hemisphere,  with  a  history  of  total  deafness. 
The  patient,  a  woman  of  forty-six  years,  fifteen  years  before  her  death  had 
an  apoplectic  attack,  which  left  her  word-deaf,  but  not  paralyzed.  Prior  to 
this  first  attack  of  apoplexy  her  hearing  had  been  good,  but  after  it  she 
could  not,  by  hearing,  understand  anything  that  was  said  to  her.  She  could, 
however,  hear  music  and  sounds  of  various  kinds ;  for  instance,  when  an 
organ  or  a  band  had  performed  upon  the  street  she  at  times  called  attention 
to  the  fact ;  and  she  had  also  come  down  from  the  second,  and  even  from 
the  third  story  to  open  the  front  door  in  answer  to  a  knock.  She  could  hear 
such  sounds  as  a  bell  ringing  or  a  clock  ticking.  These  facts  were  elicited 
from  her  relatives  through  various  statements  made  by  them,  chiefly  spon- 
taneously.    When  any  one  wished  to  communicate  with  her  it  was  done  by 

1  Shaw  :  Archives  of  Medicine,  February,  1882. 

2  Wernicke  and  Friedlander :  Fortschritte  der  Medicin,  Bd.  I.,  No.  6,  March  15,  1883  ;  Brain,  Apri  1, 
1888,  p.  19. 

3  Mills  :  Univ.  Med.  Mag.,  1891,  vol.  iv.  p.  105. 


CEREBRAL  LOCALIZATION. 


425 


means  of  writing  or  signs,  as  she  had  fully  preserved  her  vision,  and  was 
evidently  not  word-blind  either  for  writing  or  printing.  She  often  read  the 
newspapers,  and  could  do  so  with  intelligence  up  to  a  few  weeks  before  her 
death.  Her  sister-in-law  said  that  several  times  she  had  heard  her  try  to 
read  the  newspaper  aloud,  and  in  so  doing  she  had  seemed  to  understand 
what  she  read,  "  but  made  a  tangle  of  her  words."  From  the  time  of  the 
first  attack  she  had  never  been  able  to  speak  well,  her  words  being  "jum- 
bled "  or  "tangled."  From  the  description  given  of  her  manner  of  speech, 
the  defect  was  evidently  a  serious  form  of  paraphasia  and  paralexia.  Her 
relatives  spoke  positively  of  her  deafness  as  having  been  due  to  "  stroke ;" 
but  the  apoplectic  attack,  although  it  had  at  once  caused  this  word-deafness 
and  paraphasia,  had  not  in  any  way,  so  far  as  could  be  ascertained,  affected 
either  motion  or  sensation.  She  could  write,  but  "  sometimes  mixed  up  her 
words  in  writing."  Nine  years  before  her  death  she  had  another  and  more 
severe  apoplexy,  and  her  deafness  increased  for  sounds,  as  well  as  for  words, 
until  it  was  almost  total.  The  seizure  left  her  with  partial  left  hemiplegia, 
chiefly  affecting  the  arm,  and  in  this  extremity,  from  the  description,  the 
paralysis  was  more  marked  below  the  elbow. 

At  the  autopsy  the  left  supertemporal  convolution  was  found  to  be  much 
smaller  and  thinner  than  usual,  and  at  the  posterior  extremity  of  it  and  of 


Fig.  107. 


■"^.J" 


Lesion  of  the  superior  temporal  convolutions,  a.  Cyst  or  cavity,  the  result  of  an  old  embolism. 
b.  Atrophied  first  temporal,  continuous  with  retroinsular  convolution,  c.  Ascending  Sylvian 
fissure. 

the  second  temporal  was  a  depression,  covering  a  space  about  seven-eighths 
of  an  inch  in  diameter.  The  posterior  two-thirds  of  the  supertemporal  con- 
volution had  shrunken  to  a  thin  strip.  At  a  position  corresponding  to  the 
posterior  fourth  of  the  second  temporal  convolution  and  the  parallel  fissure 
the  brain  presented  a  marked  depression  or  cavity,  at  the  bottom  of  which, 
Avhen  the  specimen  was  in  a  fresh  state,  was  a  mass  of  yellow,  shrivelled, 
puckered  tissue.  This  was  evidently  the  remains  of  an  old  embolic  softening 
(Fig.  107).  The  second  temporal  (meditemporal)  convolution  was  decidedly 
atrophied,  and  in  its  posterior  fourth,  or  perhaps  third,  it  had  practically  dis- 
appeared, and  had  been  replaced  by  the  cavity  or  cyst  just  described.  The 
third,  fourth,  and  fifth  temporal  convolutions  were  undoubtedly  not  involved. 
Around  the  ascending  branch  of  the  Sylvian  fissure,  and  at  the  bases  of  the 
two  central  convolutions,  much  atrophy  had  evidently  taken  place.     The 


426  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

hinder  portion  of  the  third  frontal,  and  particularly  the  strip  of  convolution 
between  the  ascending  and  Sylvian,  and  precentral  fissures,  were  markedly 
wasted.  The  posterior  of  the  two  retroinsular  gyres  was  very  small.  The 
anterior  retroinsular  presented  the  appearance  of  being  a  continuation  of 
the  anterior  half  of  the  first  temporal,  and  the  posterior  retroinsular  was 
continuous  with  the  posterior,  much-shrunken  half  of  the  first  temporal.  In 
the  right  hemisphere  an  old  and  very  extensive  hemorrhagic  cyst  had  com- 
pletely destroyed  the  first,  and  almost  completely  the  second,  temporal  gyre, 
the  insula,  the  retroinsular  gyres,  the  lower  extremities  of  the  central  gyres, 
and  a  large  extent — but  exactly  how  much  could  not  be  determined — of  the 
ganglia  and  capsules  (Fig.  108).  Examination  from  within  showed  that 
the  caudatum  and  thalamus  were  largely  preserved,  and  that  the  chief 
interior  destruction  was  probably  of  the  lenticula  and  the  external  capsule. 
A  study  of  this  case  justifies  the  conclusion  that  the  centre  for  word-hearing 
is  situated  in  the  hinder  thirds  of  the  first  and  second  temporal  convolutions, 
and  that  the  third,  fourth,  and  fifth  temporal  convolutions  take  no  part  in 

Fig.  108. 


d 

Lesion  of  the  superior  temporal  convolutions,  d.  Hemorrhagic  cyst,  destroying  two  upper 
temporal  convolutions  and  other  parts,  e.  Depressed  lower  extremity  of  inferior  parietal  convolu- 
tion. 

word-hearing.  A  lesion  confined  to  the  posterior  thirds  of  the  first  and 
second  temporal  convolutions  of  the  left  hemisphere  will  produce  complete, 
or  almost  complete,  word-deafness,  the  corresponding  regions  of  the  other 
hemisphere  remaining  intact ;  but  the  field  or  sphere  for  all  auditory  mem- 
ories covers  a  much  larger  cortical  area  than  that  for  word-hearing,  including 
at  least  the  posterior  two-thirds  of  the  first  and  second  temporal  convolu- 
tions. The  auditory  field,  and  special  auditory  centres,  have  their  highest 
development  in  the  left  hemisphere,  but  destruction  of  the  auditory  areas  of 
the  upper  temporal  convolutions  of  both  hemispheres  is  necessary  to  com- 
plete brain-deafness. 

Ferguson^  has  reported  the  case  of  a  young  man  who  for  eight  years  had 
suffered  with  chronic  otitis  media  in  the  right  ear.  The  hearing  on  this  side 
toward  the  last  was  lost,  when  the  vibration  proceeded  from  without  the 
ear,  but  was  slightly  retained  to  vibrations  conducted  through  the  solid 
media  of  the  bones.     For  two  years  prior  to  the  death  of  the  patient  there 

1  John  Ferguson  :  Journ.  Anat,  and  Physiol.,  vol.  xxv.  N.  S.,  vol.  v.  London  and  Edinburgh,  1891, 
p.  292. 


CEREBRAL  LOCALIZATION.  427 

were  symptoms  of  cerebral  tumor  situated  in  the  right  temporal  region,  such 
as  convulsive  movements  with  auditory  aura,  both  being  referred  to  the  left 
side.  Hearing  on  the  left  side  became  gradually  lost,  and  for  at  least  six 
months  was  entirely  gone,  though  the  auditory  aurse  were  still  present.  The 
post-mortem  revealed  a  large  tumor  in  the  first  and  second  temporal  con- 
volutions on  the  right  side,  destroying  the  first  entirely  and  the  second 
slightly. 

THE    NAMING    CENTRE. 

An  area  which  includes  portions  of  the  third  and  fourth  temporal  convo- 
lutions has  been  designated  in  the  diagram  (Fig.  104)  as  the  naming  centre. 
The  setting  apart  of  a  special  area  with  this  designation  is  in  accordance  with 
the  views  of  Broadbent,  Kussmaul,  and  Charcot.  According  to  Broadbent, 
the  formation  of  an  idea  of  any  external  object  is  the  combination  of  the 
evidence  respecting  it  received  through  all  the  senses ;  and  for  the  employ- 
ment of  this  idea  in  intellectual  operations  it  must  be  associated  with  and 
symbolized  by  a  name.  The  structural  arrangement  connected  with  this 
process  he  supposes  to  consist  in  the  convergence  from  all  the  receptive  cen- 
tres of  tracts  which  go  to  a  convolutional  area  on  the  sensory  side  of  the 
nervous  system,  Avhich  may  be  called  the  naming  centre.  Its  correlative 
motor  centre  is  the  propositionizing  centre,  in  which  names  or  nouns  are  set 
in  framework  for  outward  expression,  and  in  which  a  proposition  is  realized 
in  consciousness  or  mentally  rehearsed.  The  destruction  of  this  centre 
would  cause  loss  of  the  memory  of  names  or  nouns.  As  a  provisional  guess 
Broadbent  placed  this  centre  in  an  unnamed  lobule  situated  on  the  under  sur- 
face of  the  temporal  lobe,  near  its  junction  with  the  occipital  lobe,  where 
he  believed  fibres  from  all  the  perceptive  centres  converge  to  and  end  in  the 
cortex  of  this  region.  A  careful  study  of  the  entire  subject  of  speech  dis- 
turbances, including  an  analysis  of  cases  already  reported,  will  be  convinc- 
ing as  to  the  necessity  of  a  higher  area  for  thought  and  speech,  intermediate 
between  the  sensory  or  receptive  centres,  and  the  motor  or  emissive^ 

Other  names  which  have  been  applied  to  this  centre  or  area  are  idea  cen- 
tre and  concept  centre.  Some  authorities,  as  Ross^  and  Bastian,  consider  that 
it  is  not  necessary  to  have  a  particular  region  of  the  brain  in  which  concepts 
are  elaborated  and  symbolized  by  name ;  but  even  Ross  and  Bastian  ac- 
knowledge a  special  development  of  the  cortex  for  concepts  and  names,  but 
would  not  restrict  it  to  an  isolated  area. 

Recently  a  case  Avhich  seems  to  be  convincing  as  to  the  existence  and 
location  of  this  naming  or  idea  centre  has  fallen  under  my  own  observation, 
one  which  would  seem  not  only  to  support  the  separate  localization  of  such 
a  region,  but  also  to  confirm  Broadbent's  sjieculation,  made  long  ago,  as  to 
the  exact  position  of  this  centre  in  the  temporal  lobe. 

This  patient  was  seen  by  me  in  consultation  with  Dr.  Wilson  Bowers,  and 
an  account  of  the  case  was  recently  presented  to  the  Philadelphia  Neuro- 
logical Society  by  Dr.  J.  W.  McConnell  and  the  writer.  The  following  is  a 
condensed  history  of  the  case  and  of  the  most  interesting  autopsy : 

M.  R.  W.,  white,  married,  aged  about  forty  years,  five  years  before  her  death, 
for  the  first  time  complained  of  numbness  of  the  back  of  the  neck  and  ver- 
tigo, and  had  an  attack  of  excessive  vomiting,  lasting  two  days.  Nothing 
occurred  subsequently  to  this,  or  nothing  could  be  learned  of  anything  occur- 

1  This  question  and  other  matters  connected  with  the  mechanism  of  speech  are  fully  discussed  in 
my  monograph  on  Cerebral  Localization,  and  also  in  a  paper  on  Aphasia,  in  the  Review  of  Insan- 
ity and  Nervous  Disease  for  September  and  December,  1891. 

2  Ross  :  Aphasia  ;  in  Wood's  Med.  and  Surg.  Monographs,  vol.  vi.  No.  1,  April,  1890. 


428  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ring  again,  until  three  years  later,  when  it  was  noticed  that  she  did  things 
differently  from  her  usual  custom.  Dressmaking,  at  which  she  had  been 
successful,  was  poorly  done.  She  hung  u.pside  down  a  certificate  of  mem- 
bership in  a  society  to  which  she  belonged  without  realizing  the  error.  Her 
appearance  during  the  ensuing  year  also  changed  from  that  of  a  woman  in 
her  prime  to  one  fast  advancing  in  years  ;  but  nothing  especial  occurred  until 
the  morning  of  December  31,  1893,  when  she  acted  very  strangely,  was  very 
nervous,  imagined  that  she  saw  a  light,  could  not  read,  and  remarked  that 
she  felt  "  like  killing  her  daughter."  In  the  evening  of  that  day  she  was 
seized  with  a  convulsion,  frothed  at  the  mouth,  and  was  unconscious.  The 
next  day  she  was  very  forgetful,  but  without  apparent  speech  trouble.  She 
was  confined  to  bed  for  two  weeks,  during  which  time  she  aged  very  rapidly 
and  commenced  to  complain  of  severe  headache  and  of  numbness  in  the 
neck.     Soon  after  this  verbal  amnesia  became  very  evident. 

This  patient  was  first  seen  by  me  in  consultation  with  Dr.  Wilson  Bowers, 
July  16, 1894.  In  April  she  had  a  spell  of  vertigo,  on  rising  in  the  morning, 
and  toward  noon  a  similar  attack,  and  from  this  time  on  it  had  become 
almost  impossible  for  her  to  name  objects.  Until  the  first  of  August  she 
was  seen  by  me  five  or  six  times,  and  careful  examinations  during  this  period 
showed  neither  ausesthesia  nor  paralysis.  Ophthalmological  examination 
showed  no  optic  neuritis,  but  an  irregular  left  lateral  homonymous  hemi- 
anopsia.    The  following  is  a  fac  simile  of  an  effort  to  write  her  name : 


III 


Fig.  109. 


(^^v 


p^<^^^^^ 


Name  written  by  patient  with  verbal  amnesia  and  partial  word-blindness  from  lesion  of  the 
naming  centre  and  adjoining  regions. 

She  was  word-blind  in  large  part,  but  not  letter-blind ;  she  could  name 
single  letters  slowly. 

She  could  not  name  objects  either  from  sight  or  touch.  When  a  pencil, 
pen,  scissors,  or  purse  was  held  before  her,  or  when  she  was  allowed  to  touch 
them,  she  could  not  give  their  names,  although  she  understood  what  they 
were.  On  one  occasion  she  called  the  scissors  "  what  I  sew  with,"  and  the 
purse  "what  I  buy  with."  At  times  she  became  much  worried  and  emo- 
tional because  of  this  inability  to  name  objects.  When  such  objects  were 
named  to  her  she  would  promptly,  and  with  evidences  of  satisfaction,  indi- 
cate that  the  names  were  correct ;  and  she  could  also,  as  a  rule,  repeat  the 
names  spoken  before  her,  but  not  always  quickly,  and  occasionally  she  had 
considerable  difficulty  in  repeating  them.  When  asked  her  first  name,  she 
said  "  Margaret "  with  facility,  but  she  had  great  difficuty  in  mentioning  her 
last  name,  unless  it  was  repeated  to  her,  although  she  sometimes  succeeded 
without  this  prompting.  She  used  "yes"  and  "  no  "properly,  and  in  many 
ways  indicated  that  she  knew  what  objects  were  and  their  uses,  but  could 
not  give  their  names.  She  talked  spontaneously,  but  not  freely,  not  using 
concrete  nouns,  or  but  rarely,  and  sometimes  misplacing  words.  She  was 
not  seen  by  me  after  August  1st,  but  Dr.  Bowers  has  kindly  furnished  me 
with  notes  of  her  condition  from  that  date  until  her  death. 

August  1st  she  became  unable  to  perform  shoulder  and  elbow  movements 
and  leg  "and  thigh  movements  on  the  right  side,  but  retained  power  in 
the  hand  and  fingers  and  foot  and  toes.     Gradually  the  paralysis  of  the 


CEREBRAL  LOCALIZATION. 


429 


right  limbs  became  complete,  but  without  loss  of  sensation.  The  skin  on  the 
paralyzed  side  assumed  a  pinkish  hue,  and  its  temperature  was  increased. 
The  pain  in  the  head  disappeared  when  the  paralysis  became  complete,  but 
returned  to  some  extent  a  week  before  her  death.  Three  weeks  before  her 
death  she  regained  some  power  in  the  toes  and  fingers.  During  the  last  weeks 
of  her  life  "  yes  "  and  "  no  "  were  the  only  expressions  used  by  her.  She 
became  somnolent,  and  later  stuporous ;  and  she  developed  bedsores  and  lost 
control  over  the  vesical  and  rectal  sphincters.  Death  occurred  September 
10,  1894. 

An  autopsy  was  made  by  Dr.  C.  W.  Burr,  Dr.  J.  W.  McConnell,  Dr.  W. 
Bowers,  and  the  writer.  In  the  course  of  the  removal  of  the  brain  a  small 
nodulated,  half-disintegrated  mass,  about  the  size  of  a  hickory  nut,  was  pulled 
out  of  the  brain  surface  at  a  position  which  corresponded  to  the  posterior 
fourth  of  the  third  temporal  convolution  (at  B,  in  Fig.  110).  The  surface  of 
the  third  temporal  in  its  posterior  half,  and  to  a  much  less  extent  of  the 
second  temporal  in  the  same  general  region,  and  of  the  fourth  temporal, 
presented  a  granular,  slightly  disintegrated  appearance.  On  cutting  into  the 
temporal  lobe  a  tumor,  hard  and  yellowish-brown  in  color,  was  revealed ;  its 
hardest,  and  apparently  oldest,  part  was  at  A,  about  the  middle  of  the  third 
temporal  (meditemporal  gyre),  and  passing  slightly  into  the  second  tem- 
poral. The  mass  extended  cephalad  and  caudad  a  short  distance,  almost 
entirely  in  the  white  matter  of  the  third  temporal  gyre,  but  a  soft,  nodulated, 
more  or  less  hemorrhagic   condition   reached  caudad  as  far  as  the  white 

Fig.  110. 


B  A 

Tumor  of  the  third  temporal  convolution,  indicating  the  position  of  the  naming  centre.  A, 
densest  and  probably  oldest  portion  of  the  growth.  B,  anterior  limit  of  the  lesion  beneath  the 
cortex :  the  limits  on  the  surface  of  the  portion  surrounding  the  lesion  are  indicated  by  the  dotted 
lines. 

matter  of  the  middle  of  the  occipital  lobe,  and  cephalad  to  the  junction  of 
the  first  and  middle  thirds  of  the  second  and  third  temporal  convolutions,  as 
indicated  by  the  dotted  lines.  The  parts  chiefly  destroyed  were  the  white 
matter  of  the  third  ;  to  a  less  extent,  of  the  second  ;  and  to  a  still  less  extent 
of  the  fourth  temporal  convolution.  Internally  the  roof  of  the  posterior 
horn  presented  a  slightly  granular  appearance.  The  disease  almost  certainly 
started  in  the  third  temporal  convolution,  at  a  point  in  a  line  with  the  pos- 
terior extremity  of  the  horizontal  branch  of  the  Sylvian  fissure. 


430  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 


OLFACTORY   LOCALIZATION. 

With  such  light  as  is  furnished  by  histology,  pathology,  and  physiology, 
the  olfactory  centre  can  be  best  located  in  the  uncinate  gyre,  as  indicated  in 
the  diagram,  (Fig.  105).  This  position,  as  stated  by  Ferrier,  is  indicated  by 
the  evident  anatomical  connections  of  the  region  with  the  olfactory  bulb. 
"  The  chief,  and,  in  man,  the  only  constant  connection  of  the  olfactory  tract 
with  the  hemispheres  is  by  the  so-called  external  root,  which  passes  outward 
across  the  anterior  perforated  space  to  the  cortex  of  the  hippocampal  gyrus." 
Broca  compares  the  connections  of  the  olfactory  tract  with  the  falciform  or 
limbic  lobe,  by  means  of  its  inner  and  outer  root,  to  a  tennis  racquet,  of 
which  the  circumference  is  formed  by  the  lobe  and  the  handle  by  the  olfactory 
tract  and  bulb,  the  force  of  which  comparison  is  seen  on  an  examination  of 
Fig.  105. 

Zuckerkandl,  of  Gratz,  in  1887,  published  an  anatomical  and  physiological 
monograph,  in  which  he  claims  that  the  entire  limbic  lobe  is  the  seat  of 
olfactory  sensation.  In  this  view  he  simply  follows  Broca,  who  divided  all 
animals  into  osmatics  and  anosmatics,  holding  that  the  whole  of  the  falciform 
lobe  was  the  cerebral  organ  of  smell ;  but  a  knowledge  of  the  relatively  large 
size  of  the  gyrus  fornicatus  and  hippocampal  region  in  an  animal  like  man, 
in  whom  the  sense  of  smell  plays  so  comparatively  an  unimportant  part,  is 
a  weighty  argument  against  the  views  of  Broca.  In  osmatics,  however,  the 
the  hippocampal  lobule  or  region  of  the  amygdala — the  uncinate  convolution, 
so-called — is  very  large,  while  in  the  anosmatics  it  is  comparatively  small ; 
and  Ferrier's  view  is,  therefore,  probably  correct. 

Luciani  and  Tamburini  believe  that  in  dogs  the  region  in  front  of  the 
auditory  area  is  especially  olfactory  in  function. 

Electrical  irritation  of  the  hippocampal  lobule  or  uncinate  gyrus  in 
monkeys,  cats,  dogs,  and  rabbits  furnished  Ferrier  with  significant  indications 
of  subjective  olfactory  sensations  in  the  form  of  a  peculiar  torsion  of  the  lip 
and  nostril  of  the  same  side. 

Ferrier  refers  to  cases  reported  by  W.  Ogle,  Fletcher  and  Kansom,  of  the 
occurrence  of  loss  of  smell  in  the  left  nostril  with  right  hemiplegia  and 
aphasia ;  and  he  also  alludes  to  cases  reported  by  Hughlings  Jackson  with 
lesions  of  the  region  of  the  hippocampal  lobule.  The  connections  of  the 
olfactory  tract  are  with  the  hemisphere  on  the  same  side.  I  have  had  several 
epileptic  patients  in  whom  the  attacks  were  initiated  by  an  odor,  usually 
offensive ;  and  Hughlings  Jackson  gives  interesting  histories  of  three  such 
cases  in  which  the  attacks  were  ushered  in  by  a  crude  sensation  of  smell, 
accompanied  sometimes  by  other  warnings,  as  epigastric  sensations  and  the 
dreamy  state.  These  cases  are  of  great  clinical  interest,  but  are  not  accom- 
panied by  autopsies.  He  refers,  however,  to  the  necropsy  of  a  woman  who 
had  paroxysms  with  the  dreamy  state  and  crude  sensation-warnings  of 
smell.  She  had  left  hemiplegia  and  double  optic  neuritis,  and  the  autopsy 
showed  a  tumor  in  the  right  temporal  lobe.  McLane  Hamilton^  has  reported 
a  case  of  epilepsy  with  softening  of  the  temporal  lobes,  in  a  woman  of  forty 
years,  who  always  had  as  an  aura  a  disagreeable  odor,  sometimes  of  smoke, 
sometimes  of  a  fetid  character,  and  quite  uncomplicated  by  other  sensory 
warnings.  Worcester'^  has  reported  the  case  of  a  farmer,  aged  thirty,  who 
had  had  epilepsy  for  two  years  before  admission  to  the  hospital.  For  several 
days  hallucinations  of  smell — at  first  constant,  afterward  transitory — were 

1  A.  McLane  Hamilton  ;    Am.  Journ.  Med.  Sci.,  April  1, 1S84.    Quoted  by  Starr. 

2  Worcester  ;  Am.  Journ.  of  Insanity,  July,  1887. 


CEREBRAL  LOCALIZATION.  431 

present.  Once  he  imagined  the  room  was  full  of  smoke.  He  fancied  at 
times  there  was  an  odor  like  the  vapor  of  alcohol  passing  quickly.  He 
thought  this  took  the  place  of  a  convulsion.  The  autopsy  revealed  a  small 
spot  of  red  softening  at  the  most  prominent  part  of  the  left  gyrus  uncinatus. 
The  brain  was  not  opened  until  it  had  been  hardened  in  alcohol.  A  focus  of 
softening  existed  in  the  white  matter  of  the  anterior  j)art  of  the  left  temporal 
lobe,  extending  to  the  surface,  externally,  and  internally  involving  the  pes 
hippocampi  in  the  floor  of  the  descending  cornu  of  the  lateral  ventricle.  The 
portion  of  the  hippocampus  major  not  discolored  was  swollen  and  softened. 
A  very  small  focus  of  softening,  about  the  size  of  a  lai'ge  pea,  was  found  in 
the  white  matter  of  the  frontal  lobe  on  the  same  side. 


GUSTATORY  LOCALIZATION. 

The  sense  of  taste  is  closely  related  to  that  of  smell,  and  in  the  diagram 
has  been  placed  in  the  fourth  temporal  convolution.  The  experiments  of 
Ferrier  seemed  to  show  that  affections  of  both  taste  and  smell  were  evidently 
connected  with  lesions  of  the  hippocampal  lobule  and  its  neighboi'hood.  He 
noted  in  connection  with  electrical  irritation  of  the  lower  extremity  of  the 
temporo-sphenoidal  convolutions  in  the  monkey,  and  of  the  same  region  in 
the  brain  of  a  cat,  that  the  movements  of  the  lips,  tongue,  cheek,  pouches, 
and  jaws  were  occasionally  induced — phenomena  which  he  believed  might  be 
regarded  as  indications  of  the  excitation  of  the  gustatory  sensation.  Ander- 
son^ has  recorded  a  case  of  epilepsy  in  which  ft'om  symptoms,  ocular  and 
cerebral,  detailed  in  his  report,  he  correctly  predicted  tumor  and  its  position. 
The  patient's  dreamy  state  was  associated  with  a  rough,  bitter  sensation  in  his 
mouth.  It  is  the  only  case  published,  according  to  Jackson,  in  which  a 
necropsy  has  been  had  revealing  any  morbid  changes  in  a  case  of  the  variety 
of  epilepsy  mentioned.  Gad  concluded  that  biting,  chewing,  and  swallowing 
are  in  the  rabbit  reflex  acts  dependent  upon  the  brain  stem,  while  the  forma- 
tion of  the  bolus  and  its  backward  movement  are  governed  by  the  cortex. 
Schtcherback''  attempted  to  discover  whether  these  actions  could  be  rendered 
impossible  by  the  destruction  of  any  definite  part  of  the  cortex,  and  what 
was  the  mechanism  of  the  origin  of  these  movements.  In  all  cases  in  which 
the  power  of  swallowing  at  will  is  lost,  loss  of  taste  was  also  evident.  He 
found  that  injury  to  an  area  extending  from  two  to  three  millimetres  in  front 
of  and  behind  the  line  of  the  coronal  suture,  and  vertically  ft-om  the  longi- 
tudinal fissure  to  the  lower  edges  of  the  brain,  caused  loss  of  taste  on  the 
opposite  side  of  the  tongue,  a  loss  which  lasted  for  six  days  at  the  longest. 
"  The  localization,"  he  says,  "  of  the  described  centre  presents  no  special  difli- 
culties,  neither  upon  the  skull  nor  upon  the  exposed  brain.  In  the  former 
case  the  coronal  suture  serves  as  a  guiding  line ;  in  the  latter  case  a  line  cor- 
responding to  it  and  passing  at  the  base  of  the  brain  through  the  posterior 
border  of  the  chiasm  of  the  optic  nerves.  The  gustatory  centre  extends  two 
to  three  millimetres  anterior  and  posterior  to  this  line  (somewhat  more 
posterior  than  anterior),  and  lies  upon  the  entire  convex  surface  of  the  hemi- 
sphere, from  the  longitudinal  fissure  to  the  lower  border  in  the  region  corre- 
sponding to  the  precentral  lobe." 

1  Anderson :  Brain,  October,  1886.    Quoted  by  Hughlings  Jackson  in  Brain,  July,  1888. 

2  Schtcherback  :  Centralbl.  f.  Physiol.,  vol.  ii.  pp.  289-298,  August  29, 1891.    Abstract  in  Brain,  vol. 
xiv.  1891,  p.  574. 


432  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


THE  PREFRONTAL  REGION. 

When  we  speak  of  latent  regions  we  simply  indicate  either  our  ignorance 
or  the  want  of  refinement  of  our  knowledge,  as  every  well-defined  brain  region 
must  have  its  function.  The  prefrontal  region  is  sometimes  designated  as  a 
latent  district,  but  this  is  an  error  even  with  our  present  light.  The  symp- 
toms are  largely  psychical,  and  unfortunately  the  physician  is  not  usually 
well  trained  to  study  such  phenomena.  Mental  disturbances  of  a  peculiar 
character  occur,  such  as  mental  slowness  and  uncertainty,  want  of  attention 
and  control,  and  impairment  of  judgment  and  reason ;  closely  studied,  the 
inhibitory  influence  of  the  brain,  both  upon  psychical  and  physical  action,  is 
found  to  be  diminished.  Memory  is  not  seriously  aflfected,  although  a  con- 
tinuous train  of  thought  cannot  well  be  followed,  and  complex  intellectual 
processes  cannot  be  thoroughly  performed.  The  results  of  experiments  upon 
lower  animals  have  not  been  very  helpfiil  toward  determining  the  existence 
of  prefrontal  lesions,  because  psychical  phenomena  cannot  be  studied  with 
accuracy  in  animals  below  man.  Ferrier,  however,  found,  after  removal  of 
the  prefrontal  lobe,  a  decided  alteration  in  the  behavior  of  the  animals,  diffi- 
cult precisely  to  describe.  They  had  apparently  lost  the  faculty  of  intelli- 
gent observation.  Horsley  and  Schafer,  Hitzig,  and  Goltz  have  also  observed 
apparent  mental  changes. 

The  Eight  Temporal  Lobe.  The  right  temporal  lobe  is  probably  the 
most  latent  district  of  the  brain ;  although  if  the  regions  for  word-hearing 
or  the  general  auditory  sphere  in  the  left  temj)oral  lobe  is  destroyed,  subse- 
quent destruction  of  the  corresponding  areas  in  the  right  temporal  lobe  will 
comjilete  the  cerebral  deafaess  which  has  been  partial  as  the  result  of  the 
first  lesion.  With  a  large  lesion  of  the  right  temporal  lobe,  as  a  tumor, 
hemorrhage,  or  abscess,  the  diagnosis  is  best  made  by  a  careful  considera- 
tion of  pressure  and  invasion  symptoms,  in  addition  to  those  which  are 
strictly  localizing  in  character. 


APHASIA,  AND  THE  CORTICAL   MECHANISM  OP  SPEECH. 

It  is  often  most  important  for  the  practitioner  of  medicine  to  be  able  to 
quickly  make  the  diagnosis  of  particular  varieties  of  cerebral  speech  disturb- 
ance. To  many  physicians  the  subject  has  an  unnecessarily  difficult  look. 
A  knowledge  of  the  special  cortical  centres  already  described,  with  a  further 
knowledge  of  the  tracts  which  relate  them  to  each  other  and  to  the  outside 
world,  should  enable  the  examiner  to  proceed  by  a  thoroughly  systematic 
method  to  the  determination  of  the  special  character  of  a  speech  disturbance, 
and  the  site  of  the  lesion  or  lesions  to  which  it  is  due. 

The  centres  already  alluded  to  which  have  received  consideration  in  the 
preceding  pages  are  for  word-hearing,  word-vision,  naming,  and  incidentally 
for  propositionizing  and  articulation  as  well  as  for  the  motor  centres  which 
play  their  part  in  writing  and  pantomimic  speech.  Special  terms  in  common 
use  will  need  to  be  defined.  It  will  be  especially  necessary  to  consider  briefly 
certain  anatomical  and  physiological  facts  with  reference  to  the  entering, 
associating,  and  emerging  tracts  for  speech,  in  addition  to  the  matters  already 
discussed. 

The  word  aphasia,  which  means  loss  of  speech,  is  the  general  designation 
or  the  generic  term  applied  to  all  the  various  forms  of  defects  of  the  elements 
of  speech  due  to  disease  of  the  cerebral  hemispheres — usually  lesion  of  the 


APHASIA.  433 

cortical  centres  concerned  in  the  mechanism  of  speech.  It  is  to  be  distin- 
guished from  the  defects  of  speech  that  result  from  mechanical  difficulty  in 
articulation  which  are  due  to  lesions  of  peripheral  organs  or  nerves,  and  also 
from  speech  disturbances  which  are  dependent  upon  the  cranial  nuclei,  and 
the  associating  and  co-ordinating  tracts  for  speech  in  the  cerebellum,  pons, 
and  oblongata. 

Aphasia  is  therefore  the  loss,  partial  or  complete,  of  the  power  of  expres- 
sion or  comprehension  of  language.  It  may  be  either  sensory  or  motor.  The 
former  may  be  termed  receptive  and  the  latter  emissive.  ^ 

The  subdivisions  of  the  subject  of  aphasia  which  will  be  considered  are  as 
follows : 

Motor  aphasia  : 

Aphemia  (complete  motor  aphasia), 
Articulative  ataxia, 
Articulative  paresis  or  paralysis  (?), 
Agraphia, 
Amimia. 
Sensory  aphasia : 

Auditory  aphasia  (word-deafness,  music-deafness). 
Visual  aphasia  (word-blindness,  alexia), 
Apraxia  (mind-blindness,  soul-blindness,  object-blindness). 
Conceptual  aphasia : 

Complete  verbal  amnesia, 

Incomplete  verbal  amnesia  (articulative  amnesia). 
Literal  amnesia  (amnesia  for  written  language). 
Symbolic  amnesia  (amnesia  for  signs  other  than  letters  or  words). 
Conduction  aphasia : 

(Paraphasia,  paragraphia,  paramimia,  paralexia,  dyslexia.) 
Subcortical  (infi'a-pictorial  sensory  aphasia). 
Transcortical  (supra-pictorial  sensory  aphasia). 
Transcortical  (supra-pictorial  motor  aphasia). 
Subcortical  (infra-pictorial  motor  aphasia). 
AVernicke  has  applied  the  principles  which  are  illustrated  in  the  above 
tabulation  to  written  speech,  and  differentiates  seven  varieties  of  aphasic  dis- 
turbance of  written  speech,  all  of  which  are  indicated  above.     These  are 
cortical  alexia,   cortical  agraphia,   subcortical  alexia,  transcortical    alexia, 
transcortical  agraj)hia,  and  subcortical  agraphia. 

Besides  the  subjects  indicated,  brief  attention  will  be  given  to  the  methods 
of  investigating  patients  suffering  from  cerebral  speech  disturbances. 

Four  of  the  forms  of  aphasia  included  in  the  above  arrangement  are 
usually  considered  as  elementary,  namely,  aphemia  or  complete  motor 
aphasia,  agraphia,  word-deafness  or  auditory  aphasia,  word-blindness  or 
visual  aphasia.  I  believe  that  to  these  elementary  forms  should  be  added 
verbal  amnesia,  or  at  least  that  variety  of  verbal  amnesia  which  is  due  to 
lesion  of  the  naming  centre,  and  has  been  discussed  in  the  last  section.  In 
the  first  place,  the  special  forms  of  motor  aphasia  will  be  defined  and  de- 
scribed and  the  sites  of  the  lesions  causing  them  indicated. 

The  diagi'am  (Fig.  Ill)  indicates  the  position  in  the  cerebral  cortex  of 
the  centres  concerned  in  the  mechanism  of  speech  according  to  the  views 
held  by  the  writer. 

Motor  aphamt  or  aphemia,  as  Broca,  Ross,  Wyllie,  and  others  have  pre- 

1  In  the  preparation  of  this  section,  besides  the  writings  of  Hughlings  Jackson,  Wernicke,  Lich- 
theim,  Ross,  Bateman,  and  the  older  authorities  upon  aphasia,  frequent  use  has  been  made  of  the 
valuable  series  of  papers  on  "  The  Disorders  of  Speech,"  by  John  Wyllie,  M.D.,  F.R. C.P.Ed.,  in  the 
Edinburgh  Medical  Journal  from  1891  to  1894. 

28 


434  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ferred  to  call  it,  has  been  discussed  and  by  some  authorities  subdivided  differ- 
ently. Physiological  and  clinico-pathological  observations  have  shown  that 
so  far  as  speech  is  concerned  this  motor  disturbance  may  assume  two  or  per- 
haps three  forms.  In  the  first  place,  we  have  the  true  aphasia  or  aphemia  of 
Broca  and  others,  an  affection  of  speech  which  is  limited  strictly  to  the  foot 
of  the  left  third  frontal  convolution,  the  so-called  Broca's  convolution. 
Broadbent,  in  a  remarkable  paper  on  the  mechanism  of  speech,  describes  this 
region  as  a  propositionizing  centre,  that  is,  the  place  by  the  functioning  of 
which  thoughts  are  set  into  a  framework  of  words,  but  through  which  the 

Fig.  111. 


A,  auditory  centre  (centre  for  word-hearing) ;  V,  visual  centre  (centre  for  word-seeing) ;  N,  nam- 
ing centre  (centre  where  percepts  are  given  a  name) ;  B,  motor  speech  centre  in  Broca's  convolu- 
tion) ;  G,  graphic  centre  ;  U,  utterance  centre. 

utterance  of  such  words  is  not  consummated.  Other  cortical  centres  essential 
to  motor  speech  must  therefore  be  present,  and  these  are  found  caudad  of  the 
convolution  of  Broca  at  the  foot  of  the  two  central  convolutions.  Broad- 
bent  preferred  to  call  this  region  the  utterance  centre,  and  whatever  view 
may  be  taken  of  the  nature  of  the  process  of  emissive  speech,  such  a  sub- 
division into  propositionizing  and  utterance  centres  has  a  practical  value  in 
the  consideration  of  this  subject.  Other  writers  and  observers,  while  recog- 
nizing the  necessity  of  some  such  subdivision  of  the  mechanism  of  speech  on  its 
emissive  side,  not  only  use  different  terms,  but  have  different  conceptions  of 
the  nature  of  the  processes  which  take  place,  although  their  conclusions  are 
for  practical  purposes  in  accord.  According  to  one  group  of  writers,  for  ex- 
ample, the  foot  of  the  left  third  frontal  convolution  is  the  centre  or  store- 
house for  the  guiding  psychomotor  images  or  memories,  and  these  are 
regarded  as  largely  "  sensory  in  constitution,  being  made  up  chiefly  from 
memories  of  muscular  and  tactile  sensations."  (Wyllie).  Some  cases  of 
limited  lesion  of  this  region  would  bear  out  either  interiDretation — that  is,  that 
the  centre  may  be  properly  designated  as  propositionizing,  or  as  a  centre  of 
psychomotor  pictures  or  memories  concerned  in  speech.  Total  destruction 
of  Broca's  convolution  in  right-handed  people  makes  spoken  speech  impos- 
sible, at  least  for  a  time.  As  time  progresses,  particularly  when  the  lesion 
occurs  in  the  comparatively  young,  the  hitherto  untrained  centre  in  the  right 
third  frontal  enables  the  aphasic  to  acquire  or  regain  in  some  degree  the 
faculty  of  speech  ;  although,  in  the  majority  of  cases  of  such  sj^eech  disturb- 
ance in  association  with  lesions  of  the  left  cerebrum,  the  recovery  is  as  much 


APHASIA.  435 

or  more  due  to  the  fact  that  some  portion  of  the  speech  centre  has  not  been 
destroyed. 

It  has  been  suggested  by  Moxon,  Wylhe,  and  others  that  the  reason  that 
the  vast  majority  of  individuals  are  left-brained  for  movements  of  the  limbs, 
and  particularly  of  the  arm,  for  speech,  for  word-hearing,  and  word-seeing, 
finds  its  best  explanation  in  the  fact  that  less  expenditure  of  time  and  energi^ 
would  be  called  for  in  the  development  of  the  jDOwers  of  attention  if  one 
hemisphere  rather  than  both  was  thoroughly  trained.  One  hemisphei*e  is 
much  more  highly  developed  than  the  other  in  obedience  to  the  principle  of 
economizing  energy  which  is  evident  in  the  study  of  natural  evolution. 

Under  the  designation  of  artieulative  ataxia,  Wyllie  describes  what  is 
practically  an  incomplete  motor  aphasia  from  partial  destruction  of  Broca's 
centre,  or  that  presented  by  a  patient  who  has  partially  regained  speech  after 
a  more  complete  destruction  of  this  centre  and  the  subjacent  cortex.  It  is 
simply  the  old  ataxic  aphasia,  the  asynergia  verbalis  of  Lordat.  Such  a 
patient  gradually  improves  in  speech  through  recovery  of  the  injured  centre, 
or  through  the  education  of  the  previously  uneducated  centre  of  the  right 
side ;  and  as  he  does  so  he  shows  artieulative  disturbances  of  various  kinds, 
such  as  "  slurring,  lalling,  syllable  stumbling,  sometimes  a  little  stammering, 
and  often  an  utterance  that  is  slow  and  laborious."  According  to  Wyllie,  in 
these  same  cases  patients  may  show  amnesia  verbalis  and  a  slight  degree  of 
paraphasia,  although  it  seems  to  me  questionable  whether  this  verbal  amnesia 
is  not  apparent  rather  than  real. 

Let  me  now  recur  to  the  subject  of  utterance  in  connection  with  motor 
aphasia  so-called.  In  the  act  of  utterance,  or  articulate  speech,  several 
processes  involving  movement  are  concerned.  It  includes  vocalization, 
phonation,  and  the  formation  of  sounds  into  elementary  sounds,  into  words 
and  phrases,  j)rocesses  which  are  performed  by  the  larynx,  tongue,  jaw, 
cheeks,  and  lips.  It  will  be  seen  by  consulting  several  figures  in  preced- 
ing pages  that  the  centres  for  the  larynx,  throat,  jaws,  lips,  and  mouth,  and 
movements  of  the  face  in  general,  are  situated  backward  from  Broca's  centre, 
chiefly  at  the  lower  extremities  of  the  two  central  convolutions.  If,  now, 
cases  are  recorded  in  which  limited  destruction  of  this  cortical  region  has 
caused  impairment  or  loss  of  articulate  speech,  or  the  power  of  utterance, 
Avithout  destroying  the  patient's  ability  to  recall  those  psychomotor  images 
which  are  concerned  in  speech,  while,  on  the  other  hand,  destruction  of  the 
left  third  frontal  makes  all  speech  impossible,  we  should  have  corroborative 
evidence  of  the  separation  of  the  motor  speech  area  into  these  two  subdi- 
visions. Such  a  case  has  been  described  by  me,  and  referred  to  under  the 
face  area,  the  lesion  present  being  shown  in  Fig.  101.  This  was  a  typical 
case  of  orolingual  monoparesis,  with  distinct  paralysis  of  the  lower  face  on 
the  same  side,  no  interference  with  propositionizing  being  present.  Instead 
of  sj^eaking  of  this  general  region  as  an  utterance  centre,  Wyllie  prefers  to 
describe  it  as  a  region  containing  motor  executive  cells  for  speech,  the  2>lace 
where  speech  begins  to  be  locally  exteriorized.  Whatever  names  may  be 
given  to  these  different  regions,  many  personal  observations,  as  well  as  the 
study  of  the  literature  on  this  subject,  have  convinced  me  of  the  necessity  of 
recognizing  Broca's  centre  as  separated  in  function  from  the  utterance  region, 
however  closely  the  two  may  be  allied  in  the  ordinary  processes  of  speech. 
The  motor  centres  for  utterance,  in  brief,  are  the  cortical  areas  which  inner- 
vate the  muscles  of  the  larynx,  throat,  tongue,  mouth,  and  lower  face.  In 
the  tabular  analysis  this  variety  of  speech  disturl^ance  has  been  indicated  as 
doubtfully  belonging  to  motor  aphasia,  under  the  name  of  artieulative  paresis 
or  paralysis. 

Most  cases  of  motor  aphasia  also  suflfer  from  agraphia,  or  the  inal)ility  to 


436  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

write,  although  this  loss  or  defect  may  also  be  due,  as  has  been  shown,  to 
lesions  of  the  centres  for  word-seeing.  The  motor  centre  for  writing  has  been 
placed  at  the  caudal  extremity  of  the  second  or  medifrontal  convolution,  and 
in  close  relationship  with  the  upper  or  mesal  boundary  of  the  true  speech 
centre.  Destruction  of  this  region,  which  is  just  in  advance  of  the  area  for 
movements  of  the  fingers,  hand,  and  other  parts  concerned  in  writing,  it  is 
supposed,  would  cause  a  true  agraphia,  although  no  clinico-pathological  case 
fully  corroborative  of  this  statement  has  been  put  on  record.  True  agraphia, 
however,  is  an  almost  invariable  result  of  destruction  of  Broca's  centre, 
and  opinion  is  returning  to  the  views  held  by  Trousseau  and  Gairdner. 
Wyllie,  for  example,  cites  and  indorses  the  recent  conclusions  of  Dejerine,^ 
which  are  given  in  the  following  words :  "  Thus  in  proportion  as  we  advance 
in  the  study  of  agraphia  we  find  that  Trousseau  was  right,  when,  speaking  in 
his  celebrated  cliniques  upon  aphasia,  of  the  trouble  of  Avriting  in  aphasics, 
he  said,  having  in  view  certainly  only  the  cortical  motor  aphasics,  the  only 
kind  known  at  his  epoch  :  '  Usually  the  aphasic  is  not  more  able  to  exj)ress 
his  thoughts  in  speech  than  in  writing ;  and,  although  he  has  retained  the 
movements  of  his  hands,  and  can  employ  them  with  as  much  intelligence  as 
formerly,  he  is  incapable  of  composing  a  word  with  the  pen  as  he  is  of  com- 
posing it  for  the  purposes  of  speech.'  "^ 

It  is  probable,  as  Wyllie  concludes,  that  motor  agraphia,  at  least  so  far  as 
writing  with  the  right  hand  is  concerned,  may  result  from  a  lesion  of  the 
graphic  centre  of  the  posterior  portion  of  the  second  frontal  convolution. 

The  study  of  pantomime  is  only  second  in  importance  to  that  of  the  study 
of  spoken  speech  in  the  consideration  of  aphasia.  Pantomime  is,  in  fact,  a 
part  of  speech,  and  its  losses  and  defects  are,  on  the  one  hand,  most  fre- 
quently associated  with  disorders  of  speech,  while,  on  the  other,  the  disturb- 
ances of  speech  from  cerebral  disease  usually  have  pantomimic  disorders  as 
accompaniments.  The  whole  subject  of  pantomime  may  be  here  dismissed, 
although  the  consideration  belongs  to  both  motor  and  sensory  aphasia. 

Amimia  is  loss  or  impairment  of  the  power  of  expression  by  signs  when 
this  loss  is  dependent  upon  cerebral  disease.  Paramimia  is  the  misuse  of 
signs  in  efibrts  at  the  expression  of  thoughts.  Amimia  may  be  either  sensory 
or  motor,  or  it  may  be  of  mixed  origin.  Paramimia,  like  paraphasia  for 
speech,  and  paralexia  for  reading,  is  usually  dependent  upon  destruction  of 
the  commissures  or  associating  tracts  between  sensory  and  motor  centres. 
Many  erroneous  ideas  with  reference  to  pantomime  are  prevalent  among 
physicians  and  those  engaged  in  medico-legal  work.  It  is  supposed  by  many 
that  persons  who  are  aphasic  can  usually  express  themselves  by  means  of 
signs ;  but,  on  the  contrary,  disorders  of  speech  and  pantomime  in  common 
go  hand-in-hand.  A  patient  may,  however,  regain  pantomimic  power  sooner 
or  in  a  greater  degree  than  speech,  and  each  case  should  be  studied  on  its 
own  merits.  Loss  of  pantomime  is  frequently  dependent  upon  destruction 
of  the  left  third  frontal  convolution,  but  this  power  may  be  lost  or  greatly 
impaired  by  lesion  of  the  naming  or  concept  areas  of  the  brain.  It  may 
accompany  verbal  amnesia,  dependent  upon  disease  of  these  centres,  or  of 
the  tracts  uniting  them  with  other  parts.  Just  as  aphasics  will  sometimes 
say  "yes"  when  they  mean  "no,"  so  sometimes  pantomime  indicative  of 
negation  is  used  when  affirmation  is  meant,  or  the  same  sign  is  used  for  both. 
Occasionally  patients  are  unable  to  interpret  the  pantomime  of  others.  The 
study  of  these  disorders  of  pantomime  can  be  undertaken  from  the  same 
points  of  view,  and  pursued  in  the  same  anatomical  directions  as  the  studies 

1  Comptes  Rendus  des  Seances  de  la  Societe  de  Biologie,  July,  1891. 

2  Clin.  Med.,  p.  7J8. 


APHASIA.  437 

of  ordinary  aphasia.     The  following  quotation  from  another  paper  by  the 
writer  indicates  the  peculiarities  of  pantomime  closely  studied  by  him : 

"  In  nine  cases  of  aphasia  or  pseudo-aphasia  which  were  investigated  by 
me  notable  differences  and  peculiarities  in  pantomime  were  presented  by  the 
patients.  In  one  case  of  brachio-crural  monoj^legia,  almost  complete  motor 
aphasia,  with  marked  preservation  of  pantomime,  was  present ;  in  a  hemi- 
plegic  with  convulsions,  Avord-blindness,  verbal  amnesia,  and  motor  aphasia, 
there  were  marked  sensorimotor  disturbances  of  pantomime ;  in  a  third  case, 
one  of  right  hemiplegia,  and  nearly  complete  aphasia,  chiefly  of  the  motor 
type,  the  pantomime  was  varied  and  uncertain ;  a  fourth  case  was  one  of 
right  hemiplegia,  with  marked  contractures,  complete  aphasia  of  the  mixed 
type,  with  a  single  recurring  utterance,  and  almost  complete  amimia ;  a  fifth 
was  a  case  of  rigid  hemiplegia,  paralysis  of  the  face,  almost  total  sensori- 
motor aphasia,  and  obstinate  and  energetic  emotional  gesticulation.  In  the 
sixth  case,  of  marked  hemiplegia  of  gradual  development,  with  motor  aphasia 
and  anarthria,  only  a  slight  degree  of  loss  of  pantomime  was  shown ;  while 
case  seven,  one  of  right-sided  pseudo-bulbar  j)aralysis,  with  anarthria  and 
preservation  of  writing  ability  with  the  left  hand,  exhibited  also  full  preser- 
vation of  pantomime.  Case  eight  was  an  examjole  of  right-sided  pseudo- 
bulbar paralysis  and  ophthalmoplegia,  Avith  anarthria,  marked  orolingual 
IDaresis,  and  fiiU  preservation  of  pantomime,  but  with  considerable  mental 
apathy.  The  ninth  and  last  case  recorded  was  one  of  double  hemiplegia 
from  successive  lesions  on  the  right  and  left  side  of  the  brain,  with  absolute 
abolition  of  speech  and  pantomime." 

Sensory  aphasia  is  usually  considered  as  having  at  least  three  special  forms, 
namely,  auditory  aphasia  or  word-deafness,  visual  asphasia  or  word-blind,ness, 
and  aptraxia,  sometimes  called  mind-blindness,  soul-blindness,  or  object-blind- 
ness. In  the  section  on  auditory  localization,  the  locality  of  the  centres  for 
word-hearing,  or  for  auditory  images  of  words,  has  been  thoroughly  discussed, 
and,  to  some  extent,  the  whole  subject  of  word-deafness.  From  physiological 
investigations,  and  especially  those  of  Ferrier,  from  the  study  of  a  few  re- 
ported cases,  and  especially  as  the  result  of  the  findings  in  a  case  of  word-deaf- 
ness reported  by  me,  in  which  lesions  of  the  two  superior  temporal  convolutions 
of  both  sides  were  present,  the  conclusion  Avas  reached  that  the  centre  for 
word-hearing  is  situated  in  the  hinder  thirds  of  the  first  and  second  temporal 
convolutions,  the  third,  fourth,  and  fifth  taking  no  part  in  the  process.  The 
chief  part  is  probably  played  by  the  first  or  supertemporal  convolution.  The 
symptoms  in  case  of  a  lesion  of  this  region  are,  in  the  first  place,  word-deaf- 
ness, although  this  may  not  be  complete  unless  the  corresponding  region  of 
the  right  cerebral  hemisphere  is  also  imj^aired  or  destroyed.  Other  symp- 
toms present  are  inability  to  read  aloud  correctly,  the  patient  not  being  able 
to  verify  what  he  reads  by  hearing.  In  complete  word-deafness  he  cannot 
echo  spoken  words.  Both  j^araphasia  and  paragraphia  may  also  be  present, 
and  by  some  authorities  verbal  amnesia  and  articulative  amnesia  are  also 
said  to  be  present ;  but  it  is  probable  that  in  some  of  these  cases  at  least,  these 
amnesic  phenomena  are  dependent  upon  involvement  of  the  naming  centre 
or  of  the  tracts  leading  from  the  centres  of  word-hearing  to  the  conceptual 
or  motor  centres.  Music-deafness  is  sometimes  associated  with  word-deaf- 
ness, but  the  latter  may  be  present  and  the  former  absent.  It  is  probable 
that  an  innate  musical  faculty  belongs  to  both  hemispheres  of  the  brain  to  a 
greater  degree  than  does  the  faculty  of  hearing.  As  already  stated,  the 
sphere  or  field  for  all  auditory  memories  covers  a  much  larger  region  of  the 
cortex  than  that  for  word-hearing  alone. 

Between  the  auditory  centres  at  the  base  of  the  brain  and  the  cortical 
auditory  centres  in  the  left  temporal  lobe  ai*e  also  entering  tracts  for  heai*- 


438  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

iug.  A  lesion  of  these  entering  tracts  which  probably  go  from  both  sides  of 
the  brain  will  give  a  form  of  word-deafness.  Lichtheim  has  placed  the 
entering  auditory  tract  chiefly  in  the  left  temporal  lobe,  believing  that  the 
fibres  from  both  acoustic  nuclei  and  both  primary  acoustic  centres  come  to- 
gether in  this  lobe  and  pass  to  the  centre  for  word-hearing.  A  lesion  of  this 
tract  will  cause  pure  word-deafness,  as  will  also  a  lesion  of  the  centre  for 
word- hearing ;  but  in  the  latter  case  paraphasia  and  paralexia  will  be  present, 
as  the  patient  will  not  be  able  to  verify  what  he  says  or  means  through  his 
centre  for  word-hearing,  whereas,  in  the  former  case,  he  can  do  this.  A 
case  of  lesion  probably  restricted  to  this  entering  auditory  tract  has  been 
rej)orted  by  Lichtheim.  This  patient  preserved  the  power  of  volitional 
speaking  and  writing  and  of  reading  aloud,  which  is  lost  in  deafness  fr-om 
lesion  of  the  centre  for  auditory  images.  He  had  neither  paraphasia  nor 
paragraphia. 

For  a  full  comprehension  of  cortical  auditory  localization  and  auditory 
aphasia  we  should  have  an  understanding  of  the  entire  auditory  tract  or 
path.  Meynert  held  that  the  central  acoustic  fibres  all  passed  through  the 
cerebellum  on  their  way  to  the  cerebral  hemispheres ;  but  this,  as  Ferrier 
points  out,  is  not  consistent  with  the  results  of  the  destruction  of  the  cere- 
bellum, and  an  explanation  is  to  be  found  in  the  fuller  understanding  which 
has  been  recently  reached  of  the  subdivisions  and  functions  of  the  so-called 
eighth  nerve,  which,  in  reality,  consists  of  two  distinct  portions,  which  might, 
perhaps,  be  better  classed  as  two  distinct  nerves.  These  and  their  central 
paths  have  been  studied  experimentally  by  Baginski,  and  microscopically 
with  great  care  by  Flechsig,  Bechterew,  Bruce,  and  Hans  Held,  and  particu- 
larly by  the  latter.  A  dorsal  or  posterior  root  becomes  the  cochlear  nerve, 
the  true  nerve  of  hearing,  while  a  ventral  or  anterior  root  becomes  the  vesti- 
bular nerve,  which  is  probably  a  nerve  of  space  or  equilibration.  The  vesti- 
bular nerve,  which  arises  in  the  ganglion  of  Scarpa,  in  the  semicircular 
canals,  has  a  portion  of  its  central  path  by  way  of  the  cerebellum.  Possibly 
a  centre  for  equilibration  or  space  may  be  present  in  the  cerebral  cortex,  but 
of  this  we  have  not  as  yet  any  knowledge.  In  connection  with  the  question 
of  auditory  localization,  we  need  at  present  only  to  concern  ourselves  with 
the  source  and  termination  of  the  cochlear  nerve.  This  cochlear  or  acoustic 
nerve,  according  to  the  latest  researches,  originates  in  the  spiral  ganglion  or 
organ  of  Corti,  which  corresponds  to  a  posterior  spinal  ganglia.  It  passes  to 
the  lateral  tubercle  and  accessory  nucleus  of  the  same  side,  thence  decussa- 
ting by  the  traj)ezium  and  medullary  strise,  its  fibres  enter  the  lateral  layers 
of  the  fillet,  passing  by  way  of  the  superior  olives,  trapezoid  nuclei,  lateral 
nucleus,  post-geminum  and  post-geniculum,  and,  eventually,  by  cerebral  fibres 
to  the  cortex  of  the  temporal  lobe.  The  post-geminum  or  posterior  quadri- 
geminal  body,  and  post-geniculum  or  internal  geniculate  body,  are  probably 
primary  acoustic  centres,  or  central  terminations  of  the  reflex  acoustic  paths. 
It  is  altogether  probable,  as  Luciani  and  Tamburini  have  suggested,  that  we 
have  a  semidecussation  of  the  acoustic  nerves  similar  to  that  of  the  optic 
nerves,  and  that  therefore  both  ears  are  represented  in  each  cerebral  hemi- 
sphere. "  This  latter  is  undoubtedly  the  case ;  for  unilateral  extirpation 
never  gives  rise  to  permanent  deafness  of  the  one  ear ;  but  though  I  have  had 
on  many  occasions,  after  extirpation  of  the  auditory  area  in  one  hemisphere, 
observed  loss  or  impairment  of  hearing  in  the  opposite  ear,  I  have  never 
been  able  to  detect  the  slightest  impairment  of  hearing  in  the  ear  of  the  same 
side."     (Ferrier). 

Just  as  there  are  anatomical  and  physiological  homologies  between  the  optic 
and  the  acoustic  paths,  so  there  are  doubtless  clinical  phenomena  which  are 
more  or  less  fully  comparable  with  those  of  simple  amblyopia  and  hemi- 


APHASIA.  439 

anopsia ;  and  the  discovery  and  study  of  these  will  eventually  assist  in  the 
subdivision  of  the  auditory  field. 

Visual  localization,  like  auditory  localization,  has  already  been  considered 
at  length.  Although  Henschen  believes  that  the  macular  field  lies  in  the 
calcarine  cortex,  I  do  not  accord  with  this  view.  The  cortical  field  for  the 
macula  is  doubtless  also  the  field  wherein  are  stored  the  visual  images  of 
words,  of  letters,  and,  probably,  of  objects  ;  and  this  is  probably  in  the  angulo- 
occipital  region  on  the  lateral  surface  of  the  hemisphere,  practically  where  it 
was  located  by  Ferrier.  Limited  destruction  in  this  region  will  produce 
word-blindness,  and  letter-blindness.  Alexia,  or  the  inability  to  read,  will 
also,  of  course,  be  produced  by  such  a  lesion,  as  will  also  agraphia,  at  least, 
so  far  as  this  is  dej)endent  upon  sight.  Patients  who  have  been  rendered 
word-blind  and  alexic  by  a  lesion  of  the  cortical  area  for  word-seeing  can 
sometimes  write  their  names  or  a  few  simple  words,  or,  in  rare  cases,  a  num- 
ber of  words,  apparently  doing  this  through  tovich  or  recognition  of  psycho- 
motor images. 

Between  the  primary  optic  centres  at  the  base  of  the  brain  and  the 
primary  visual  centres  in  the  cortex  of  the  occipital  lobe,  which  are  situated 
in  the  calcarine  region,  are  certain  entering  tracts  for  vision,  the  optic  radia- 
tions of  Gratiolet.  The  primary  cortical  visual  centres  themselves  are  con- 
nected with  the  retinas  of  both  eyes,  but  only  with  half  of  the  retina  of  each 
eye,  the  half  on  the  same  side  of  the  head  as  itself.  From  these  primary 
cortical  centres  of  both  occipital  lobes  tracts  pass  to  the  angular  region  and 
its  neighborhood  in  each  hemisphere.  This  region  is  a  centre  of  high  func- 
tion, one  in  which  is  stored  the  visual  images  for  words  and  objects.  A 
lesion  which  severs  the  tracts  going  from  both  occipital  lobes  to  this  higher 
visual  centre  will  cause  word-blindness  but  not  agraphia,  as  the  memory 
pictures  can  still  be  revived  and  made  use  of  by  the  motor  centres  for  writ- 
ing. Commonly  a  lesion  of  this  kind  causing  word-blindness  will  also  cause 
hemianopsia,  because  the  radiations  of  Gratiolet  are  usually  involved. 

Xot  infrequently  associated  with  word-blindness  is  another  disorder  Avhich 
has  been  variously  called  mind-blindness,  soul-blindness,  and  object-blind- 
ness. The  word  apraxia  is  also  used  by  Kussmaul  in  practically  the  same 
sense  for  the  loss  of  memory  of  the  uses  of  things  and  the  understanding 
of  the  signs  by  which  things  are  expressed.  In  testing  for  this  condition, 
the  physician  observes  whether  the  individual  examined  shows  signs  of  recog- 
nition of  objects  of  various  kinds  which  are  presented  to  him  ;  he  may  not 
comprehend  the  use  of  the  simplest  things ;  and  he  also  may  not  recognize 
persons  with  whom  he  is  intimate.  In  such  cases  the  person  may  recognize 
another  when  he  speaks,  or  by  touching  him,  even  when  he  cannot  by  sight. 
Sometimes,  however,  a  comparable  form  of  mind  or  psychical-deafness  is 
observed  in  which  the  patient  cannot  recognize  another  by  a  word  used  or 
by  the  familiar  sound  of  the  voice.  The  centre  for  the  visual  images  of  things 
may  or  may  not  be  separate  from  that  for  the  visual  images  of  words,  but 
both  are  in  the  same  adjacent  regions  of  the  cerebral  cortex.  Both  hemi- 
spheres of  the  cerebrum  doubtless  take  part  in  the  storage  of  such  object 
images,  and  probably  in  nearly  equal  degree,  whereas  for  words,  the  man  is 
mainly  left-brained  as  for  many  other  of  the  higher  faculties.  It  is  true  that 
a  few  cases  of  partial  mind-blindness  are  on  record  in  which  unilateral  lesions 
are  present. 

The  mental  percepts  of  objects  and  the  mental  percepts  of  names  are  the 
results  of  different  processes  of  cerebration.  Wyllie  holds,  with  many  others, 
that  it  is  not  necessary  to  have  a  special  cortical  centre  set  apart  for  either  of 
these  processes,  that  is,  that  special  "  ideational "  centres  and  "  naming  "  cen- 
tres probably  do  not  exist ;  but  that  the  interaction  of  the  entire  cortex,  or 


440  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  certain  of  its  layers,  is  concerned  with  ideation,  and  that  names  arise  in 
consciousness  through  the  action  of  the  centres  for  percepts  and  the  motor 
centres.  Whatever  may  be  trae  as  regards  the  formation  of  ideas,  my  own 
experience  and  views  as  to  cerebral  action  have  led  me  to  the  opinion  of 
Broadbent,  that  a  naming  centre  at  least  exists  in  the  cortex,  and  in  the  pre- 
ceding pages  I  have  recorded  the  details  of  a  case  which  would  seem  to  be 
corroborative  of  this  position. 

As  shown  in  the  preceding  section  on  the  naming  centre,  destruction  of 
this  area  will  cause  loss  of  memory  of  names  or  nouns,  in  other  words,  one 
of  the  forms  of  verbal  amnesia,  but  this  may  be  considered  as  a  conceptual 
aphasia,  using  the  word  conceptual  in  the  sense  already  described  in  speak- 
ing of  idea,  concept  or  naming  centres.  A  form  of  verbal  amnesia  of  incom- 
plete type,  incojnplete  aHieulative  amnesia,  may  be  due  to  partial  destruction 
of  this  region,  or  of  the  channels  connecting  it  with  its  correlated  centres  on 
either  the  receptive  or  emissive  side  of  the  brain.  It  must  not  be  forgotten 
that  real  or  apparent  verbal  amnesia  may,  however,  be  due  to  lesions  vari- 
ously situated,  in  fact  lesions  in  almost  any  area  concerned  with  the  mechan- 
ism of  speech.  Amnesia  literarmn,  to  which  Wyllie  refers,  may  be  due  to 
lesions  similarly  located  to  those  causing  verbal  amnesia.  This  term  is  used 
"  as  indicative  of  a  failure  (on  the  productive  side)  to  call  up  the  images  of 
letters  and  words  in  the  mind  when  the  effort  to  write  is  being  made ;  in  con- 
trast to  word-blindness,  which  implies  a  failure  on  the  side  of  reception  and 
interpretation." 

Conduction  aphasias  are  those  forms  of  speech  disturbance  which  are  due  to 
defect  or  destruction  of  the  tracts  which  associate  the  different  regions  con- 
cerned in  this  mechanism  of  speech.  Certain  terms  need  to  be  defined  in 
this  connection.  The  general  term  for  these  conduction  aphasias  is  para- 
phasia, which  may  have  as  many  types  as  there  are  commissures.  Para- 
grajjhia  is  the  misuse  of  words  in  writing;  ptaramimia,  the  misuse  of  signs  or 
pantomime  ;  and  p)aralexia,  the  misuse  in  reading  of  either  syllables  or  words ; 
dyslexia  refers  to  difficulty  or  fatigue  shown  in  reading.  These  may  all  be 
regarded  as  forms  of  conduction  aphasia. 

The  following,  which  is  summarized  from  Wyllie,  expresses  the  different 
varieties  of  speech  which  are  present  in  the  different  varieties  of  conduction 
aphasia  in  connection  with  the  special  sites  of  different  lesions.  The  first 
names  given  are  those  of  Lichtheim  and  Wernicke,  the  designation  given 
parenthetically  being  those  used  by  Wyllie.  These  varieties  of  aphasia  are 
(1)  subcortical  (infra-pictorial  sensory  aphasia) ;  (2)  transcortical  (supra- 
pictorial  sensory  aphasia)  ;  (3)  transcortical  (supra-pictorial  motor  aphasia)  ; 
(4)  subcortical  (infra-pictorial  motor  aphasia).  Wyllie  has  suggested  the 
name  inter-pictorial  aphasia  for  the  conduction  a2:)hasias,  applying  the  term 
pictorial  also  to  both  the  sensory  and  motor  aphasias  which  we  have  already 
considered. 

In  subcortical,  or  infra-pictorial  sensory  aphasia,  simple  word-deafness,  with- 
out verbal  amnesia  or  other  associated  symptoms  of  speech  disturbance,  is 
characteristic.  The  auditory  centre  is  intact,  but  is  cut  off  from  incoming 
words  which  usually  reach  it  from  both  ears.  Speaking,  reading,  and  writ- 
ing are  not  affected,  the  patient  is  word-deaf,  he  hears  the  words  as  sounds, 
but  does  not  understand  what  is  said.  In  transcortical  or  supra-j^ictorial  sen- 
sory aphasia,  incoming  audible  speech  is  not  understood,  nor,  according  to 
Lichtheim  and  Wernicke,  is  incoming  visual  speech,  as  the  path  betAveen  the 
auditory  centre  "  and  the  centi'e  Avhere  the  idea  or  meaning  to  be  expressed, 
or  to  be  ev-oked  is  located  " — what  I  would  call  the  naming  or  concept  centre 
— is  cut  across,  so  that  the  auditoiy  word-pictures  revived  in  the  auditory 
centre  do  not  call  up  the  ideas  or  meanings  in  this  higher  centre.     What  is 


APHASIA. 


441 


heard  or  read  is  not  understood,  and  yet  the  word-images  in  the  auditory 
centre  are  intact  and  can  be  revived  from  without.  Whatever  is  heard  can 
be  repeated,  and  the  patient  can  easily  read  aloud,  but  he  understands  neither 
what  he  hears  nor  what  he  reads.  He  can  write  to  dictation  and  he  can 
copy  from  print  or  from  writing.  A  true  echolalia  is  the  most  characteristic 
symptom,  which  has  its  equivalent  in  his  written  speech,  in  his  power  of 
copying  or  of  writing  to  dictation,  which  he  retains  without  any  understand- 
ing of  the  words  so  written  or  copied.  Amnesia  of  nouns,  paraphasia,  and 
in  consequence  of  the  latter,  paragraphia,  are  also  shown.  The  patient  can- 
not call  up  from  the  centre,  where  the  meaning  to  be  exj^ressecl  is  located, 
the  auditory  images  at  the  auditory  centre  for  motor  memories  of  speech.  In 
transcortical  or  supra-pictorial  motor  aphasia,  the  path  between  the  cen- 
tre where  the  idea  or  meaning  to  be  expressed  is  located,  and  the  centre 
for  motor  memories  of  speech  in  Broca's  convolution,  has  been  cut  across. 
The  patient  cannot  express  his  thoughts  when  he  tries  to  speak  volitionally. 
The  failure  is  the  same  as  in  an  ordinary  case  of  motor  aphasia,  when  the 
centre  for  the  motor  memories  of  speech  is  destroyed.  According  to  Lich- 
theim,  he  cannot  express  his  thoughts  any  better  in  writing  than  in  voli- 
tional speech.  Everything  else  is  normal.  What  he  reads  and  what  is  said 
to  him  are  both  understood,  and  he  can  repeat  with  correct  articulation  words 
that  are  spoken  to  him,  understanding  them  in  this  variety.  He  can  also 
write  to  dictation  and  copy  writing  with  ease  and  correctness,  understanding 
in  both  cases  what  he  writes. 

Fig.  112 


A,  auditory  centre  (centre  for  word-hearing) ;  V,  visual  centre  (centre  for  word-seeing) ;  N,  nam- 
ing centre  (centre  where  percepts  are  given  in  name) ;  B,  motor  speech  centre  in  Broca's  convolu- 
tion (regarded  by  Broadbent  as  a  propositionizing  centre  ;  an  utterance  centre — motor  centre  U  in 
Fig.  Ill  is  also  required  to  complete  the  motor  side  of  the  speech  process  ;  if  the  view  is  accepted) ; 
G,  graphic  centre ;  R.  Oc,  primary  cortical  visual  centre  in  the  right  occipital  lobe;  L.  Oc,  primary 
cortical  visual  centre  in  the  left  occipital  lobe  ;  R.  P.  O.  C,  optic  centres  at  the  base  of  the  brain, 
right  side  ;  L.  P.  O.  C,  optic  centres  at  the  base  of  the  brain,  left  side  ;  R.  T.,  primary  cortical  au- 
ditory centres  in  the  right  temporal  lobe  ;  L  T.,  primary  cortical  auditory  centres  in  the  left  temporal 
lobe  ;  R.  P.  A..  C,  auditory  centres  at  the  base  of  the  brain,  right  side ;  L.  P.  A.  C,  auditory  centres  at 
the  base  of  the  brain,  left  side. 


442  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

In  subcortical  or  infra-pictorial  motor  aphasia  the  lesion  cuts  across  only 
those  fibres  which  connect  the  centre  for  the  motor  memories  of  speech  in 
Broca's  convolution  with  the  centres  for  the  nerves  of  sjDeech  in  the  oblongata. 
The  connecting  fibres  between  the  centre  of  motor  memories  of  speech  and  the 
other  speech  centres,  and  the  fibres  between  it  and  the  centre,  where  the  idea 
or  meaning  to  be  expressed  is  located,  are  all  intact.  If  this  lesion  exists, 
spoken  speech,  both  volitional  and  on  attempted  repetition  of  the  words  heard, 
would  be  disabled.  "  Otherwise,  everything  would  be  normal ;  there  would 
be  no  amnesia  verbalis,  no  difiiculty  in  volitional  writing,  writing  to  dictation 
or  copying,  and  no  word-deafness."  If  paralysis  prevents  writing  with  the 
right  hand  it  can  still  be  done  with  the  left.  In  some  cases  sensory  centres, 
motor  centres  and  associating  fibres,  may  all  be  involved  at  the  same  time, 
giving  forms  of  combined  or  mixed  aphasia,  or  it  may  be  what  is  termed  total 
aphasia. 

The  diagram  (Fig.  112),  which  has  been  modified  from  Lichtheim,  indi- 
cates in  accordance  with  the  views  expressed  in  this  and  the  preceding  sec- 
tions the  various  centres  concerned  in  speech,  and  of  the  entering,  associat- 
ing and  emerging  tracts. 

Wyllie  makes  the  following  suggestions  for  the  systematic  examination 
of  a  patient  supposed  to  be  suffering  from  one  of  the  various  forms  of  aphasia. 
He  takes  each  of  the  two  forms  of  speech,  the  spoken  and  the  written, 
separately.  If  there  is  danger  of  over-tasking  the  impaired  brain  of  the 
patient,  the  examination  should  be  made  gradually. 

Spokex  Speech.  1.  How  is  it  received  and  interpreted  f  Is  the  hearing 
good  ?  The  hearing  being  good,  is  there  any  difficulty  in  interpreting  the 
meaning  of  words  heard  (word-deafness)  ?  The  patient's  replies  to  questions, 
even  if  these  replies  are  made  only  by  gesture,  will  show  whether  or  not  he 
understands  what  is  said.  Ask  him  to  put  out  his  tongue,  to  shut  his  eyes, 
to  give  his  hand,  etc.  He  should  also  be  tested  specially  as  to  his  power  of 
interpreting  nouns  and  verbs.  Ask  him  to  touch,  one  by  one,  as  the  parts 
are  named,  his  nose,  ear,  eye,  chin,  etc.  Ask  him  to  try  to  whistle,  to  shut 
his  eyes,  to  smile,  etc.  If  the  examiner  carefully  refrains  from  giving  the 
patient  hints,  by  gesture  or  expression  of  countenance,  of  what  is  wanted, 
the  recorded  answers  to  such  questions  will  indicate  Avhether  word-deafness 
is  present,  and  in  what  degree. 

2.  Hoio  is  it  produced  f  When  there  is  pronounced  motor  aphasia,  and 
speech  is  reduced  to  a  recurring  utterance,  one  or  two  familiar  words,  and, 
upon  occasion,  an  emotional  or  conventional  expression,  the  whole  vocabu- 
lary of  the  patient  should  be  carefully  noted  down.  When,  in  either  motor 
or  auditory  aphasia  there  is  considerable  vocabulary  we  should — 

a.  Record  words  or  phrases  of  the  patient  showing  evidence  of  defective 
powers  of  articulation.  As  to  his  utterance,  for  example,  we  should  note  any 
specimens  of  lalling,  stammering,  syllable-stumbling,  or  slurring. 

h.  Look  for  evidences  of  amnesia  verbalis,  and  its  companion  symptoms, 
articulative  amnesia  and  paraphasia.  In  doing  so  we  should  show  the  patient 
common  objects  and  ask  him  to  name  them ;  and,  in  recording  his  answers, 
we  should  make  note  of  difficulties  in  remembering  nouns,  etc.,  as  well  as 
of  mistakes  in  the  use  of  them.  When  the  patient  is  pi'actically  dumb  we 
should  test  him  for  amnesia  verbalis  by  asking  him  to  write  answers  to 
questions ;  if  he  cannot  write,  by  asking  him,  after  Lichtheim's  method,  to 
indicate  with  his  fingers  the  number  of  syllables  in  the  names  of  the  com- 
mon objects  shown  him.  If  there  is  paraphasia,  we  should  note  whether  the 
patient  is  immediately  conscious  of  the  errors  he  makes  in  the  use  of  nouns, 
etc.,  or,  on  the  other  hand,  is  quite  unconscious  of  them. 

3.  Sow  is  it  repeated  or  echoed  f   The  patient  should  be  got  to  attempt  the 


APHASIA.  443 

repetition  or  echoing  of  words  spoken  to  him.  If  he  is  word-deaf,  and  can- 
not understand  a  mere  verbal  request,  to  attempt  this  the  examiner  must  try- 
to  get  him  to  understand  what  is  wanted  by  putting  the  request  into  the 
language  of  gesture,  and  repeating  the  word  or  phrases  over  and  over  again. 
If  the  patient  is  able  to  echo  words  or  phrase  the  attemj)t  should  be  made 
to  ascertain  whether,  in  doing  so,  he  understands  what  he  is  saying. 

Written  Speech.  1 .  Hoiv  is  it  received  and  interpreted  f  Is  the  sight  good  ? 
Is  hemianopsia  present?  Is  the  patient  able  to  understand  questions  put 
before  him  in  print  or  writing  ?  If  he  is  speechless,  and  cannot  by  speech 
indicate  how  much  he  understands,  show  him  in  writing  or  print  such  requests 
as  "Put  out  your  tongue,"  "Give  me  your  left  hand,"  etc. ;  and  note  how 
he  complies  with  them.  If  there  is  some  power  of  interpreting  written 
or  printed  words,  try  to  ascertain  how  much  there  is  by  asking  the  patient 
silently  a  sentence  in  a  book  or  newspaper,  and  then  questioning  him  about 
it  in  such  a  manner  that  he  will  not  be  able  to  answer  them  by  gesture  or  by 
pantomime. 

2.  How  is  it  produced?  Ask  the  patient  to  write  his  name.  If  he  succeeds, 
put  simple  questions  to  him,  and  ask  him  to  answer  them  in  writing.  If  he 
writes  with  comparative  ease,  ask  him  to  Avrite,  at  his  leisure,  the  history  of 
his  illness.  Note  in  his  performance  evidence  of  (1)  paragraphia,  which  is 
usually  only  the  written  translation  of  paraphasia ;  (2)  intoxication  of  the 
mind  with  a  letter  or  word,  and  (3)  faults  of  spelling  or  syntax.  If  the  right 
hand  is  paralyzed,  let  the  patient  try  to  write  with  the  left.  If  the  right 
hand  is  not  paralyzed,  but  is  agraphic,  let  him  ftirnish  examples  of  the  per- 
formance in  writing  of  both  the  right  hand  and  the  left. 

3.  Hoiv  does  the  patient  ivrite  to  dictation  and  from  copy  f  Try  him  in  both 
ways,  and  if  he  is  able  to  do  either,  or  both,  try  to  ascertain  if  he  under- 
stands the  meaning  of  what  he  writes. 

Associated  Phenomena.  1.  Gesture  language  (Pantomime).  Does  the 
patient  understand  the  gesture  language  of  the  examiner,  and  does  he  him- 
self employ  gesture  language  intelligently  ?  Or,  on  the  other  hand,  are  there 
evidences  of  amimia  or  of  paramimia  ? 

2.  Extra-grap)hic  Symbols.  How  does  he  understand  and  employ  such 
graphic  symbols  as  numbers,  algebraic  signs,  if  previously  shown  to  him ; 
musical  notation,  if  he  was  previously  a  musician,  etc.  ? 

3.  Is  there  any  evidence  of  Mind- blindness  (Psychical  Blindness')  as  shown 
by  inability  to  recognize  common  objects  shown  to  him,  and  to  indicate  their 
uses ;    or  by  inability  to  recognize  intimate  friends  at  sight  ? 

4.  The  Emotional  and  Intellectual  Faculties.  Are  the  emotions  lively  and 
their  expression  vivid,  or  are  they  dull  ?  Is  self-control  well  maintained,  or 
does  the  patient  frequently  exhibit  emotional  disturbance  ? 

What  is  the  condition  of  the  intelligence  as  exhibited  in  expressive  actions 
and  in  capability  in  engaging  in  games  of  skill,  of  conducting  business 
affairs,  etc. 

5.  The  Motor  and  Sensory  Functions.  All  symptoms  of  motor  or  sensory 
paralysis  should,  of  course,  be  careftilly  described. 


CHAPTEK  XY. 

FOCAL  DISEASES  OF  THE  BRAIN. 

By  CHARLES  L.  DANA,  M.D. 

APOPLEXY. 

Introductory.  By  apoplexy,  as  I  shall  use  the  term,  is  meant  a  sud- 
den shock  due  to  the  bursting  of  an  intra-cranial  bloodvessel  or  to  a  stoppage 
of  the  same,  with  consequent  laceration  or  softening  of  tissue.  Apoplexy 
is  a  term  which  has  been  used  more  especially  in  connection  with  intra-cra- 
nial hemorrhage,  but  since  it  is  often  impossible  in  an  apoplectic  attack  to 
say  whether  the  condition  is  due  to  rupture  of  a  vessel  or  to  obstruction  of  it, 
with  consequent  local  softening,  the  term  must  be  used  to  include  both  con- 
ditions. Apoplexy  is  so  often  associated  with  hemiplegia  that  clinically  we 
often  speak  of  apoj)lexy  as  the  beginning  and  hemiplegia  as  the  later  condi- 
tion ;  but  there  may  be  an  attack  of  apoplexy  without  hemiplegia,  and  there 
may  also  be  a  hemiplegia  which  is  not  due  to  any  apoplectic  insult.  The 
later  and  secondary  effects  that  follow  an  intra-cranial  hemorrhage  resemble 
very  closely  those  of  an  acute  softening,  so  that  it  would  be  in  many  respects 
advantageous  to  describe  the  two  conditions  together.  This,  however,  is  not 
possible,  for  the  reason  that  the  causes  of  intra-cranial  hemorrhage  are  differ- 
ent from  those  of  intra-cranial  acute  softening,  and  the  same  may  be  said  of 
the  mode  of  onset,  of  the  immediately  subsequent  symptoms,  of  the  prog- 
nosis, and  of  the  treatment.  I  shall  therefore  have  to  describe,  first  of  all, 
the  intra-cranial  hemorrhages  and  the  secondary  effects  from  them.  In  de- 
scribing the  acute  softenings  I  shall  be  able,  in  going  over  the  later  symptoms, 
simply  to  refer  to  many  of  the  facts  given  under  the  head  of  the  chronic 
stage  of  cerebral  hemorrhage. 

There  are  some  general  facts  which  may  be  stated  here  with  regard  to  the 
two  pathological  conditions  which  I  am  about  to  describe.  Apoplexy  from 
intra-cranial  hemorrhage  is  a  condition  which  occurs  most  often  a  little  after 
middle  life,  and  much  oftener  in  men  than  in  women.  It,  however,  is  found 
with  considerable  frequency  in  the  first  year  of  life,  while  it  hardly  ever 
occurs  in  the  period  of  advanced  senility.  Acute  softenings  practically 
never  occur  in  infancy.  They  are  met  with  just  before  the  middle  period  of 
life,  and  then  again  in  life's  last  decade.  Acute  softenings  stand  much  more 
often  in  relation  to  syphilis,  while  hemorrhages  are  much  more  closely  related 
to  chronic  alcoholism.  Hemorrhages  are  more  dangerous  to  life  and  are  not 
so  frequently  repeated  as  are  the  acute  softenings.  These  are  some  of  the 
general  facts  which  the  student  may  bear  in  mind  before  proceeding  to  more 
particular  inquiry  into  the  nature  of  the  two  disorders. 


CEREBRAL  HEMORRHAGE.      CEREBELLAR,  PONTILE,  AND 
BULBAR   HEMORRHAGES. 

Hemorrhages  in  the  l)rain  occur  in  various  localities.     The  most  frequent 
are  those  of  the  cerebrum,  and  they  are  called  cerebral  hemorrhages.     Very 


FOCAL  DISEASES  OF  THE  BRAIN.  445 

often  the  term  cerebral  hemorrhage  is  used  loosely  to  indicate  a  hemorrhage 
in  any  part  of  the  brain. 

For  ordinary  purposes  a  simple  anatomical  classification  of  hemorrhage 
may  be  used  such  as  I  have  indicated  at  the  head  of  the  section.  But  owing 
to  peculiarities  in  the  distribution  of  the  cranial  arteries  it  is  often  conveni- 
ent to  make  another  division.  Thus  hemorrhages  of  the  central  arteries  of 
the  brain  which  supply  the  great  ganglionic  deposits  are  specially  frequent 
and  clinically  distinct,  so  that  we  speak  of  central  hemorrhages  in  the  same 
way  we  speak  of  cortical  or  pial  hemorrhages  and  of  dural  or  pachymenin- 
geal  hemorrhages,  because  diflTerent  groups  of  arteries,  as  well  as  different 
parts  of  the  brain,  are  involved.  The  forms  of  intra-cranial  hemorrhage, 
therefore,  from  the  standpoint  of  arterial  distribution  and  anatomical  struc- 
ture, are  the  central,  cortical  (or  pial),  dural,  or  pachymeningeal,  cerebellar, 
and  pons-medulla  hemorrhages. 

Finally,  it  is  somewhat  unfortunate  that  the  hemorrhages  of  infancy  have 
been  studied  and  described  separately,  and  we  have  as  a  result  the  term  in- 
fantile cerebral  hemorrhage  spoken  of. 

The  Blood  Supply  of  the  Brain.  In  order  to  understand  the  symp- 
toms and  pathology  of  apoplexy  it  is  necessary  to  know  the  anatomy  of  the 
blood  supply  of  the  brain  and  its  membranes.  While  I  do  not  propose  to 
go  into  many  details,  I  shall  give  a  description  sufficient  to  remind  the  reader 
of  the  general  facts  regarding  the  subject.  The  external  carotids  furnish  the 
blood  supply  to  the  scalp,  the  skull,  and  dura  mater ;  the  internal  carotids 
and  vertebrals  fiirnish  the  blood  supply  to  the  brain  proper,  the  pia  mater, 
and  the  eye.  It  follows  that  most  of  the  meningeal  hemorrhages,  in  fact, 
nearly  all  those  that  are  due  to  injuries  of  the  skull  and  dura  mater,  are  the 
result  of  ruptures  of  some  branches  of  the  external  carotid.  The  hemor- 
rhages into  the  brain  substance,  however,  in  all  its  parts,  as  well  as  hemor- 
rhages of  the  vessels  of  the  pia  mater,  are  due  to  ruptures  of  some  branches 
of  the  internal  carotids  or  vertebrals.  Practically  the  internal  carotid 
arteries  are  those  whose  branches  are  most  affected  in  non-traumatic  intra- 
cranial hemorrhages. 

The  Brain  Arteries.  The  internal  carotid  passes  up  through  the  carotid 
foramen  into  the  cavity  of  the  skull,  and  reaching  the  base  of  the  brain  gives 
off"  arteries  which  unite  with  the  branches  from  the  vertebrals  and  basilar 
to  form  the  circle  of  Willis.  The  most  important  arteries  that  this  latter 
gives  off  are  the  anterior  and  middle  cerebral,  the  posterior  communicating, 
and  the  central  arteries.  The  vertebral  arteries  give  ofi"  the  inferior  cere- 
bellar and  then  unite  into  a  single  basilar  trunk  which  give  off  the  posterior 
cerebral,  and  this,  in  turn,  gives  off  the  posterior  communicating,  which 
unites  with  the  middle  cerebral  to  form  the  circle  of  Willis.  It  also  gives 
off  also  central  arteries.  This  circle  is  completed  by  the  anterior  communi- 
cating, which  unites  the  two  anterior  cerebrals.     (Fig.  113.) 

The  Central  Arteries.  From  the  circle  of  Willis  and  the  beginnings  of 
the  anterior,  middle,  and  posterior  cerebrals  several  groups  of  vessels,  six 
in  all,  are  given  ofi";  they  supply  the  great  basal  ganglia  and  adjacent 
white  matter  and  are  called  the  central  arteries  of  the  brain.  They  are  the 
vessels  usually  affected  in  cerebral  hemorrhages  of  adult  life. 

Of  the  groups  of  central  arteries  which  are  sent  off  from  the  circle  of 
Willis  and  the  three  large  cerebral  vessels  the  most  important  are  those 
given  off  from  the  middle  cerebral.  These  consist  of  two  groups,  one  a 
proximal,  the  other  a  distal.  The  proximal  group  consists  of  small  arteries, 
called  lenticular  arteries  by  Duret,  which  pass  directly  up  into  tlie  internal 
and  middle  segments  of  the  lenticular  nucleus  and  the  internal  capsule.  The 
distal  group  consists  of  the  lenticulo-striate  arteries,  which  send  branches 


446 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


directly  to  the  outer  segment  of  the  lenticular  nucleus,  external  capsule, 
and  caudate  nucleus,  and  the  lenticulo-optic  arteries  which  pass  to  the  outer 
and  posterior  part  of  the  lenticular  nucleus  and  the  outer  part  of  the  optic 
thalamus.  One  of  the  lenticulo-striate  arteries,  larger  than  the  rest,  is 
considered  to  be  an  especially  frequent  seat  of  cerebral  hemorrhage.  _  It 
losses  outward  and  upward  at  the  junction  of  the  anterior  and  middle  thirds 
of  the  lenticular  nucleus,  between  the  latter  and  the  external  capsule,  and 
perforates  the  internal  capsule  to  end  in  the  caudate  nucleus.  It  is  called 
by  Charcot  the  artery  of  cerebral  hemorrhage.  The  lenticular-striate  and 
the  lenticulo-optic  sets  of  arteries,  as  well  as  the  proximal  set  of  arteries,  do 
not  anastomose,  consequently  when  one  of  them  is  plugged  softening  inevit- 
ably occurs  in  the  area  of  brain  substance  which  it  supplies. 


Fig.  113. 


Diagram  of  the  arteries  of  the  base  of  the  brain,  showing  LO.  the  lenticular-optic  and  LS.  len- 
ticular-striate sets  of  arteries.  One  of  the  latter  is  called  the  artery  of  cerebral  hemorrhage.  T'.  A. 
Vertebralis.  S.a.  Spinalis  ant.  S.p.  Spinalis  posterior.  B.  A.  Basilaris  with  median  branches. 
C.6.S.  A.  Cerebralis  superior,  c.i.  A.  Cerebelli  inferior.  C.p.  A.  Cerebralis  posterior  (profunda 
cerebri).  Com.  p.  A.  Communicantes  posteriores.  C.a.i.  Carotis  interna,  o.  A.  Opthalmica.  C. 
m.  A.  Cerebralis  media.  (A.  fossae  Sylvii).  i.  A.  Insularis.  est.  A.  Corp.  striati.  C.a.  A.  Cere- 
bralis anterior.    Com.  A .  Communicans  anterior.    C.  c.a.ll.  A.  Corp.  callosi. 


While  the  most  important  of  the  central  arteries  are  those  which  we  have 
just  mentioned  as  being  given  off  at  the  beginning  of  the  middle  cerebral, 
there  are  two  other  sets  of  central  arteries  that  deserve  notice,  they  being 
furnished  by  the  posterior  cerebral.  These  are  known  as  the  postero-mesial 
central  arteries  and  the  postero-lateral  central  arteries.  The  former  group 
ascend  through  the  posterior  perforated  space  and  supply  the  inner  part  of  the 
crus  cerebri,  part  of  the  optic  thalamus,  and  the  wall  of  the  third  ventricle. 
The  second  group  supplies  the  corpora  quadrigemina  and  the  hinder  part  of 
the  optic  thalamus,  together  with  a  few  twigs  which  join  the  posterior  choroid 
arteries  and  go  to  the  velum  interpositum.  The  anterior  cerebral  artery  sends 
off  also  a  few  sets  of  central  arteries,  which  have,  however,  a  very  limited  dis- 


PLATE 


Showing  the  distributiou  of  the  anterior,  middle  and  posterior  cerebral  arteries  on  the  sur- 
face of  the  brain.     The  numbers  1, 11,  III,  IV  indicate  the  areas  supplied  by  the  different  branches; 
the  dotted  lines  indicate  the  main  trunks.     In  the  smaller  figures,  i  indicates  the  anterior  cerebral 
2,  the  posterior  ;  3,  the  middle  cerebral.     (Modified  from  Merkel  and  Debierre.) 


F.  Softening  or  rupture  of  left  inferior  external  frontal  arterj',  Motor  Aphasia.  .Softening 
of  central  convolutions  occurs  mainly  from  involvement  of  (3)  median  parietal  artery,  (Duret), 
Hemiplegia.  Softening  of  inferior  parietal  and  ist  temporal,  from  involvement  of  (4)  posterior 
parietal  artery.  Sensory  Aphasia. 


FOCAL  DISEASES  OF  THE  BRAIN. 


447 


tribution.     They  j^ierce  the  inner  part  of  the  anterior  perforated  space  and 
supply  the  anterior  extremity  of  the  caudate  nucleus. 


Fig.  114. 


L.S. 


~Art  O.E. 


Showing  common  location  of  hemorrhages  and  softenings.  Areas  supplied  by :  ^r^Z. 5.  Lenticular 
striate.  .47-i-L.O.  Lenticular-optic  arteries.  Art  O.E.  Postero-central  arteries.  In  hemorrhage  these 
limits  are  often  exceeded  ;  in  softening  not  so  often.  In  softening  or  hemorrhage  of  the  thalamus 
alone,  the  arteria  optic  externa  or  the  perforating  arteries  from  the  choroid  plexus  may  be  involved. 

The  Cortical  Arteries.  (Plate  I.)  The  three  great  cerebral  arteries  above 
referred  to,  besides  giving  off  these  groups  of  central  branches,  send  larger 
branches  over  the  surface  of  the  entire  cerebral  hemispheres.  The  vessels  are 
distributed  in  the  pia  matei",  and  from  this  membrane  they  send  down  arteries 
into  the  cortex  and  white  matter  of  the  brain.  These  are  called  the  cortical 
arteries.  They  are  practically  the  terminal  branches  of  the  great  cerebral 
arteries.  These  vessels  have  each  a  somewhat  distinct  area  of  the  cortex 
which  they  supply  Avith  blood.  Thus  the  anterior  cerebrals  supply  the  larger 
part  of  the  frontal  lobe  ;  the  middle  cerebral  supplies  the  central  convolu- 
tions and  island  of  Reil,  and  some  of  the  temporal  and  parietal  lobe ;  the 
posterior  cerebral  suj^plies  the  occipital  and  part  of  the  temporal  lobe.  The 
three  great  arteries  do  not  anastomose  with  each  other  in  their  cortical  dis- 
tribution to  any  great  extent,  but  a  degree  of  anastomosis  does  exist,  so  that 
when,  for  example,  some  of  the  branches  of  the  anterior  cerebral  are  plugged 
a  certain  amount  of  blood  may  be  furnished  vicariously  by  the  middle  cere- 
bral. The  cortical  arteries  leave  the  pia  and  pass  directly  into  the  convolu- 
tions at  nearly  a  right  angle  with  the  membrane  from  which  they  start.  There 
are  two  sets  of  these  cortical  arteries — one  small  and  short,  which  supplies  the 
gray  matter  of  the  cortex,  and  known  as  the  cortical  arteries  proper ;  the 
arteries  of  the  other  set  are  longer,  pass  deep  into  the  white  matter  of  the 


448  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

hemispheres,  and  are  known  as  the  long  or  medullary  arteries.  The  short  or 
cortical  arteries  proper  are  smaller,  measuring  from  0.005  to  0.003  mm.  in 
diameter ;  the  long  arteries  or  medullary  arteries  measure  from  0.08  to  0.14 
mm.  and  are  from  3  to  4  cm.  in  length.  One  of  these  often  passes  down 
along  the  axis  of  the  convolution.  Both  kinds  of  arteries  anastomose  freely 
in  their  finer  branches. 

From  the  anatomical  arrangement  it  is  believed  that  the  intra-vascular 
pressure  is  less  in  the  gray  than  in  the  white  substance.  The  blood  from 
the  arteries  of  the  pia  mater  leaves  the  capillaries,  enters  small  veins,  and 
passes  for  the  most  part  upward  in  veins  that  lie  in  the  pia.  Toward  the 
longitudinal  sinus  most  of  the  vessels  enter  the  posterior  portion  of  the  sinus 
and  in  a  direction  forward  and  upward,  that  is,  against  the  current  in  the 
sinus.  The  course  of  the  blood  current  is,  therefore,  opposed  both  to  gravi- 
tation and  to  venous  flow.  The  veins  as  they  leave  the  pia  and  arachnoid 
in  the  neighborhood  of  the  longitudinal  sinus  pass  through  the  arachnoid 
cavity,  and  in  many  cases  enter  the  substance  of  the  dura  and  run  through 
that  a  short  distance  before  emptying  into  the  longitudinal  sinus.  It  is 
thought  that  at  this  point  where  the  veins  pass  from  the  pia-arachnoid  to  the 
dura  the  venous  trunks  are  subjected  to  an  extra  amount  of  strain,  owing 
to  the  fact  that  the  brain  is  movable  while  the  dura  mater  is  immovable ; 
consequently,  at  this  point,  the  veins  can  be  more  easily  ruptured. 

The  Circle  of  Willis.  The  arteries  at  the  base  of  the  brain  (see  Plate  II.) 
form,  as  I  have  stated,  the  circle  of  Willis.  This,  in  its  typical  form,  is  made 
uj)  of  the  anterior  communicating,  the  anterior  cerebrals,  the  middle  cerebral 
or  two  carotids,  the  two  posterior  communicating,  and  the  posterior  cerebrals. 
This  arrangement  occurs  in  over  three-fourths  of  the  cases.  The  trunk  of  the 
basilar  artery  averages  very  nearly  in  size  that  of  one  internal  carotoid,  that 
is  to  say,  it  furnishes,  supposing  the  pressure  to  be  equal,  one-third  of  the 
blood  supply  to  the  brain  (Ehrmann). 

We  thus  see  that  the  cerebral  hemispheres  are  supplied  in  the  main  by 
three  large  arteries — the  anterior,  middle,  and  posterior  cerebrals ;  that 
these  give  off  at  their  origin  various  groups  of  small  arteries  which  pass 
directly  up  into  the  centre  of  the  brain,  supplying  the  basal  ganglia  and 
adjacent  parts,  and  known  as  the  central  arteries.  We  see  also  that  these 
three  great  arteries  send  the  most  of  their  blood  to  the  cortical  substance  of 
the  hemispheres,  being  distributed  in  the  pia  mater  covering  these  parts,  and 
that  each  one  of  the  three  great  arteries  has  its  own  special  area  of  distri- 
bution. 

Hind-Brain  Arteries.  The  pons-medulla  and  cerebellum,  constituting 
the  hind-brain,  are  supplied  by  the  branches  of  the  vertebral  arteries.  These 
vessels  enter  the  skull  through  the  foramen  magnum,  and  bending  from  the 
side  toward  the  front  of  the  medulla  oblongata  unite  in  the  middle  Hue  at 
the  lower  border  of  the  pons-varolii  to  form  the  basilar  artery.  This  runs 
forward  along  the  median  line  and  extends  from  the  lower  to  the  upper 
border  of  the  pons,  along  the  median  groove  in  which  it  lies  under  cover  of 
the  arachnoid.  At  the  upper  border  of  the  pons  it  divides  into  the  two  pos- 
terior cerebral  arteries.  The  vertebral  arteries  within  the  skull  send  off  a 
small  artery  to  the  dura  mater  known  as  the  posterior  meningeal.  They 
send  off  also  spinal  arteries  and  numerous  small  arteries  which  are  known 
as  bulbar  branches,  which  supply  the  medulla  oblongata.  The  vertebral 
arteries  also  give  off  the  inferior  cerebellar  artery  which  supplies  the  infe- 
rior surface  of  the  cerebellum.  The  basilar  artery  gives  off  transverse 
arteries  on  each  side  which  pass  outward,  supplying  the  pons,  and  it  gives 
off  also  the  anterior  and  the  superior  cerebellar  arteries. 

Veins.     I  have  already  stated  that  the  blood  from  the  convexity  and  me- 


PLATE 


A.  cer.  ant. 


A.  carotis. 

.  A.  cer.  med. 

R.  commun.  post. 

A.  cer.  post. 


Diagram  showing  the 
central  arteries  and  effects 
of  rupture  or  obliteration 
of  them  and  of  the  posterior 
cerebral  arteries.  O.  Soft- 
ening of  occipital  convolu- 
tions from  involvement  of 
posterior  cerebral  ;  Hem- 
ianopsia, Word-blindness, 
Hemiansesthesia  ?  C  C. 
Crura  cerebri,  involvement 
of  posterior  communicat- 
ing and  posterior  cerebral. 
O  T.  Optic  thalamus,  mainly  supplied  by  posterior  cerebral  and  post-communicating.  C  O. 
Corpora  quadrigemina,  mainly  supplied  by  posterior  cerebral.  C.  Corpus  callosum,  mainly 
supplied  by  anterior  cerebral.     C  vS.  Corpora  striata,  supplied  by  lenticular-striate  arteries. 


Fig.   2. 


A.  cereb.  med- 

R.  conim.  post 

A.  cer.  post 

A.  cbell.  sup_ 
A,  basil 
cbell.  inf.  ant. 
A.  audit. 
A.  verteb 


A.  spinal,  ani 


Showing  t^ie  arteries  at  the  base  of  the  brain.      (After  Merkel.) 


FOCAL  DISEASES  OF  THE  BBAIX.  449 

dian  surface  of  the  cerebral  hemispheres  passed  into  veins  which  had  a  direc- 
tion upward  and  forward,  and  Avhich  finally  emptied  into  the  longitudinal 
sinus.  These  veins  are  known  as  the  super-cerebral  veins.  The  blood  from 
the  inferior  and  lower  surfaces  of  the  hemispheres  enters  veins  which  pass 
to  the  cavernous,  superior  petrosal,  and  lateral  sinuses.  One  of  these  ves- 
sels is  particularly  large,  and  is  known  as  the  middle  cerebral  or  Sylvian  vein  ; 
it  runs  along  the  fissure  of  Sylvius  to  end  in  the  cavernous  sinus,  and  collects 
blood  from  the  frontal,  parietal,  and  temporal  lobes.  The  blood  from  the 
central  arteries  may  be  said  in  general  to  pass  into  veins  which  are  in  connec- 
tion with  the  veins  of  Galen,  or  the  Galenic  system,  and  which  end  in  the 
straight  sinus.  The  blood  from  the  cerebellum  j)asses  into  the  superior 
cerebellar  veins  which  run  to  the  straight  sinus  and  the  veins  of  Galen  in 
part,  and  in  part  to  the  superior  petrosal  and  lateral  sinuses.  On  the  under 
surface  of  the  cerebellum  the  blood  j)asses  into  the  inferior  cerebellar  veins, 
which,  together  with  the  veins  from  the  medulla  oblongata  and  pons,  carry 
blood  into  the  inferior  petrosal,  lateral,  and  occipital  sinuses. 

General  Facts  Regarding  the  Circulation  in  the  Brain.  The  size  of  the 
different  trunks  of  the  brain  arteries  is  a  matter  which  has  been  studied  by 
various  authors.  Bevan  Lewis,  investigating  the  average  diameters  in  45 
cases  of  the  insane,  found  that  the  right  vertebral  had  an  average  diameter 
of  3.147  mm.  ;  the  left,  3.42  mm.  The  diameter  of  the  basilar  was  3.82 
mm. ;  of  the  right  carotid,  3.951  mm. ;  of  the  left,  4.002  mm.;  the  right  middle 
cerebral,  3.133  mm. ;  and  the  left,  3.55  mm.  The  diameter  of  the  internal 
carotids  is  given  by  Gerhardt  as  4  mm. ;  that  of  the  vertebrals,  as  3.5  mm. 
Lowenfeld  has  found  that  often  the  width  of  the  brain  vessels  rises  and  falls 
with  the  width  of  the  aorta,  and  that  not  rarely  abnormally  small  brain  arter- 
ies occur  in  otherwise  well-developed  arterial  systems.  JEe  finds  also  that 
the  left  carotid  is  usually  wider  than  the  right. 

The  pressure  in  the  internal  carotid  arteries  is  estimated  by  Geriiardt  to 
be  about  150  mm.  Mendel  finds  exjDerimentally  that  the  pressure  in  the 
central  or  striate  arteries  is  not  much  less  than  that  in  the  carotids,  while 
the  j^ressure  in  the  cortical  arteries  is  very  materially  less.  Mendel's  inves- 
tigations, however,  were  made  with  an  artificial  system  of  vessels,  and  it  is 
doubtful  if  they  can  be  strictly  applied  to  the  living  subject. 

Etiology.  Age.  It  is  generally  conceded  that  at  the  time  of  birth  and 
during  the  first  two  years  of  life  there  is  a  considerable  predisposition  toward 
intra-cranial  hemorrhages.  Gowers  states  that  among  1000  persons  living 
in  the  first  decade  of  life  1.8  will  have  an  intra-cranial  hemorrhage.  In  a 
table  showing  the  annual  number  of  deaths  from  apoplexy,  including  hemor- 
rhage and  acute  softening,  in  the  city  of  New  York  from  1866  to  1893 
inclusive — a  table  which  was  kindly  furnished  me  by  the  New  York  City 
Board  of  Health — I  find  that  in  the  first  year  of  life  the  deaths  from  apo- 
plexy range  from  15  to  20  in  a  population  of  one  and  a  half  millions.  For 
example,  in  1868,  among  a  total  of  356  cases  of  apoplexy,  15  occurred 
during  the  first  year  of  life.  In  1886  there  were  20  cases  in  a  total  of  762, 
and  in  1893,  18  cases  in  a  total  of  1171.  This  mortality-rate  drops  very 
rapidly  after  the  first  year,  so  that  by  the  fourth  year  there  were  often  no 
cases  of  apoplexy  reported,  and  practically  none  began  to  occur  until  after 
the  fifteenth  year.  The  number  of  deaths  from  apoplexy,  then,  begins  to  rise 
very  rapidly  after  the  twenty-fifth  year,  and  reaches  its  maximum  in  the 
decade  between  forty-five  and  fifty-five.  It  then  gradually  sinks  to  the 
eighty-fifth  year,  after  which  very  few  cases  occur.  The  statistical  tallies 
obtained  from  boards  of  health  show  pretty  accurately  the  numlDcr  of  deatlis 
from  intra-cranial  hemorrhage  in  the  first  year  of  life ;  but  after  that  time 
they  are  of  less  value,  because  distinctions  between  hemorrhage  and  soften- 

29 


450  J^EBVOUS  DISEASES  A^D  THEIR  TREATMENT. 

ing  are  not  made.  In  a  statistical  table  of  forty-five  cases  of  cerebral  hemor- 
rhage, prepared  by  myself,  I  found  that  the  greatest  number  of  cases  occurred 
between  the  ages  of  thirty-one  and  fifty,  and  these  may  be  considered  as  the 
apoplectic  decades.  My  own  table  includes  only  hemorrhages  of  the  central 
arteries ;  the  cases  of  meningeal  hemorrhage  are  excluded  for  the  reason 
that  many  of  them  are  traumatic,  and  cannot  be  fairly  introduced : 

Central  Hemorrhages,  Including  Mid-  and  Hind-brain. 

Age.  Cases. 

10  to  20 1 

21  "  30 6 

31  "  40 10 

41  "  50 9 

51  "  60 6 

64  "  70 8 

71  "  80 5 

Total 45 

The  age-curve  of  cerebral  hemorrhage,  then,  starts  rather  high,  drops 
during  the  first  year  of  life  rapidly,  sinks  almost  to  a  normal  line  until  the 
age  of  fifteen,  gradually  rises  to  the  age  of  twenty-five,  and  reaches  its 
height  at  the  age  of  forty-five  to  fifty-five,  then  sinks  gradually  to  the  age  of 
seventy-five,  after  which  time  cerebral  hemorrhages  rarely  occur.  This  age- 
curve  diflers  somewhat  from  that  given  by  the  French  observer,  Gintrac,  and 
places  the  maximum  period  somewhat  earlier  than  that  given  by  Gowers  ;  it 
is  correct,  however,  at  least  for  the  locality  of  New  York.  It  is  possible 
that  in  rural  and  more  temperate  neighborhoods  hemorrhages  occur  some- 
what later  in  life. 

Sex.  Hemorrhage  occurs  oftener  in  men  than  in  women,  and  the  propor- 
tion of  males  in  my  experience  is  greater  than  that  given  by  other  observers, 
namely,  «about  two  to  one. 

As  to  raee,  1  do  not  know  that  any  statistics  have  been  collected  which 
will  have  a  very  wide  range  of  value.  In  a  statistical  report  of  the  Mutual 
Life  Insurance  Company,  prepared  by  Dr.  Winston,  and  covering  a  long 
period  of  years,  it  was  shown  that  diseases  of  the  heart  and  bloodvessels 
and  apoplexy  occurred  rather  more  frequently  in  the  English  race.  In 
this  city  it  occurs  more  frequently  in  the  Irish  race,  but  this  is  doubtless  due 
to  the  preponderance  of  that  nationality  in  our  drinking  population. 

Occupation.  It  is  frequently  stated  that  occupations  calling  for  excessive 
muscular  strain  tend  to  predispose  to  apoplexy ;  this,  however,  is  not  in 
accordance  with  my  experience.  Apoplexies  occur,  to  be  sure,  in  coachmen 
and  drivers,  and  sometimes  in  laboring  men  ;  but,  on  the  whole,  they  are 
found  more  frequently  among  mechanics  and  artisans,  salesmen,  and  those 
who  lead  a  more  or  less  in-door  life,  accompanied  with,  if  anything,  only 
moderate  exertion. 

Climate.  Cerebral  hemorrhage  is  more  frequent  in  temperate  than  in 
tropic  climes,  more  common  in  winter  than  in  summer. 

Hereditary  Influence.  Undoubtedly,  there  is  a  hereditary  influence  in  a 
small  proportion  of  cases.  This  influence  is  shown  in  a  tendency  to  arterial 
and  renal  diseases,  rather  than  in  a  distinct  inheritance  of  apoplectic  attacks. 

Alcoholism.  Of  all  the  single  predisposing  causes  to  hemorrhage  chronic 
alcoholism  takes  the  first  rank.  The  excessive  indulgence  in  alcohol  for  a 
number  of  years  produces  arterial  disease,  thickening  of  the  meninges,  and 
atrophy  of  the  brain,  with,  in  many  instances,  a  terminal  condition  of 
cerebral  hemorrhage.  The  moderate  indulgence  in  alcohol  in  persons  not 
especially  predisposed  to  arterial  disease  has  no  particular  influence  in  lead- 
ing to  apoplexy. 


FOCAL  DISEASES  OF  THE  BBAIN.  451 

The  use  of  tobacco  I  have  fouud  in  two  cases  to  have  acted  as  an  apparent 
predisiDOsing  cause,  but  no  general  statement  can  be  made  as  to  the  specific 
effect  of  tobacco  as  a  factor  in  predisposing  to  cerebral  hemorrhage ;  on  the 
contrary,  its  moderate  use  would  perhaps  have  the  opposite  effect,  on  account 
of  its  tendency  to  relax  the  vasomotor  tonus.  Gout  is  a  predisposing  cause, 
but  rheumatism  is  not. 

Next  to  alcohol,  syjjhilis  is  perhaps  the  most  potent  factor  in  predisposing 
to  cerebral  hemorrhage,  although  it  much  more  often  leads  to  thromboses 
and  softening  than  to  rupture  of  the  vessels.  Among  179  cases  of  apoplexy 
I  found  sypnilis  to  be  present  in  about  one-fourth  of  the  cases.  Among 
these,  however,  there  was  a  large  number  of  acute  softenings,  so  that  I  esti- 
mate syphilis  to  be  the  cause  of  less  than  one-sixth  of  the  total  number  of 
cases  of  cerebral  hemorrhage. 

The  bloodvessels  of  the  brain  sometimes  rupture  as  a  consequence  of  the 
fatty  changes  produced  in  the  walls  by  acute  infectious  fevers,  so  that  we 
may  have  intra-cranial  hemorrhage  following  scarlatina,  measles,  whooping- 
cough,  etc.,  though  these  are  rather  rare  sequelae.  Cerebral  hemorrhage  also 
sometimes  complicates  attacks  of  pupura  hemorrhagica  and  scurvy. 

The  exciting  causes  of  intra-cranial  hemorrhage  are  sometimes  violent 
exertion,  such  as  lifting  a  heavy  weight,  straining  at  stool,  or  it  occurs  as  the 
result  of  great  mental  excitement,  and  in  coitus ;  still,  the  great  majority  of 
cases  are  not  brought  on  in  this  way.  The  vessels  often  rupture  while  a 
person  is  engaged  in  eating,  or  talking,  or  walking  quietly.  In  my  experi- 
ence, bloodvessels  do  not  rupture  during  sleep,  as  is  often  supposed,  the 
attacks  of  apoplexy  occurring  during  sleep  being  almost  always  due  to 
thrombosis  and  softening.  One  of  the  most  frecjuent  exciting  causes  is 
indulgence  in  alcohol,  and  it  is  a  common  exjjerieuce  in  hospitals  to  have 
patients  brought  in  who  are  both  drunk  and  hemiplegic,  the  hemiplegia  being 
the  termination  of  some  debauch.  Falls  and  blows  on  the  head  may  alsa 
be  considered  as,  at  times,  causes  of  intra-cranial  hemorrhage,  although  in 
most  instances  the  hemorrhage  is  in  these  cases  due  to  rupture  of  meningeal 
vessels. 

Symptoms.  The  immediate  symptoms  of  an  attack  of  apoplexy  vary 
somewhat  in  accordance  with  the  extent  and  location  of  the  hemorrhage. 
In  an  ordinary  case  of  cerebral  hemorrhage  the  phenomena  are  somewhat 
as  follow^s :  The  patient  is  often  feeling,  at  the  time  of  the  occurrence,  quite 
well ;  in  some  instances,  however,  his  attack  is  preceded  by  sensations  of  ftil- 
ness  in  the  head,  perhaj)s  slight  nose-bleed,  sometimes  a  somewhat  persistent 
headache.  He  may  have  had  insomnia  for  a  few  nights,  or  disturbed  sleep 
and  bad  dreams,  and  may  have  suffered  from  feelings  of  numbness  and  prick- 
ling in  one  side  of  the  body.  These  premonitory  symptoms,  however,  are 
much  more  frequently  associated  with  thrombosis  and  softening  than  they 
are  with  intra-cranial  hemorrhage.  With  or  without  such  premonitory  symp- 
toms, the  patient  suddenly  experiences  a  feeling  of  fulness  and  dizziness  in 
the  head,  and  then  falls  down  unconscious.  He  is  lifted  into  the  bed,  and 
then  found  to  be  suffering  with  a  pai'alysis  of  one  side  of  the  body ;  this 
paralysis  involving  the  arm  and  leg,  and  to  some  extent  the  face.  The  eyes 
are  partly  closed ;  the  face  is  flushed ;  the  heart  beats  slowly  (50  to  60  per 
minute)  ;  the  pulse  feels  hard  and  full ;  the  carotids  can  be  distinctly  felt,  and 
perhaps  seen  throbbing  in  the  neck ;  the  respiration  is  slow  and  stertorous. 
On  the  paralyzed  side  the  cheek  is  blown  out  with  each  expiration.  On  lift- 
ing the  paralyzed  arm  it  falls  helpless  to  the  side,  and  if  the  leg  is  drawn  up 
it  also  drops  down  limply  upon  the  bed  again.  On  pricking  or  pinching  the 
patient  some  manifestation  of  consciousness  is  shown  ;  the  leg  may  l)e  jerked 
up  slowly,  but  the  arm  often  remains  helpless,  and  the  patient  simply  carries 


452 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  sound  arm  over  aud  tries  to  j)usli  awa)^  the  hand  of  the  person  who  is 
producing  the  painful  irritation.  The  pupils  of  the  eyes  are  generally  con- 
tracted and  rather  immobile,  and  one  pupil  may  be,  and  often  is,  a  little  larger 
than  the  other,  the  jDupil  being  more  contracted  on  the  sound  side  than  on  that 
which  is  paralyzed.  On  taking  the  temperature  in  the  rectum  it  may  be  found 
that  it  has  fallen  two  or  thi'ee  degrees,  being  96°  or  97°  F.,  though  this  is  not 
always  the  case  ;  in  four  or  five  hours  it  will  be  found  about  normal,  or  a  degree 
higher  than  normal,  and  it  continues  thus  for  twelve  or  twenty-four  hours  after 
the  onset  of  the  disease.  It  will  be  about  one  degree  higher  on  the  paralyzed 
side  than  on  the  sound  side.     (See  Fig.  115.)     The  patient  may  continue  in 

Fig.  115. 


Case  I. 


Case  II. 


DAY 

99 

100° 

101° 

102" 

103' 

1^^ 

F 

ftx.y^.R 

K^ 

2Nt) 

_,.. 

_ll 

yxH 

\^ 

'-■-'- 

'     " 

1 

1ST 

R 

W^ 

-t* 

W.. 

..«.■ 

flX. 

2N0 

^ 

fjnr 

"T-'"-^- 

3H0. 

V 

X 

jrH. 

■^ 

^^ 

7 

gTH 

/. 



3flo 

R  fl 

X 

L.A 

< 

4TH 

„^ 

__ 

Case  III. 


Showing  unilateral  temperature  in  cerebral  hemorrhage.    The  first  patient  had.  a  difference  of  2°  F. 
on  second  day ;  the  second  a  nearly  similar  difference  on  third,  fourth,  and  fifth  days. 


this  comatose  or  semi-comatose  condition  for  several  hours  or  a  day ;  he 
gradually,  however,  becomes  more  conscious,  recognizes  friends,  answers 
simple  questions,  begins  to  swallow  food,  and  shows  a  general  improve- 
ment in  symptoms.  At  the  end  of  twenty-four  hours  he  may  be  able  to 
move  the  leg  a  little,  and  perhaps  the  arm.  The  breathing  is  less  stertorous, 
and  the  pulse  has  become  more  rapid,  and  regular  and  softer.  Within 
three  days,  if  the  patient  is  going  to  recover,  he  will  have  regained  largely 
his  consciousness,  and  with  it  some  slight  mobility  on  the  affected  side. 
With  returning  consciousness  it  may  be  found  that  there  is  loss  of  sensation 
upon  the  paralyzed  side,  but  this  is  rarely  complete  unless  the  hemorrhage 
is  a  most  severe  one.  By  the  third  day  the  apoplectic  patient  begins  to  show 
evidences  either  of  a  recovery  from  the  attack  or  a  fatal  issue.  In  the  former 
case  there  is  a  subsidence  of  the  tendency  on  the  part  of  the  temperature  to 
rise,  both  in  the  rectum  and  on  the  paralyzed  side ;  in  other  words,  the  uni- 
lateral disturbance  of  temj^erature  becomes  less,  consciousness  gradually  re- 
tui-ns,  and  the  patient  is  able  to  sj^eak,  to  describe  his  condition,  and  to 
understand  the  conversation  addressed  to  him.  The  paralysis  improves 
slightly,  although  it  still  remains  very  considerable,  and  by  this  time  there 


FOCAL  DISEASES  OF  THE  BRAIN.  453 

may  be  a  slight  increase  in  the  dee])  reflexes  of  the  affected  side.  The  pulse 
becomes  normal,  the  pupils  even,  the  patient  swallows  and  digests  his  food. 
There  is  a  steady  improvement  in  all  symptoms,  until  at  the  end  of  from 
four  to  six  weeks  he  has  reached  a  very  considerable  degree  of  recovery.  At 
this  period  he  enters  upon  what  might  be  called  the  chronic  stage,  which  I 
will  describe  later.  In  cases  in  which  the  lesion  is  in  the  left  hemisphere  the 
patient  has  a  disturbance  in  the  faculty  of  language,  known  as  aphasia ;  he 
is  unable  to  express  his  ideas,  although  he  understands  what  is  said  to  him  ; 
or,  on  the  other  hand,  he  may  be  able  to  talk  a  little,  but  he  skips  various 
words  and  puts  them  together  wrongly,  and  is  in  a  condition  which  is  known 
as  paraphasia ;  or,  finally,  he  may  be  able  to  talk  intelligently,  and  express 
his  wants  by  writing,  but  he  is  unable  to  understand  what  is  said  to  him, 
and  is  unable  to  read.  This  condition,  which  is  known  as  sensory  aphasia, 
is  often  associated  with  some  degree  of  anaesthesia  on  the  paralyzed  side,  and 
with  some  hemianopsia.     (See  article  on  Aphasia,  page  432.) 

If  the  patient  at  the  end  of  the  third  day  does  not  begin  to  improve,  new 
symptoms  develop.  His  temperature  begins  to  rise  again  until  it  may  reach 
in  a  few  days  102°  or  103°,  being  still,  as  a  rule,  a  little  higher  on  the  par- 
alyzed side.  He  becomes  unconscious  again,  or  lies  in  a  state  of  muttering 
delirium,  being  restless,  throwing  his  sound  limbs  about,  pressing  his  hand 
to  his  head,  apparently  suffering  from  pain.  He  will  often  in  this  condition 
pass  his  feces  involuntarily,  the  mouth  becomes  foul  with  saliva,  and  degluti- 
tion is  often  difficult.  The  restlessness  and  delirium  may  pass  into  a  condi- 
tion of  coma,  and  in  this  state  the  patient  dies  within  four  or  five  days  or  a 
week.  Sometimes  the  patient  lingers  on  a  week  to  ten  days,  but  rarely  over 
this  latter  period  of  time.  In  many  instances,  a  pneumonia  develops  which 
seriously  complicates  the  condition  and  hastens  the  end. 

The  phenomena  of  an  attack  of  apoplexy  vary,  as  I  have  already  stated, 
in  accordance  with  the  extent  and  location  of  the  hemorrhage ;  but  when  the 
hemorrhage  is  extensive  it  usually  breaks  into  the  ventricles,  and  then  is 
almost  uniformly  fatal,  and  the  symptoms,  when  this  occurs,  are  those  which 
I  have  just  described  as  being  characteristic  of  an  ordinary  fatal  attack  of 
hemorrhagic  apoplexy. 

Si^ecial  Symptovis  in  Accordance  luith  Location  of  Hemorrhage.  When  the 
lesion  is  in  the  frontal  lobe  there  are  at  first  the  usual  symptoms  of  an 
attack  of  apoplexy,  but  without  very  much  hemiplegia.  The  patient  gradually 
recovers  from  unconsciousness,  and  is  found  to  have  only  a  moderate  degree  of 
paralysis.  This  rapidly  improves,  and  if  then  the  hemorrhage  does  not  ex 
tend  he  may  gradually  come  out  of  the  attack  with  comparatively  slight 
motor  disturbance.  In  many  cases,  however,  the  hemox-rhage  in  the  frontal 
lobe  gradually  extends  back,  so  that  in  a  day  or  tw^o  hemiplegia  does  come 
on,  or  the  blood  breaks  into  a  lateral  ventricle,  producing  a  severer  apo- 
plectic state  than  existed  at  first.  Frontal  lobe  hemorrhages  may  therefore 
iDclong  to  that  class  of  cases  in  which  patients  have  what  is  first  considered 
a  mild  apoplectic  attack  with  a  later  severe  and  fatal  recurrence  of  it. 

Sometimes  the  hemorrhage  occurs  in  the  occijyital  und  back  part  of  the^^orte- 
tal  lobes.  In  that  case  the  hemiplegia  is  not  very  marked,  and  the  leg  is  more 
affected  than  the  arm  or  face.  There  is  with  this  condition  also  a  good  deal 
of  hemianresthesia,  and,  perhaps,  hemiataxia.  If  the  lesion  is  on  the  left 
side  there  is  a  disturbance  of  the  mechanism  of  language,  causing  aphasia. 
A  test  of  the  field  of  vision,  if  it  can  be  made,  often  shows  a  hemianopsia. 
Hemorrhages  of  this  kind  are  rare  ;  the  pathological  condition  being  usually 
thrombosis. 

In  some  cases  hemorrhages  occurring  in  any  part  of  the  cerebrum  burst 
through  the  cortex,  and  the  blood  is  })()ured  out  into  the  suliaraclmoid  and 


454  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

arachnoid  cavities.  If  this  occurs  convulsions  almost  invariably  result,  and 
these  convulsions  involve  chiefly  the  side  opposite  the  lesion.  A  case  of 
apoplexy,  therefore,  which  is  complicated  in  a  day  or  two  by  an  attack  of 
unilateral  convulsions  is  probably  one  in  which  the  hemorrhage  has  burst 
through  the  cortex. 

Sometimes  the  hemorrhage  attacks  especially  the  j^o.sie^^ior  basal  ganglia, 
destroying  the  optie  thalami  and  parts  of  the  tubercula  quadrigemina.  If 
this  is  the  case,  and  particularly  if  the  quadrigemina  are  affected,  there  will 
be  paralysis  of  some  of  the  eye-muscles,  with  ptosis  and  contraction  or  dila- 
tation of  the  pupils  ;  also  hemianesthesia  and  some  hemiplegia.  Such  cases 
are  usually  promptly  fatal. 

Ingravescent  Apojjlexy.  There  is  a  form  of  cerebral  hemorrhage  which  has 
been  described  as  having  a  special  symptomatology,  and  is  known  as  ingra- 
vescent or  progressive  aj^oplexy.  Dr.  Broadbent  first  reported  six  case  of 
this  type,  and  later,  cases  have  been  reported  by  Puesch,  Mills,  MacBride, 
and  myself.  In  this  form  of  apoplexy  the  patient  is  siezed  with  sudden 
headache  and  vertigo,  sometimes  with  vomiting,  but  without  loss  of  con- 
sciousness. Complete  hemiplegia  with  hemianesthesia  rapidly  sets  in  ;  in  the 
course  of  twenty-four  hours  the  patient  becomes  somnolent  and  stupid, 
and,  finally,  comatose.  Death  occurs  at  the  end  of  three  to  five  days,  Avith 
characteristic  disturbances  of  respiration  and  with  rise  of  temperature.  In 
this  form  of  ajjoplexy  it  has  been  found  that  the  vessel  ruptured  is  one  of  the 
branches  of  the  external  lenticular  artery  and  that  the  hemorrhage  lies 
mainly  at  first  in  the  external  capsule,  cleaving  forward  and  backward 
through  the  white  matter,  but,  finally,  breaking  into  the  lateral  ventricle. 
The  special  characteristic  of  these  cases  is  that  they  begin  without  loss  of 
consciousness,  and  that  they  steadily  j^rogress,  and  the  special  imjDortance  of 
recognizing  them  lies  in  the  fact  that  if  it  be  possible  by  treatment  to  stop 
the  hemorrhage  the  patient  may  be  saved,  for  the  cases  would  get  well  if  the 
hemorrhage  did  not  finally  break  into  the  lateral  ventricles. 

Cortical  Hemorrhage.  Primary  hemorrhages  into  the  substance  of  the 
cortex  of  the  brain  are  very  rare  unless  they  are  the  result  of  trauma,  and 
if  this  factor  is  present  the  location  of  the  tronble  is  more  easily  determined. 
The  symptoms,  when  the  hemorrhage  is  in  the  cortex,  are  almost  always  those 
of  localized  convulsions,  for  hemorrhages  that  occur  primarily  in  the  cortex 
are  always  small.  Thus,  a  hemorrhage  occurring  into  the  motor  area,  in- 
volving the  arm,  will  be  associated  with  convulsive  movements  of  that  ex- 
tremity. Besides  these  local  convulsions,  however,  the  patient's  conscious- 
ness is  usually  seriously  disturbed ;  he  may,  in  fact,  be  semi-comatose  most 
of  the  time,  this  condition  being  interrupted  by  frequent  local  spasms. 

Pons  Hemorrhage.  Hemorrhages  into  the  j^ons  are  very  rare  and  usually 
small.  They  are  accompanied  with  initial  loss  of  consciousness  and  with 
spasmodic  jerking  movements  of  the  limbs,  more  particularly  of  the  legs. 
The  puj^ils  are  often  contracted  and  the  resj^iration  slow.  There  may  be  some 
disturbance  in  sensation  and  some  hemiplegia ;  there  is  almost  always  a  rise 
of  temperature  from  102°  to  103°  or  104°.  The  hemorrhages  are  usually 
fatal. 

While  hemorrhage  into  the  pons  does  occasionally  occur,  hemorrhage  in 
the  medulla  oblongata  is  very  much  more  rare,  acute  lesions  of  this  part 
being,  as  a  rule,  due  to  obliteration  of  the  arteries  and  softening.  If  the 
hemorrhage  in  these  parts  is  in  anywise  considerable,  death  rapidly  ensues ; 
if  only  moderate  in  amount,  there  is  even  then  serious  disturbance  in  the 
functions  of  the  cranial  nerves,  producing  paralysis  of  the  throat  and  tongue 
muscles  and  disturbances  in  circulation  and  respiration.  Hemiplegia  and 
hemiansesthesia  also  occur. 


FOCAL  DISEASES  OF  THE  BBAIN.  455 

Hemorrhage  into  the  cerebellum  is  not  very  uncommon,  but  its  recognition 
is  difficult.  Loss  of  consciousness  occurs  almost  invariabl}',  and  there  may- 
be hemiplegia,  but  this  is  not  always  the  case.  Very  often  the  patients 
simply  lie  in  a  state  of  profound  coma,  with  stertorous  respiration  and  con- 
tracted pupils.  Vomiting  occurs  in,  it  is  said,  half  the  cases ;  but  I  have 
never  observed  it,  nor  has  it  been  noted  in  any  of  the  patients  brought  to 
Bellevue  Hospital.  Cerebellar  hemorrhages  are  apt  to  burst  into  the  fourth 
ventricle  and  produce  death. 

Meningeal  hemorrhages  are  considered  elsewhere.  (See  page  362.) 
The  relative  frequency  with  which  different  parts  of  the  brain  are  affected 
by  hemorrhage,  as  shown  by  my  statistics,  is  as  follows  :  First,  hemorrhages 
involving  the  basal  ganglia  and  breaking  into  the  ventricles.  Next  in  order, 
hemorrhages  involving  the  corpus  striatum  and  vicinity.  Next,  hemorrhages 
of  the  meninges ;  then  hemorrhages  into  the  cerebellum,  and  last,  in  about 
equal  order  of  frequency,  hemorrhages  into  the  optic  thalamus,  corpora 
quadrigemina,  and  pons  varolii.  In  fifty  cases  of  intra-cranial  hemorrhages 
the  various  localities  were  involved  in  the  following  frequency : 

Meningeal : 

Pachymeningeal 7 

Pial  and  cortical     ....  .  ....      7 

—  14 
Central : 

Ventricular 23 

Corpus  striatum  and  vicinity 7 

Optic  thalamus 1 

Corpora  quadrigemina 1 

—  32 

Pons 1 

Cerebellum 3 

Total 50 

Symptoms  of  the  Chronic  Stage — Hemiplegia.  About  two-thirds  of  the  per- 
sons who  are  attacked  with  cerebral  hemorrhage  recover  from  the  immediate 
effects.  After  passing  through  the  symptoms  that  ai'e  connected  with  the 
attack  they  gradually  improve,  and  at  the  end  of  from  four  to  eight  weeks 
enter  upon  what  is  termed  the  chronic  stage  of  the  disease.  The  patient  is 
then  commonly  spoken  of  as  a  sufferer  from  hemiplegia  or  a  "hemij^legic," 
since  hemiplegia  is  the  striking  and  important  symptom  in  the  case.  The 
paralysis  which  had  at  first  affected  the  whole  of  one  side,  so  that  the 
patient  was,  perhaps,  barely  able  to  move  the  arm  and  leg,  has  now  become 
so  much  diminished  that  he  can  walk  and  use  this  arm  somewhat,  while  the 
face  seems  almost  entirely  well.  The  paralysis,  in  almost  all  cases,  disapj^ears 
to  the  greatest  extent  from  the  face,  so  that  it  can  only  be  detected  by  a  close 
inspection  of  the  facial  movements,  there  being,  perhaps,  a  slight  diminution 
in  the  innervation  of  the  lower  muscles  of  the  face,  and  the  angle  of  the 
mouth  on  the  affected  side  being  a  little  lower  than  that  on  the  sound  side. 
Protrusion  of  the  tongue  will  sometimes  show  a  deviation  slightly  toward  the 
affected  side.  The  control  of  the  orbicularis  palpebrarum  and  muscles  of 
the  forehead  is  never  much  disturbed,  and  now  shows  no  disturbance  at 
all.  In  very  old  cases  a  certain  amount  of  contracture  ma}"  set  in,  so  that 
the  angle  of  the  mouth  on  the  affected  side  is  drawn  up,  and  when  the  patient 
laughs  the  face  is  pulled  over  toward  the  paralyzed  side.  This  phenomenon 
is  particularly  frequent  in  hemiplegia  occurring  in  children.  The  paralysis 
improves  next  in  amount  in  the  leg;  the  patient  is  able  to  stand  upon  the 
once  paralyzed  limb ;  he  can  easily  extend  the  foot,  but  flexes  it  with  more 
difficulty.  Flexion  and  extension  of  the  leg  are  less  perfect,  while  the 
control  of  the  thigh  muscles  is  most  limited  of  all,  not  because  there  is  a 
great  degree  of  paralysis,  but  on  account  of  the  stiffness  of  the  part.  Tlie 
arm  recovers  least.     The  patient  is  able  to  swing  the  arm  as  a  whole  for- 


456 


NERVOUS  DISEASES  AND  THEIR  TREAIMENT. 


ward  and  backward,  but  he  can  raise  it  but  slightly ;  he  can  flex  the  f  oreann 
and  extend  it  with  a  fair  degree  of  strength.  The  movements  of  the  fingers 
and  hand  are  imperfect.     Flexion  is  fairly  well  preserved,  and  the  patient 


Diagram  showing  the  secondary  degeneration  which  occurs,  a  cerebral  hemorrhage  or  softening, 
and  which  follows  the  course  of  the  motor  tracts  into  the  spinal  cord.  H,  site  of  lesion.  The  con- 
tinuous lines  are  fibres  going  to  the  legs,  the  dotted  are  those  going  to  arms  and  motor  cranial 
nerves.    (Modified  from  Van  Gehuchten.) 

can  grasp  things,  holding  a  cane  or  a  table  utensil  often  with  a  certain 
degree  of  ease ;  extension  of  the  fingers,  however,  is  very  weak  and  so  also  is 
supination,  pronation  being  fairly  well  retained.     It  will  be  seen  in  examin- 


FOCAL  DISEASES  OF  THE  BRAIN. 


457 


Fig.  117. 


ing  cases  of  chronic  hemiplegia  that  it  is  the  extensor  muscles  of  the  toes  and 
leg  and  thigh,  also  the  extensors  of  the  fingers,  hand,  arm,  and  upper  arm 
which  are  more  involved. 

The  paralysis  in  both  arm  and  leg  is  made  very  much  more  marked  by  the 
supervention  of  what  is  known  as  secondary  rigidity  and  contractures.  Both 
the  rigidity  of  the  muscles  and  the  contractures  are  due  to  the  gradual  degen- 
eration of  the  voluntary  motor  tract  in  the  brain  and  of  the  direct  and  crossed 
pyramidal  tracts  in  the  cord  (Fig.  116).  The  effect  of  this  degeneration  is 
to  lessen  the  inhibitory  activities  of  the  higher  cerebral  centres,  and  as  a 
result,  an  excessive  amount  of  action  is  brought  to  play  upon  the  flexor 
groups.  As  time  goes  on,  what  was  at  first  simply  stiffness  and  rigidity  in 
the  affected  parts  becomes  a  fixed  condition  of  contraction,  or,  as  it  is  more 
commonly  called,  contracture.  These  contractures  affect,  as  I  have  said,  the 
flexor  groups,  causing  the  toes  to  be  drawn  down,  the  heel  to  be  elevated, 
and  the  foot  extended,  the  leg  to  be  flexed  slightly  upon  the  thigh  and  the 
thigh  slightly  upon  the  trunk.  In  the  arm  the  same  process  causes  a  ten- 
dency of  the  fingers  to  close  upon  the  palms,  of  the 
wrist  and  forearm  to  be  fiexed,  and  of  the  upper  arm 
to  be  held  down  next  to  the  trunk.  There  is  finally 
produced  a  condition  of  paralysis  and  contracture 
which  gives  to  the  attitude  and  gait  of  the  patient 
a  characteristic  appearance  (see  Fig.  117).  He  walks 
slowly,  swinging  the  toe  of  the  paralyzed  side  out,  so 
that  it  scrapes  the  floor,  forming  the  arc  of  a  circle  as 
he  goes  along.  The  arm  is  held  to  the  side,  the  hands 
are  closed,  the  body  is  also  slightly  bent  forward,  and 
the  position  may  be  considered  as  one  of  very  greatly 
exaggerated  senility.  The  muscles  of  the  trunk  are 
very  slightly  affected  in  hemiplegia,  although  in  the 
early  stages  some  disturbance  may  be  noticed.  This 
is  due  to  the  physiological  law  that  all  muscles  which 
act  stjnchronoiisly  iipon  symmetrical  joarts  are  inner- 
vated by  each  side  of  the  brain.  Thus  the  respiratory 
muscles  of  the  chest  and  abdomen  are  innervated  on 
each  side  by  centres  in  each  half  of  the  brain,  and 
when  the  centre  in  one  cerebral  hemisphere  is  de- 
stroyed the  function  is  assumed  by  the  centre  on  the 
other  side.  It  has  been  shown,  however,  by  recent 
researches,  that  the  pyramidal  or  motor  tracts  do  not 
supply  the  opposite  half  of  the  body  exclusively,  but 
that  some  fibres  go  to  the  muscles  of  the  same  side. 
As  the  result  of  this  there  is  always  in  hemiplegia  a 
certain  amount  of  impairment  of  power  even  upon 
the  sound  side. 

Along  with  the  paralysis,  rigidity  and  contractures 
which  I  have  described,  there  develops  the  condition 

of  exaggeration  of  the  deep  reflexes.  The  jDatella  tendon  reflex,  the  triceps 
reflex,  and  the  Achilles  tendon  reflex  are  exaggerated.  Ankle  clonus  can 
be  obtained  in  most  cases.  During  the  acute  stage  of  apoplexy  the  super- 
ficial or  skin  reflexes  are  often  abolished  on  the  paralyzed  side,  but  in  the 
later  stages  they  reappear,  and  become  exaggerated  also.  Scratching  the 
sole  of  the  foot  causes  quick,  jerking  movements  of  the  leg.  Scratching  the 
inner  surface  of  the  thigh  produces  a  contraction  of  the  cremaster,  and  so  on. 

In  a  good  many  cases  there  is  a  slight  amount  of  hemianpesthesia  during  the 
early  stage  of  cerebral  apoplexies,  but  this  almost  invariably  disappears  in  a 


Left  hemiplegia  involving 
face,  arm,  and  leg. 


458  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

few  days,  or  weeks,  and  it  is  rare  that  any  anaesthesia  of  the  cutaneous  or  mus- 
cular senses  is  observed.  Sometimes  patients  with  hemiplegia  suffer  from  pains 
in  the  affected  parts.  These  pains  are  at  times  associated  with  cramp-like  con- 
tractions of  the  arm  or  leg.  In  other  cases  they  are  burning,  tearing,  or  neu- 
ralgic pains,  and  are  due  to  the  fact  that  the  lesion  irritates  some  part  of  the 
sensory  tract  or  sensory  centre  in  the  brain.  In  hemiplegia  of  adults  the  af- 
fected side  does  not  waste  ;  the  muscles,  though  but  little  used,  do  not  become 
smaller  to  any  notable  extent.  This  is  because  the  trophic  centres  for  these 
muscles  lie  in  the  spinal  cord — a  part  that  is  not  affected  in  the  disease. 
Once  in  a  while,  however,  we  find  marked  muscular  atrophy  in  cerebral 
hemiplegia,  though  the  cases  are  so  rare  that  they  may  be  considered  freaks. 
When  atrophy  does  occur  it  is,  I  think,  usually  due  to  the  fact  that  the  motor 
cortex  is  involved.  In  very  bad  cases  of  hemiplegia,  where  the  patient 
remains  so  paralyzed  that  he  is  for  the  most  part  bed-ridden,  some  atrophy 
takes  place,  though  this  affects,  as  a  rule,  both  sides.  In  these  cases  also  there 
may  develop  arthropathies,  that  is  to  say,  a  knee-joint,  or  an  ankle,  or  an 
elbow  may  become  enlarged  and  show  evidences  of  exudation  and  of  prolifer- 
ation of  the  osseous  and  connective  tissues. 

The  patient's  general  bodily  functions  are  usually  carried  on  in  a  fairly 
normal  manner.  There  is  no  great  disturbance  in  digestion  or  in  the  activity 
of  the  kidneys.  The  sphincters  of  the  bladder  and  rectum  also  perform  their 
functions  normally,  although  constipation  is  a  frequent  s3''mptom,  owing  to 
the  enforced  inactivity  of  the  patient.  There  is  no  doubt  that  the  patient's 
general  bodily  vitality  is  somewhat  lowered,  and  he  is  made  somewhat  more 
succeptible  to  the  onset  of  infectious  diseases  or  to  the  effects  of  renal,  hej)atic, 
or  pulmonary  troubles,  which  he  may  have  had  before  the  disease  came  on. 

The  mental  condition  of  hemiplegic  patients  is  a  somewhat  characteristic 
one.  There  is  almost  always  a  slight  degree  of  mental  impairment.  This  is 
shown  in  a  weakness  of  memory  and  in  an  increase  of  emotionality,  so  that 
he  laughs  or  cries  easily,  and  becomes  easily  excited  and  irritable,  or  easily 
depressed.  He  may  suffer  from  insomnia.  In  many  cases,  however,  the 
patient  is  able  to  jDursue  his  former  vocations,  if  they  do  not  greatly  tax  his 
mental  or  physical  powers. 

A  certain  proportion  of  hemiplegics  are  affected  in  the  beginning  with 
disturbances  of  sjDeech  which  are  known  as  aphasia.  This  aphasia  is  always 
associated  with  right  hemiplegia  in  right-handed  persons,  and  is  due  to 
lesions  affecting  the  centres  concerned  in  the  faculty  of  language.  It  is  not 
my  purpose  here  to  describe  the  different  forms  of  aphasia.     (See  page  432.) 

Among  the  rarer  symptoms  of  the  chronic  stage  of  hemiplegia  are  certain 
spasmodic  movements  of  the  affected  side  of  the  body.  These  spasmodic  disturb- 
ances occur  much  more  frequently  in  connection  with  hemiplegia  in  children 
than  in  hemiplegia  in  adults,  but  they  are  occasionally  seen  in  the  latter  class 
of  patients.  The  most  common  of  these  disturbances  is  a  cramp-like  contrac- 
tion of  the  fingers,  hand,  and  arm,  and  also  of  the  lower  extremity.  These 
contractions  occur  in  a  slow,  clonic  spasm,  accompanied  with  much  pain ; 
they  are  in  fact  muscular  cramps  due  to  the  excessive  irritability  of  the 
motor  nerves  and  muscles  of  the  paralyzed  part.  Tremor  is  occasionally 
seen  in  the  arm  and  leg.  When  present  it  is  a  tremor  of  the  coarse  type ; 
that  is  to  say,  the  rhythmical  movements  occur  at  the  rate  of  five  or  six  jjer 
minute,  and  the  tremor  is  one  that  is  usually  increased  upon  voluntary  move- 
ment of  the  part.  It  rarely  affects  the  face,  but  at  times  there  is  a  certain 
amount  of  twitching  of  the  tongue  and  facial  muscles.  Inco-ordinated 
movements  of  the  hemiplegic  side  are  also  observed ;  the  patient,  on  at- 
tempting to  place  the  hand  in  a  certain  position,  or  to  move  it  in  a  certain 
definite  manner,  goes  through  awkward  and  irregular  ataxic-like  motions. 


FOCAL  DISEASES  OF  THE  BEAIN.  459 

The  condition  is  really  an  ataxia  of  the  disordered  limbs,  and  is  due  to  an 
injury  of  the  centres  connected  with  the  muscular  memories.  It  is  very  rare 
indeed  to  find  in  adult  hemiplegics  anything  in  the  nature  of  choreic  move- 
ments. These,  however,  occur  in  infantile  hemiplegia  and  even  in  hemi- 
plegia occurring  in  youth  ;  after  the  age  of  twenty,  however,  the  hemiplegia 
is  practically  never  associated  with  chorea.  The  same  statements  may  be 
made  with  regard  to  the  condition  known  as  athetosis  (vic^e  Athetosis).  Asso- 
ciated movements  are  sometimes  observed  in  hemiplegics.  By  this  is  meant 
that  Avhen  the  patient  tries  to  write,  or  makes  some  definite  movements 
with  the  paralyzed  arm  or  leg,  there  is  at  the  same  time  a  movement  in  the 
arm  or  leg  of  the  sound  side.  The  associated  movements  of  the  sound  side  re- 
semble, in  a  measure,  those  of  the  affected  side.  The  electrical  irritability 
of  the  muscles  in  hemiplegia  is  at  first  somewhat  increased ;  later  it  is  dim- 
inished, but  there  are  no  qualitative  changes  in  the  ordinary  types  of  the 
disease. 

Mirror  writing  is  a  phenomenon  sometimes  seen  in  hemiplegics,  though 
more  common  in  young  children.  A  right-handed  person  who  has  right 
hemiplegia  attempts  to  write  with  the  left  hand  and  finds  that  he  almost  un- 
consciously writes  from  right  to  left,  and  reverses  the  letters  so  that  in  order 
to  read  them  the  sheet  must  be  held  before  a  mirror. 

Different  Types  of  Hemiplegia.  Leg  Sensory  Tijpe.  In  the  pre- 
ceding remarks  I  have  described  the  common  type  of  hemiplegia  following 
an  intra-cranial  hemorrhage.  There  are  certain  forms  which  differ  from 
this  type,  and  which  merit  some  special  attention.  In  one  form  the  paralysis 
affects  the  leg  much  more  than  the  arm  or  face.  The  patient  in  these  cases, 
after  the  attack,  gradually  recovers  the  use  of  the  arm  to  a  very  considerable 
extent,  and  the  face  becomes  entirely  free  from  any  trace  of  paralysis.  The 
leg,  hoAvever,  remains  very  much  weakened,  so  that  the  patient  is  unable  to 
w^alk,  except  with  slowness  and  difficulty.  Rigidity  and  contractures  make 
the  leg  additionally  clumsy  and  useless.  In  these  cases  there  is  often  a  hemi- 
ataxia  with  or  without  a  considerable  anaesthesia  of  the  skin  of  the  afl^ected 
leg,  and  even  of  the  arm,  and  sometimes  there  is  also  a  hemianopsia  and 
aphasia.  Hemiplegias  of  this  leg  type  are  due  to  the  fact  that  the  lesion  is 
situated  more  postei'iorly,  involving  especially  the  leg  fibres  of  the  internal 
capsule,  and  some  of  the  sensory  tract.  It  is  a  comparatively  rare  type,  and 
is  due  to  a  lesion  of  the  lenticulo-optic  arteries. 

Arm.  Type.  In  another  form  of  hemiplegia  one  sees  the  arm  especially 
affected.  In  these  cases  the  patient  walks  fairly  well,  but  the  arm  is  almost 
entirely  powerless,  the  fingers  are  tightly  ffexed  in  the  j)alm,  and  can  with 
difficulty  be  extended.  The  face  is  perhaps  somewhat  affected  also,  and  if 
the  hemiplegia  is  upon  the  right  side  a  motor  aphasia,  often  very  complete, 
accompanies  the  condition.  Here  the  lesion  involves  the  inferior  anterior 
frontal  artery. 

Hemiataxic-aplmsic  Typje.  In  another  class  of  cases  the  hemiplegia  is  very 
slight,  and  can  perhaps  be  detected,  after  a  few  weeks,  only  by  careful  ex- 
amination, but  there  is  with  it  a  disturbance  of  the  faculty  of  language,  if 
the  lesion  is  on  the  left  side.  There  is  often  a  considerable  degree  of  hemi- 
ataxia  and  hemiansesthesia,  and  there  may  be  also  hemianopsia.  The  patients 
in  these  cases  are  usually  unable  to  read,  or  perhaps  unable  to  understand 
spoken  language  ;  they  are  blind  on  one  half  of  each  eye,  on  the  side  corre- 
sponding to  the  paralysis,  and  they  use  their  arms  and  legs  in  a  clumsy  and 
awkward  manner,  due  to  the  aniesthesia  of  the  muscular  sense. 

Alternate  or  Crossed  Hemiplerjia.  This  name  is  given  to  cases  in  which  the 
paralysis  affects  the  arm  and  leg  on  one  side  and  a  cranial  nerve  or  nerves  on 
the  opposite  side.    Alternate  hemiplegia  is  due  usually  to  acute  softening, 


460 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


and  this  in  turn  to  syphilitic  disease  at  the  base  of  the  brain.     (See  also 
Chapter  XXIV.)     The  lesion  is  situated  in  the  crus,  pons  or  medulla. 

When  the  paralysis  involves  the  arm  and  leg  on  one  side  and  the  third 
cranial  nerve  on  the  other,  the  lesion  is  in  the  crus  cerebri,  near  its  junction 
with  the  pons.  This  is  the  most  common  type.  When  there  is  paralysis  of 
the  fifth  (trigeminal)  nerve  on  one  side,  with  hemiplegia  on  the  other,  the 
lesion  is  in  the  j^ons  on  one  side,  and  near  the  ventral  portion.  When  there 
is  paralysis  of  the  seventh  (facial)  nerve  on  one  side,  with  hemiplegia  of  the 
other,  the  lesion  lies  at  the  junction  of  the  pons  and  medulla ;  usually,  the 
sixth  and  eighth  cranial  nerves  are  also  involved. 


Fig.  lis. 


Showing  the  mechanism  of  alternate  hemiplegias.  A  lesion  at  A  causes  complete  hemiplegia  by 
destroying  the  motor  tract.  One  at  M  causes  paralysis  of  third  cranial  nerve  (motor  oculi)  by 
destroying  its  nucleus  or  root  on  same  side,  and  paralysis  of  arm  and  leg  on  opposite  side.  A  lesion 
at  F  causes  facial  palsy  on  same  side,  hemiplegia  on  opposite  side.  In  a  lesion  at  H  the  hypoglossus 
would  be  affected  on  one  side,  with  hemiplegia  on  the  other.    (Modified  from  Edinger). 

The  mechanism  of  this  hemiplegia  is  shown  in  the  accompanying  diagram. 
(Fig.  118.) 

Pathology  and  Pathological  Anatomy.  The  morbid  condition  underlying 
intra-cranial  hemorrhages  which  are  not  due  to  trauma  is  invariably  disease 
of  the  bloodvessels  of  the  brain,  and  in  most  cases  disease  of  the  arteries. 
It  is  impossible  to  rupture  a  healthy  artery  by  any  ordinary  physiological  or 
pathological  disturbance ;  consequently,  the  fundamental  facts  concerning 
the  pathology  of  cerebral  hemorrhage  are  those  Avhich  pertain  to  arterial 


FOCAL  DISEASES  OF  THE  BBAIN.  461 

disease.  An  immense  amount  of  study  and  laborious  investigation  have  been 
put  upon  this  subject,  l)ut  it  has  not  yet  been  entirely  and  satisfactorily 
cleared  up.  It  is  generally  admitted  that  the  cerebral  arteries  are  subjected 
to  three  different  morbid  conditions :  one  of  these  is  that  known  as  fatty 
degeneration ;  the  second  is  that  known  as  a  degenerative  arteritis,  and  the 
third  that  of  atheroma — a  condition  which  really  should  be  classed  along 
with  degenerative  arteritis.  In  addition  to  this,  there  probably  also  exists  at 
times  certain  congenital  weaknesses  or  deficiencies  in  the  coats  of  the  arteries 
or  in  their  size  which  lead  to  their  occlusion  or  ruj)ture.  The  fatty  degenera- 
tion of  the  arteries  of  the  brain  affects,  in  an  important  way,  at  least,  only 
the  small  arterioles.  It  causes  a  weakening  of  the  walls  at  certain  points, 
and  in  consequence  of  this  a  rupture  occurs.  Such  fatty  degeneration  takes 
place  in  marasmic  conditions,  in  leucocyth^emia,  scurvy,  purpura,  and  it 
probably  is  caused  also  by  the  infectious  fevers.  The  toxins  developed 
by  these  diseases  circulating  in  the  blood  appear  at  times  to  cause  a  fatty 
degeneration  and  softening  of  certain  parts  of  the  arterial  walls.  In  septic 
conditions  also  the  microbe  itself  may  be  carried  into  the  brain  and  de- 
posited in  some  small  arteriole,  causing  there  acute  inflammatory  destruction 
of  the  vessel.  Hence  we  find  that  cerebral  hemorrhages  occur  in  connec- 
tion with  all  the  conditions  which  I  have  just  mentioned.  Atheromatous 
degeneration  affects  only  the  larger  vessels,  and  chiefly  those  at  the  base 
of  the  brain ;  it  is  found  in  from  one-eighth  to  one-fifth  of  the  cases  of 
cerebral  hemorrhage.  The  atheromatous  process  lessens  the  elasticity  of 
the  arterial  walls,  and  probably  indirectly  leads  to  cerebral  hemorrhage. 
It  is  not,  however,  uniformly  present,  and  an  extensive  atheroma  of  the 
cerebral  arteries  is  known  to  be  compatible  with  a  long  life.  Arteritis 
in  its  various  forms  is  the  most  frequent  cause  of  the  so-called  idiopathic 
hemorrhages  of  the  brain.  There  is  still  much  discussion  as  to  the  exact 
nature  of  this  process.  While  some  look  upon  it  as  being  originally  a  peri- 
arteritis, others  as  being  originally  an  endarteritis,  still  others  think  that  the 
process  begins  in  the  middle  coats  of  the  vessels.  My  own  conviction,  from 
a  study  of  the  subject  and  from  an  examination  of  specimens,  is  that  the 
original  process,  in  most  cases,  at  least,  is  located  in  the  intima,  that  this  coat 
of  the  vessel  is  destroyed  and  the  arterial  wall  is  thus  weakened.  In  conse- 
quence of  the  strain  and  bulging,  there  is  a  proliferation  of  connective  tissue 
of  the  outer  coat  and  an  apparent  peri-arteritis.  Before  this  peri-arteritis 
occurs,  however,  the  vessel  undergoes  a  certain  amount  of  fusiform  or  sac- 
cular dilatation  in  some  cases,  and  these  dilatations  are  known  as  miliary 
aneurisms.  Their  importance  in  connection  with  cerebral  hemorrhage  was 
first  demonstrated  by  Charcot  and  Bouchard  in  1872.  It  must  be  confessed 
that  there  have  been  very  few  thorough  and  systematic  investigations  subse- 
quent to  those  of  these  authors,  and  that  their  results  have  been,  perhaps,  too 
uniformly  accepted.  While  miliary  aneurism  undoubtedly  is  a  factor,  and 
an  imjjortant  one,  in  cerebral  hemorrhage,  I  feel  sure  that  it  is  not  always 
the  direct  cause  of  it,  and  that  sometimes  vessels  rupture  without  any  notable 
preliminary  dilatation.  The  small,  or  miliary  aneurisms,  range  in  size  from 
one-fifth  to  one  millimetre  in  diameter.  They  are  usually  not  very  numerous, 
but  there  may  be  as  many  as  one  hundred  in  the  brain.  They  occur  almost 
exclusively  during  the  degenerative  period  of  life. 

Along  with  the  causes  of  intra-cranial  hemorrhage  that  I  have  already 
mentioned  there  are  cei'tain  other  rarer  conditions  which  should  l^e  alluded 
to.  Thus  it  may  happen  that  in  the  case  of  a  tumor  of  the  l)rain,  especially 
a  sarcoma,  bloodvessels  rupture  and  hemorrhage  occur.  In  abscess  of  the 
brain  a  cerebral  artery  or  vein  is  sometimes  opened  and  the  patient  dies 


462  NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 

from  a  liemorrliage  into  the  cavity  of  the  abscess.^  Hemorrhages  also  occur 
sometimes  secondarily  to  emboKsm  or  thrombosis.  The  sudden  blocking  up 
of  an  artery  causes  a  necrosis  of  the  parts  supplied  by  it.  There  follows 
a  collateral  hyperemia,  then  a  congestion  of  the  parts  about  the  necrosed 
area,  small  hemorrhages  take  place  or  a  large  vessel  may  rupture. 

In  syphilitic  inflammation  of  the  arteries  of  the  brain  there  may  be  so 
much  arterial  disease  that  one  of  the  vessels  is  weakened  and  is  ruptured. 
More  commonly  in  syphilitic  disease  of  the  brain  and  of  its  arteries  throm- 
bosis is  the  result. 

The  large  majority  of  hemorrhages  of  the  cortical  (pial)  arteries  are  due 
to  trauma.  Idiopathic  hemorrhages,  if  they  occur,  are  always  small  and  of 
slight  imjDortance,  while  traumatic  hemorrhages  are  also  apt  to  be  small  and 
accompanied  with  lacerations  of  the  tissue,  which  are  more  important  than 
the  hemorrhage.  Hemorrhages  into  the  arachnoid  cavity,  which  result  in 
hematoma  of  the  dura,  are  considered  elsewhere.     (See  p.  351). 

Cerebral  hemorrhages  occur  with  very  different  frecjuency  in  different  parts 
of  the  brain.  I  have  already  dwelt  upon  this  point,  however,  in  connection 
with  the  symptomatology,  and  I  showed  there  that  the  parts  most  frequently 
involved  were  those  supplied  by  the  central  arteries  given  off  by  the  middle 
cerebral.  The  order  as  ordinarily  given  of  the  parts  affected  is :  the  central 
ganglia,  then  the  centrum  ovale,  then  the  cortex,  cerebellum,  and  pons.  The 
medulla  oblongata,  crura  cerebri,  and  corpus  callosum  are  almost  always 
spared.  In  traumatic  hemorrhages  the  most  frequent  part  is  that  which  is 
most  exposed  to  injury,  namely  the  convexity  and  the  under  surfaces  of  the 
brain.  Cortical  hemorrhages  are,  as  already  stated,  generally  small,  and  may 
be  confined  to  the  subarachnoid  cavity  or  break  through  into  the  arachnoid. 
Ventricular  hemorrhages  are  almost  always  secondary  to  a  rupture  in  the 
neighborhood,  in  the  basal  ganglia,  and  it  is  the  lateral  ventricles  that  first 
and  oftenest  receive  the  effiision.  Pons  hemorrhages  usually  occur  in  the 
median  line,  and  are,  as  a  rule,  small.  Cerebellar  hemorrhages  are  oftenest 
due  to  rupture  of  the  superior  cerebellar  artery.  They  are  apt  to  be  large 
and  to  cleave  their  way  externally,  breaking  into  the  fourth  ventricle. 

After  a  hemorrhage  takes  place,  if  life  is  preserved,  certain  reparatory 
changes  occur.  These  consist  of  coagulation  of  the  blood,  which  in  a  few 
days  becomes  softened,  and  in  a  week  or  two  is  absorbed.  Then  there  is  the 
formation  of  a  fibrinous  wall  about  the  sac,  and  this  occurs  from  the  seventh 
to  the  ninth  day.  After  this  the  fibrinous  wall  becomes  organized,  and  a  cyst 
with  transparent  fluid  contents  is  developed.  Sometimes  fibrous  trabeculse 
run  through  it.  Tlais  cyst  may  be  formed  by  the  twentienth  to  the  thirtieth 
day.  Contraction  of  the  cyst  wall  takes  place  by  the  fortieth  day,  and, 
finally,  if  the  hemorrhage  was  small,  the  cyst  may  close,  leaving  nothing  but 
a  cicatrix.  This  latter,  however,  occurs  only  in  quite  small  hemorrhages. 
Finally,  a  very  important  pathological  change  takes  j)lace  in  connection  with 
the  destruction  of  brain  tissue  by  the  clot,  and  this  is  known  as  secondary 
degeneration.  Owing  to  the  fact  that  hemorrhages  so  frequently  occur  in 
the  neighborhood  of  the  internal  capsule,  the  voluntary  motor  tract  which 
carries  impulses  from  the  cortex  of  the  brain  to  the  motor  cells  of  the  spinal 
cord  is  more  or  less  completely  cut  in  two.  This  motor  tract  is  really  made 
up  of  the  nerve-cell  processes  (neuraxons),  starting  in  the  cortical  motor  area, 
and  when  these  jorocesses  are  cut  off  their  peripheral  portions  die  throughout 
their  whole  extent ;  consequently,  within  a  few  days  (from  the  tenth  to  the 
fourteenth)  it  is  found  that  the  whole  of  the  motor  fibres  below  the  lesion, 
extending  down  into  the  spinal  cord,  begin  to  undergo  a  degenerative  soften- 

1  A  case  of  this  kind  was  reported  by  the  writer,  Journ.  of  Nervous  and  Mental  Diseases,  July,  1889. 


FOCAL  DISEASES  OF  THE  BBAIX.  463 

iug.  The  fibres  ultimately  are  destroyed  and  disappear,  and  in  their  place 
connective  tissue  is  developed.  Hence,  from  the  seat  of  the  lesion,  passing 
down  through  the  crura  cerebri  and  the  pons  and  medulla  and  lateral  and 
anterior  median  columns  of  the  cord  there  runs  a  strip  of  connective  tissue 
instead  of  normal  nerve  fibres.  This  process  is  called  a  secondary  degenera- 
tion, and  its  existence  is  the  cause  of  many  of  the  serious  symptoms  that  are 
seen  in  the  chronic  stage  following  the  apoplectic  stroke. 

Prognosis.  The  prognosis  of  intra-cranial  hemorrhage  depends  a  great 
deal  on  the  seat  and  size  of  the  lesion.  Taking  intra-cranial  hemorrhages  as 
a  whole  it  is  my  ex]Derience  that  one-half  to  two-thirds  recover  from  the  first 
attack  of  hemorrhage,  less  than  one-half  of  the  remainder  recover  from  a 
second  attack,  and  very  few,  indeed,  recover  from  a  third ;  although  I  have 
known  persons  to  have  as  many  as  five  successive  attacks,  dying  in  the  last. 
Apoplexies  in  which  there  is  a  very  profound  loss  of  consciousness,  lasting  for 
at  least  three  days,  are  usually  fatal.  If  the  temperature,  instead  of  falling 
on  the  second  or  third  day,  begins  to  rise,  the  outlook  is  uniformly  unfavor- 
able. The  appearance  of  Cheyne-Stokes  respiration  is  an  extremely  bad 
sign,  although  I  have  seen  a  case  in  which  recoveiy  took  place  after  a  free 
venesection.  When  any  symptoms  develop  during  the  attack  which  indicate 
involvement  of  the  medulla  the  prognosis  is  most  unfavorable,  and  the  same 
may  be  said  of  hemorrhages  involving  the  tubercula  quadrigemina  and  caus- 
ing ocular  paralysis.  When  a  case  of  apoplexy  which  is  apparently  doing 
well  suddenly  develops  coma  or  convulsions,  the  outlook  is  most  unfavorable, 
for  it  indicates  the  extension  of  the  hemorrhage.  Cases  in  which  the  hemi- 
jDlegia  is  very  complete,  so  that  the  patient  can  move  neither  hand  nor  foot, 
are  most  serious,  though  not  necessarily  fatal.  On  the  other  hand,  when  the 
attack  is  not  associated  with  lofes  of  consciousness  nor  rise  of  temperature  to 
any  marked  degree,  the  outlook  is  very  good.  The  presence  of  Bright's  disease 
is  of  bad  omen,  and  if  pneumonia  develops  the  patient  dies.  As  for  the  final 
issue  of  the  disease,  it  is  difficult  to  lay  down  positive  rules.  In  many  cases, 
cerebral  apoplexy  seems  to  put  a  check  upon  the  activity  of  the  patient,  enforc- 
ing a  quiet  and  regular  life,  and  tending  even  to  j^rolong  existence.  It  may 
be  thus  considered  almost  a  conserv^ative  process.  Many  cases  of  hemiplegia 
live  for  five  or  ten  or  more  years.  The  prognosis  as  to  the  recovery  from  the 
paralysis  also  varies  very  much.  As  a  rule,  recoveiy  begins  to  take  place 
within  a  fortnight,  and  it  continues  up  to  the  end  of  a  year.  Rapid  improve- 
ment, however,  ceases  at  the  end  of  a  cou23le  of  months,  and  after  that  time 
progress,  if  it  takes  place,  is  very  slow. 

Diagnosis.  Attacks  of  intra-cranial  hemorrhage  must  be  distinguished 
from  acute  softening,  from  coma  due  to  alcohol,  opium,  chloral,  uraemia,  dia- 
betes, the  conditions  of  syncope  and  shock,  the  result  of  injury,  and  finally 
from  epileptic  coma.  The  diagnosis  of  intra-cranial  hemorrhage  from  acute 
softening  due  to  thrombosis  or  embolism  will  be  discussed  later.  Alcoholic 
coma  is  distinguished  by  the  history  of  the  case,  the  odor  of  alcohol  in 
the  breath,  the  equality  of  the  pupils,  the  absence  of  any  evidence  of  hemi- 
plegia, and  the  absence  of  a  slow  tense  pulse,  suffiised  face,  and  a  puffing 
respiration.  In  alcoholic  coma  there  is  no  unilateral  disturbance  of  tempera- 
ture, and  there  is  no  fall  of  temj^erature.  Coma  from  opium  poisoning  is  dis- 
tinguished by  the  pin-point  contraction  of  the  pupils,  the  slow  respiration, 
the  congested  condition  of  the  skin,  and  the  even  bilateral  temperature ;  also 
by  the  history  of  the  case  and  the  examination  of  the  stomach-contents  when 
that  is  possible.  In  ursemic  coma  there  is  usually  a  history  of  Bright's  dis- 
ease and  often  a  history  of  preliminary  uraemic  twitchings  or  convulsions ; 
there  is  the  peculiar  physiognomy  of  the  jiatient  with  chronic  Bright's  dis- 
ease, the  thickened  arteries,  the  presence  of  albumin  and  casts  in  the  urine. 


464  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

The  pupils  are  usually  even,  moderately  contracted,  respiration  is  not  as  a 
rule  stertorous,  and  the  patient's  coma  is  usually  not  extremely  profound.  In 
epilepsy  there  is  a  history  of  preliminary  convulsions,  there  is  often  a  condi- 
tion of  rigidity,  there  is  also  frequently  a  frothy  red  mucus  in  the  mouth 
due  to  a  bitten  tongue,  the  pupils  are  dilated,  and  there  is  an  absence  of  any 
evidence  of  paralysis.  Sometimes  apoplexy  begins  with  convulsions,  and 
then  the  apoplectic  coma  cannot  be  distinguished  easily  from  epileptic  coma 
except  by  the  evidence  of  the  paralysis. 

When  a  person  is  recognized  as  having  an  apoplectic  seizure,  the  diagnosis 
between  hemorrhage  or  plugging  of  an  artery  has  to  be  made. 

In  attempting  to  solve  this  problem,  which  is  often  one  of  extreme  im- 
portance, many  factors  have  to  be  taken  into  consideration,  and  a  positive 
conclusion  cannot  always  be  reached.  Still  if  one  sees  the  patient  during  or 
soon  after  the  attack  I  believe  that  one  need  rarely  make  a  mistake. 

Practically  the  distinction  lies  most  frequently  between  acute  softening 
from  thrombosis  and  cerebral  hemorrhage.  Cerebral  hemorrhage  occurs 
most  frequently  in  the  middle  periods  of  life,  between  the  ages  of  thirty  and 
fifty.  After  the  age  of  sixty-five  or  seventy  and  before  the  age  of  thirty  and 
thirty-five  we  should  expect  softenings  from  senile  or  syphilitic  arteritis.  There 
is  in  hemorrhage  often  a  history  of  arterial  disease,  that  is  to  say,  of  gout  or 
chronic  alcoholism,  or  Bright's  disease.  We  have  also  sometimes  a  hereditary 
history  of  cerebral  hemorrhage  which  may  help  us  in  diagnosis.  Hemorrhage 
has,  as  a  rule,  few  marked  premonitory  symptoms ;  the  patient  may  even  be 
feeling  unusually  well  at  the  time  of  his  attack,  and  a  history  of  this  condi- 
tion gives  rise  to  a  strong  presumption  of  vascular  rupture.  Cerebral  hem- 
orrhage is  sometimes,  though  not  always,  the  result  of  a  sudden  exertion, 
whereas  thrombosis  rarely  occurs  under  such  a  condition.  Hemorrhages 
occur  more  often  in  the  morning  or  evening,  and  they  do  not  often  occur 
during  sleep.  When,  therefore,  a  person  wakes  up  in  the  morning  and 
finds  that  he  has  a  hemiplegia  we  may  pretty  safely  assume  that  it  is  due  to 
an  acute  softening.  Cerebral  hemorrhages  come  on  suddenly  and  usually 
with  loss  of  consciousness.  The  flushed  face,  the  slow  hard  pulse,  the  throb- 
bing carotids,  and  other  evidences  of  intense  cerebral  congestion  and  over- 
action  of  the  heart,  aU  point  toward  hemorrhage.  On  the  other  hand,  in 
thin,  anaemic  and  weakened  individuals  the  occurrence  of  a  sudden  hemiple- 
gia would  be  more  likely  to  suggest  an  acute  softening.  In  cerebral  hem- 
orrhage consciousness  is  more  frequently  and  profoundly  lost,  while  in  acute 
softening  the  patient  may  retain  consciousness  or  be  only  semi-comatose.  An 
inequality  of  the  pupils,  indicating  an  unequal  pressure  in  the  brain,  suggests 
hemorrhage  rather  than  softening.  Vomiting  indicates  hemorrhage  rather 
than  softening ;  but  convulsions  may  occur  in  either  state. 

In  cerebral  hemorrhage,  if  it  is  at  all  large,  and  there  is  decided  shock, 
with  loss  of  consciousness,  the  temperature  in  the  rectum  within  a  few  hours 
after  the  attack  sometimes  falls  two  or  three  degrees.  After  twelve  or  twenty- 
four  hours  the  temperature  in  cerebral  hemorrhage  is  apt  to  be  a  little  ele- 
vated, perhaps  about  one  degree,  and  usually  it  is  a  degree  higher  on  the 
paralyzed  side ;  on  the  other  hand,  in  acute  softenings  the  tem^Derature  of 
the  body  is  very  slightly  affected  ;  it  is  equal  or  nearly  so  on  the  two  sides,  and 
practically  normal  in  the  rectum.  In  hemorrhages  also  the  temperature  is 
more  apt  to  rise  a  little  on  the  second  or  third  day,  while  in  acute  softening 
such  change  does  not  occur  unless  the  softening  is  very  great,  or  afiects  the 
pons,  or  is  associated  with  some  septic  process.  In  cerebral  hemorrhage  one 
finds  more  evidences,  as  a  rule,  of  arterial  disease  than  in  embolism,  but 
rather  less  than  in  thrombosis,  unless  the  patient  be  a  syphilitic.  A  history 
of  syphilis,  especially  of  an  infection  occurring  within  three  or  four  years, 


FOCAL  DISEASES  OF  THE  BRAIN.  465 

suggests  a  thrombosis  and  softening  rather  than  a  hemorrhage,  although 
sometimes  a  cerebral  hemorrhage  does  occur  as  a  result  of  syphilis. 

Finally  a  quicker  return  of  consciousness  and  a  more  rapid  progress  toward 
recovery  indicate  softening  rather  than  hemorrhage.  Hemorrhages  are 
more  serious  and  more  fatal  than  softenings.  Embolism  practically  never 
occurs  without  a  serious  and  generally  an  active  form  of  endocarditis  being 
present.  It  does,  however,  occur  after  pregnancy  and  in  certain  cases  of 
sepsis.  When,  therefore,  a  person  has  an  abscess  in  any  part  of  the  body  or 
an  acute  endocarditis  the  possibility  of  embolism  may  be  considered  great. 
The  age  of  the  patient  is  also  a  helj).  Embolism  rarely  occurs  in  the  aged, 
and  is  most  frequent  in  the  earlier  periods  of  life,  at  least  before  the  degenera- 
tive changes  have  set  in.  The  history  of  syphilis  would  lead  one  to  make  a 
diagnosis  of  thrombosis  or  hemorrhage  rather  than  embolism.  Embolism 
occurs  more  often  in  women,  and  is  rare  in  children.  A  profound  anaemia 
would  lead  one  to  expect  an  embolism  rather  than  thrombosis,  though  this 
factor  has  not  a  very  great  weight.  In  embolism  one  rarely  gets  a  history  of 
any  premonitory  symptoms,  Avhile  in  thrombosis  a  previous  history  of  head- 
aches, mental  confusion,  vertigo,  parsesthesia,  and  transitory  paralysis  is 
often  found.  The  onset  in  embolism  is  always  sudden  ;  it  begins  often  with 
some  motor  symptoms,  that  is,  a  slight  convulsive  twitching  or  a  slight  hemi- 
plegia followed  by  complete  paralysis.  In  thrombosis  the  symptoms  come  on 
gradually. 

Treatment.  The  treatment  of  the  condition  depends  naturally  very  much 
upon  the  fact  whether  or  not  the  physician  has  been  able  to  make  a  positive 
diagnosis  of  intra-cranial  hemorrhage.  If  he  is  satisfied  upon  this  point 
prompt  and  vigorous  treatment  may  be  of  gi^eat  use.  The  patient,  if  seen 
early,  should  be  placed  in  bed,  with  the  head  and  chest  well  raised,  and  the 
clothes  loosened,  so  that  the  circulation  from  the  head  is  not  impeded.  The 
extremities  should  be  swathed  in  hot  cloths  wrung  out  in  mustard  water  ; 
an  ice-bag  should  be  placed  upon  the  head  ;  a  drop  or  two  of  croton  oil 
mixed  with  a  httle  sweet  oil  should  be  placed  upon  the  tongue.  I  believe 
that  it  is  a  wise  practice  in  cerebral  hemorrhage  to  attempt  compression  of  the 
carotid  upon  the  affected  side,  provided  the  patient  is  seen  within  two  or  three 
hours  of  the  attack  and  the  symptoms  do  not  show  positively  that  there  is  a 
rupture  into  the  lateral  ventricles.  If  this  has  occurred,  carotid  compression 
can  avail  little.  Compression  should  be  continued  for  three-quarters  to  an 
hour.  The  suggestion  which  has  been  made  to  tie  the  carotid  is  not  to  be 
recommended.  To  relieve  the  stertor,  turn  the  patient  on  the  paralyzed  side 
and  see  that  the  tongue  is  drawn  forward.  In  plethoric  patients  with  a 
strong  heart-action,  congestion  of  the  face  and  plain  evidences  of  great 
cerebral  hypei'semia  and  over-action  of  the  heart,  bleeding  to  the  amount  of 
ten  or  twelve  ounces  is  advisable,  and  I  have  seen  some  desperate  cases  ap- 
parently brought  up  by  this  measure.  Contrary  to  what  might  be  expected, 
bleeding,  if  not  done  to  great  excess,  does  not  necessarily  injure  a  person 
with  thrombosis.  I  base  this  statement  on  cases  in  which  thrombosis  has 
occurred,  bleeding  has  been  performed,  and  symptoms  of  improvement  have 
appeared.  I  would  not  have  it  understood,  however,  that  I  consider  it  at 
all  advisable  to  bleed  in  such  conditions,  l)ut  rather  the  contrary.  If  the 
patient's  condition  is  such  that  one  does  not  feel  justified  in  bleeding,  a 
somewhat  similar  effect  can  be  produced  by  giving  two  or  three  drops  of 
tincture  of  aconite  every  half  hour  until  the  evidences  of  lowered  arterial 
tension  and  weaker  heart-action  are  obtained.  The  tincture  of  veratrum 
viride  is  recommended  for  the  same  purpose.  Duquesnel's  aconitia  in  doses 
of  2-^^  of  a  grain,  repeated  in  three  hours,  may  be  used  instead  of  tincture 
of  aconite,  which  is  not  always  a  trustworthy  preparation.     The  administra- 

30 


466  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tion  of  ergot  has  been  advised,  but  I  do  not  believe  in  its  utility,  nor  have  I 
seen  any  results  from  bromides.  The  preparations  of  hydrastis  are  recom- 
mended strongly  as  useful  in  hemorrhage ;  but  their  value  in  cerebral  hem- 
orrhage has,  so  far  as  I  know,  not  yet  been  determined.  In  some  cases  of 
cerebral  hemorrhage  the  shock  and  the  weak  condition  of  the  patient  are 
such  that  there  is  evidence  of  heart  failure,  and  if  this  be  present  then  we 
must  not  hesitate  to  use  small  amounts  of  alcohol,  digitalis,  and  str3^chnine. 

After  the  first  few  hours  any  attempt  to  control  the  hemorrhage  is  futile  ; 
it  has  by  this  time  done  its  work.  There  may,  however,  sometimes  be  a  sec- 
ond rupture  of  an  artery  or  a  breakage  into  the  ventricles,  and  in  order  to 
avoid  this  the  greatest  care  must  be  taken  to  keep  the  patient  extremely 
quiet.  If  he  is  restless  and  delirious,  bromide  and  chloral,  or  morphine, 
should  be  given,  preferably  the  former.  On  the  second  or  third  day  it  is 
advisable,  in  suspected  syphilis,  to  give  small  doses  of  iodide  of  potassium ; 
that  is  to  say,  doses  of  two  or  three  grains  every  two  hours.  If  the  patient 
gradually  recovers  consciousness  all  medication  may  be  suspended  except 
the  iodide  of  potash  and  such  measures  as  may  be  indicated  in  accordance 
Avith  the  development  of  the  symptoms.  At  the  end  of  ten  days  or  a  fort- 
night, if  the  patient  has  satisfactorily  improved,  one  may  begin  cautiously 
to  apply  the  faradic  current  to  the  paralyzed  limbs.  If  the  i^aralysis  is 
slight  this  need  not  be  done  so  soon  ;  but  if  complete,  there  is  some  benefit 
in  beginning  electrical  applications  early,  provided  they  are  made  very  short 
and  very  mild  ;  that  is  to  say,  each  group  of  muscles  should  be  made  to 
contract  three  or  four  times  by  means  of  the  current.  If  the  patient  does 
not  progress  favorably,  if  he  continues  in  a  state  of  partial  unconsciousness 
and  develops  a  slight  fever,  there  is  httle  to  be  done  except  to  keep  the 
emunctories  open ;  the  skin  should  be  bathed  with  warm  water,  the  kidneys 
should  be  acted  upon  by  sweet  spirits  of  nitre  and  iodide  of  potassium,  and 
the  bowels  should  be  kept  regular.  A  milk  diet  is  to  be  recommended  dur- 
ing this  time.  Special  care  should  be  taken  lest  pneumonia  should  develop. 
The  mouth  should  be  kept  thoroughly  disinfected,  and  the  patient  should  be 
prevented  from  lying  in  the  same  position.  Thorough  cleanliness  is  neces- 
sary in  order  to  prevent  the  development  of  bed-sores,  for  in  some  cases  the 
patients  void  the  urine  and  feces  in  the  bed. 

When  the  chronic  stage  has  been  reached  the  medical  treatment  will 
have  to  vary  very  much  in  accordance  with  the  general  health  of  the  patient. 
In  some  cases  where  there  is  evidence  of  syphilis  large  doses  of  iodide  of 
potash,  with  occasional  courses  of  mercury,  must  be  given.  If  the  patient  is 
gouty  and  has  some  renal  complications  the  use  of  tincture  of  iron  and  of 
the  iodides,  or  the  acetate  of  potash  and  digitalis,  may  be  indicated.  Strych- 
nine is  of  some  use,  not  because  it  directly  affects  the  j^aralyzed  limbs,  but 
because  it  strengthens  the  heart  and  is  a  good  general  tonic. 

For  the  first  year  after  his  stroke  the  patient  should  have  courses  of  elec- 
trical treatment,  massage,  hydrotherapy,  and  mechanical  treatment  of  vari- 
ous kinds.  An  electrical  treatment  should  not  last  more  than  six  weeks, 
and,  as  a  rule,  three  applications  a  week  are  sufficient.  The  faradic  battery 
with  the  current  of  high  tension  is  a  useful  one,  but  it  seems  from  my  expe- 
rience that  the  long  sparks  of  the  static  machine  give  the  most  successfiil 
results.  I  do  not  know  that  any  advantage  is  to  be  gained  from  the  use  of 
galvanism.  After  a  course  of  electrical  treatment  the  patient  may  rest  a 
week,  and  then  have  a  course  of  massage  daily  for  a  month.  He  should  rest 
then,  and  may  afterward  begin  the  electricity  again.  In  some  instances 
lukewann  baths  are  usefiil  auxiliaries.  The  patient  should  be  placed  in  a  bath 
of  a  temperature  of  95°,  and  should  be  made  to  exercise  his  muscles  while 
there  for  a  period  of  about  ten  minutes  daily.     He  should  afterward  be 


FOCAL  DISEASES  OF  THE  BRAIN.  467 

taken  out  and  rubbed  well  with  cool  water  and  alcohol.  In  some  patients 
the  contractures  of  the  affected  limbs  are  very  great,  and  the  deformities  result- 
ing render  the  limbs  almost  useless.  The  fingers  of  the  hand  are  particularly 
apt  to  be  affected  in  this  way.  I  have,  in  some  instances,  had  the  arm  and 
the  foot  hyjierextended  and  placed  in  plaster-of-Paris  with  fairly  good  re- 
sults. It  has  seemed  to  me  that  if  a  patient  began  his  treatment  by  steady 
attention  to  the  prevention  of  the  excessive  contracture  a  good  deal  of  it 
might  be  avoided.  Some  improvement  in  the  hemiplegia  may  be  expected 
for  over  a  year ;  after  that  not  much  can  be  done,  still  in  cases  which  have 
been  not  thoroughly  treated  in  the  first  year,  or  in  cases  in  which  there  has 
been  neglect  of  mechanical  treatment,  help  may  be  given  even  late  in  the 
disease. 


ACUTE   SOFTENING  OF  THE  BRAIN.      EMBOLISM, 
THROMBOSIS. 

Acute  softening  of  the  brain  is  a  condition  caused  by  the  plugging  of  a  blood- 
vessel with  an  embolus  or  thrombus,  and  is  characterized  by  a  more  or  less  sud- 
den apoplectic  seizure  ;  the  symptoms  in  the  later  stage  resembling  those 
that  follow  intra-cranial  hemorrhage. 

Etiology.  Embolism  occurs  rather  more  often  in  women,  thrombosis  in 
men.  Embolism  is  rare  in  children  ;  it  occurs  oftenest  between  the  ages  of 
tw^enty  and  fifty,  thrombosis  between  the  ages  of  fifty  and  seventy.  The 
most  important  predisposing  factors  in  embolism  are  acute  or  recurrent  endo- 
carditis, infectious  fevers,  profound  anaemia,  pregnancy,  and  blood  dyscra- 
si?e ;  in  thrombosis,  syphilitic,  lead,  or  gouty  arteritis,  fatty  heart,  and  blood 
dysci-asise.  The  same  causes  which  lead  to  the  arterial  disease  which  pro- 
duces cerebral  hemorrhage  also  predispose  to  thrombosis,  though  in  the  lat- 
ter condition  atheroma  plays  the  important  part. 

Symptoms.  In  embolism  there  are  rarely  any  premonitory  sym^itoms ; 
the  onset  is  sudden  ;  it  may  begin  with  some  convulsive  twdtchings,  then  fol- 
low hemiplegia  and  temporary  loss  of  consciousness.  Coma,  liowever,  is 
rarer  than  in  hemorrhage,  and  if  present  is  usually  shorter.  There  is  rarely 
vomiting,  nor  do  we  find  the  hard,  pulsating  arteries,  flushed  face,  and  severe^ 
stertorous  breathing.  The  initial  temj^erature  changes  are  slight,  but  in  a 
few  days  fever  may  develop. 

In  thrombosis  premonitory  symptoms  are  frequent.  In  syphiHtic  cases  there 
are  headaches  and  cranial  nerve  palsies.  In  other  cases  vertigo,  temporary 
aphasia,  transient  hemiplegia,  numbness  of  the  hand  and  foot,  and  drowsi- 
ness may  be  present.  The  onset  is  more  gradual ;  the  hemiplegia  slowly 
develops,  taking  several  hours,  perhaj^s,  for  its  completion ;  meanwhile  the 
])atient  gradually  becomes  comatose.  The  attack  sometimes  is  rather  sud- 
den, with  no  loss  of  consciousness,  and  it  may  occur  in  sleep.  The  tempera- 
ture often  has  a  slight  initial  fall,  followed  by  a  rise,  just  as  in  hemorrhage. 
In  both  embolism  and  thrombosis  the  hemiplegia  tends  to  improve  very 
much  in  a  few  days  or  weeks  unless  the  vessel  obliterated  is  a  large  one. 

The  right  side  of  the  body  is  affected  sHghtly  more  than  the  left,  owing  to 
the  fact  that  the  left  middle  cerebral  is  rather  more  easily  reached  by  an 
embolus. 

Acute  softening  may  kill  within  twenty-four  hours;  but,  as  a  rule,  the 
patient  survives  the  onset,  and  if  he  dies  it  is  not  for  several  weeks.  After 
the  acute  stage  is  over  the  patient  passes  into  the  chronic  stage,  which  resem- 
bles in  nearly  all  resi)ects  that  of  hemorrhage.  (Vide  Hemorrhage.)  After 
an  acute  softening,  however,  it  is  believed  that  there  are  more  spastic  symp- 


468  NERVOUS  DISEASES  A2sD  THEIR  TREATMENT. 

toms  and  a  greater  tendency  to  mobile  spasm.  In  embolism,  owing  to  the 
youth  and  freedom  fi-om  arterial  disease,  the  mind  is  less  affected ;  while  in 
thrombosis  the  contrary  is  the  case. 

Prognosis.  The  prognosis  as  regards  the  attack  is  somewhat  better  than  in 
hemorrhages  as  a  rule.  In  embolism  it  is  good  as  regards  recurrence ;  in 
thrombosis,  bad.  The  mental  condition  is  better  in  embolism  ;  usually  worse 
in  thrombosis.  The  recoveiy  from  attack  is  more  complete  in  acute  soften- 
ing. After  the  chronic  stage  is  reached,  however,  the  prognosis  is  about  the 
same  in  all  forms. 

Treatment.  The  treatment  of  the  attacks  consists  essentially  in  rest  and 
such  attention  to  the  bowels,  kidneys,  and  heart  as  may  be  indicated.  In 
thrombosis  it  is  important  to  give  heart  stimulants  and  arterial  depressants, 
and  for  this  purpose  I  advise  the  use  of  alcohol,  digitalis,  or  strophanthus 
with  nitroglycerin.  Iodide  of  potassium  and  mercury  ought  to  be  given  if 
there  is  the  slightest  suspicion  of  syphilis.  Later  one  should  prescribe  courses 
of  the  iodides  and  mercury  and  of  strophanthus,  nitroglycerin,  strychnine, 
and  such  tonics  as  may  be  indicated.  The  symptomatic  treatment  of  the 
chronic  stage  is  the  same  as  in  hemorrhage : 

Softening  in  the  I'egion  of  the  frontal  convolutions  on  the  inner  surface  of 
the  hemispheres  as  far  as  the  calloso-marginal  sulcus— due  to  obliteration  of 
the  trunk  of  the  anterior  cerebral  arteiy. 

Total  softening  of  the  territory  of  the  artery  of  the  fissure  of  Sylvius,  in- 
cluding the  cor^Dus  striatum — due  to  obliteration  of  the  first  two  centimetres 
of  this  artery.     Softening  is  found  in  all  the  convolutions  named  hereafter. 

Total  softening  of  the  cortical  areas  supplied  by  the  artery  of  the  fissure 
of  Svlvius,  the  corpus  striatum  excluded — due  to  occlusion  of  the  artery  just 
beyond  the  giving  off  of  the  arteries  of  the  corpus  striatum. 

"Partial  softening  in  the  area  suppKed  by  the  arteries  of  the  fissure  of  Syl- 
vius— due  to  embolism  of  the  inferior  external  frontal  artery.  The  result  is 
a  softening  of  the  island  of  Reil  and  of  the  third  frontal  convolution.  If 
this  is  on  the  left  side,  aphasia  results. 

Softening  in  the  posterior  part  of  the  second  frontal  convolution  and  in 
the  first  central  convolution — obliteration  of  the  anterior  parietal  arteiy. 

Softening  of  both  central  convolutions  and  the  Rolandic  fissure,  the  anterior 
part  of  the  first  parietal  convolution,  and  the  island  of  Reil — due  to  closure 
of  the  median  parietal  artery. 

Softening  of  the  lower  parietal  convolution  and  the  first  temporal  convo- 
lution as  well  as  of  the  island  of  Reil — due  to  obliteration  of  the  posterior 
parietal  artery. 

Softening  in  the  area  of  the  posterior  cerebral  artery,  rarely  complete,  in- 
volves the  inferior  part  of  the  occipital  lobe  and  the  tip  of  the  occipital  lobe. 

The  secondary  changes  after  thromljosis  resemble  those  after  embolism  ;  a 
thrombus,  however,  may  lead  to  supplementaiy  embolism  through  breaking 
off  of  a  clot,  and  both  conditions  may  cause  a  complicating  cerebral  hemor- 
rhage. 

Total  softening  of  the  corpus  striatum,  including  the  capsule,  the  lenticular 
and  caudate  nucleus  and  the  anterior  third  of  the  thalamus — seat  of  throm- 
bus in  the  beginning  of  the  artery  of  the  fissure  of  Sylvius. 

Partial  softening  in  the  form  of  a  cone  whose  apex  lies  in  the  anterior  part . 
of  the  lenticular  nucleus,  while  the  base,  directed  forward,  involves  the  ante- 
rior two-thirds  of  the  corpus  striatum  ;  the  cone  is  formed  h\  the  anterior  part 
of  the  nucleus  caudatus,  the  internal  capsule,  and  the  third  segment  of  the 
lenticular  nucleus — the  seat  of  the  occlusion  here  lies  in  the  lenticular  striate 
artery. 

Partial  softening  lying  more  posteriorly  than  the  preceding,  involving  the 


FOCAL  DISEASES  OF  THE  BRAIN.  469 

postero-external  part  of  the  lenticular  nucleus,  the  internal  capsule,  the  an- 
terior part  of  the  thalamus,  and  the  tail  of  the  corpus  striatum — the  lesion 
involves  the  lenticular  optic  artery. 

Partial  softening  of  the  thalamus  opticus,  the  lesion  ranges  in  size  from  a 
pea  to  a  hazelnut — the  vessels  involved  are  the  perforating  arteries  of  the 
choroid  plexus. 

Softening  of  the  frontal,  j^arietal,  and  sphenoidal  lobes — due  to  embolism 
at  the  point  of  bifurcation  of  the  internal  carotid,  extension  of  the  thrombus 
into  the  anterior  cerebral  artery  as  far  as  the  anterior. 

Pathology.  The  embolus  or  thrombus  cuts  off  the  blood  supply  from  a 
certain  area  of  brain  tissue.  In  twenty-four  hours  this  begins  to  soften.  If 
the  area  is  in  the  cortex  it  becomes  red  (red  softening)  ;  if  in  the  white  and 
less  vascular  part,  it  is  usually  white  with  a  few  red  punctate  spots.  The  red 
softening  gradually  becomes  yeUow  (yellow  softening).  The  dead  tissue  softens 
and  is  absorbed,  leaving  a  cicatrix  or  cyst.  If  the  embolus  contains  infective 
microbes  there  may  be  a  local  encephalitis  and  abscess. 

In  thrombosis  there  are  usually  evidences  of  extensive  atheroma  or  of 
syphilitic  arteritis.  In  those  instances  in  which  the  thrombosis  is  caused  by 
the  blood  state,  as  in  scurvy  or  after  wasting  fevers  and  a  weak  heart,  little 
arterial  change  occurs.  Atheroma  affects  chiefly  the  internal  carotids  and 
the  large  arteries  at  the  base,  viz.,  the  middle,  anterior,  and  posterior  cere- 
brals and  the  basilar  and  vertebrals. 

Thrombotic  softenings  occur  oftenest  in  the  corpora  striata  and  optic  thala- 
mus, next  in  the  pons  and  medulla.  Thrombosis  affects  the  vertebrals,  basilar 
and  the  posterior  cerebral  arteries  much  oftener  than  do  hemorrhages  or  em- 
bolism. An  embolism  may,  however,  plug  up  the  basilar  or  the  vertebral  at 
its  junction  with  the  basilar.  Embolism  usually  affects  the  middle  cerebrals 
(75  per  cent,  of  79  cases,  Pitt),  and  the  two  hemispheres  are  almost  equally 
involved,  there  being  only  a  small  preponderance  in  favor  of  the  left  side. 
The  cerebellum  is  practically  not  affected  by  embolism  or  thrombosis. 


CHAPTER   XYI. 
FOCAL  DISEASES  OF  THE  BRA^. 

(Continued.) 

By  M.  ALLEN  STARR,  M.D. 

TUMOR  OP  THE  BRAIN. 

General  Considerations.  This  subject  is  an  important  one  to  the 
neurologist,  both  because  of  the  relative  frequency  of  this  disease  as  com- 
pared with  other  organic  nervous  diseases,  not  only  in  adults,  but  also  in 
children,  and  also  because  of  the  possibility  of  its  treatment  by  surgical 
means.  Collections  of  cases  of  brain  tvimors  have  been  published  during 
the  past  fifteen  years  by  Bernhardt',  StefFan'^  Bramwell,^  Mary  Putnam 
Jacobi,^  Mills  and  Lloyd,*  Knapp,*^  and  myself.'  It  is  possible  by  the  study 
of  these  collections  of  cases  to  make  a  fair  estimate  of  the  relative  frequency 
of  different  varieties  of  tumor  and  of  the  various  situations  in  the  brain  in 
which  tumors  grow,  and  also  to  estimate  the  probabilities  of  success  in  find- 
ing and  removing  a  tumor.  Without  attaching  too  great  importance  to 
statistics  on  this  subject  and  realizing  that  a  complete  study  of  a  single  case 
is  of  more  value  than  many  carelessly  reported  cases,  I  have  selected  as  the 
basis  of  this  article,  from  the  collections  already  named,  600  tumors.  These 
are  tabulated  in  Table  I,  in  which  tumors  in  individuals  below  the  age  of 
twenty,  chiefly  children,  are  sepai"ated  from  those  in  adults,  for  the  purpose 
of  contrast.  In  this  table  no  tumors  are  included  which  have  been  removed 
or  in  which  surgical  interference  has  been  attempted.  Yet  during  the  past 
six  years  over  130  tumors  have  been  operated  upon. 

The  percentage  of  cases  open  to  operation  has  been  variously  estimated 
by  different  authors,  and  their  results  are  demonstrated  in  Table  II. 

From  this  table  it  is  evident  that  about  7  per  cent,  of  tumors  can  be  re- 
moved. The  various  authors  cited  have  made  collections  of  cases  with  post- 
mortem records,  and  from  a  study  of  the  condition  found  at  autopsy  have 
estimated  the  probability  of  success  in  the  removal  of  the  tumor  found. 

Etiology.  Little  is  known  regarding  the  cause  of  brain  tumor,  though  in 
a  certain  small  percentage  of  cases  a  history  of  a  blow  or  fall  on  the  head 
has  been  obtained.  It  is  known  that  males  are  more  subject  to  brain  tumor 
than  females,  and  persons  of  all  ages  are  liable  to  brain  tumor. 

It  is  not  my  purpose  in  this  chapter  to  cite  special  cases  of  brain  tumor 
or  to  recount  histories.  But  anyone  interested  in  this  subject  is  referred  to 
the  articles  and  works  already  cited,  from  which  the  general  conclusions 
which  are  hei'e  combined  have  been  drawn. 

1  Bbitrage  zur  Symptomatologie  und  Diagnostik  der  Hirngeschwlilste,  1881.    Also  yearly  summary 
in  Virchow's  Jahresbericht,  1881  to  1895. 

2  Die  Krankheiten  des  Gehirns  im  Kindesalter.    Gerhardt's  Handb.  der  Kinderkrankheiten,  1880, 
vol.  V. 

3  Intra-eranial  Tumours,  1888.    Edinburgh  Medical  Journal,  Dec.,  1894. 
■>  Reference  Handbook  of  Medical  Sciences,  1888. 

6  Pepper's  System  of  Medicine,  vol.  v.  «  Intra-cranial  Growths,  1891. 

7  Medical  News,  Jan.  12, 1889  ;  Intra-cranial  Tumors,  Keating's  Cyclopaedia  of  Children's  Diseases, 
1890,  and  Brain  Surgery,  1893. 


FOCAL  DISEASES  OF  THE  BRAIN. 


471 


Table  I. 

(The  first  column  are  children's  tumors;  the  second  column  adults'  tumors.) 


Situation. 

^9. 
5" 

o2 

Glioma- 
tous. 

.  3 

oS 

5§ 

0 

11 

oi  a 

(^ 

Sa- 
gs 
30 
0^ 

0'^ 

1 

I.  Cortex  cerebri . 
II.  Centrum  ovale . 

III.  Cerebral  axis : 

1.  Basal  ganglia  and  la 

ventricles 

2.  Corpora  quadrigemii 

and  crura  cerebri 
3    Pons    . 

4.  Medulla 

5.  Base    . 

6.  Fourth  ventricle 

IV.  Cerebellum 

V.  Multiple  tumors 

teral 
la 

13 
6 

14 

16 

19 

2 

"i 

47 
34 

9 
2 

3 

1 
11 

"3 

"s 

4 

1 
5 

5 

3 
5 

"i 

1 

10 
3 

46 

7 

8 

2 

1 

"3 

1 

13 
5 

6 
1 

3 

1 
10 

"i 

15 

... 

19 
11 

9 
2 

"i 
2 

"s 
2 

1 

"2 
"i 
"i 

8 
4 

5 

1 

i 

15 

1 

"1 

1 
1 

"9 
2 

1 
"1 

1 
1 

1 

"2 
1 

1 
3 

19 
3 

2 

1 
2 

"2 
"2 

"i 
i 

13 

1 
"3 

"3 

"5 

3 

1 
1 
1 
4 
1 

11 
3 

12 
4 

5 

7 

"i 

1 

10 
1 

21 
35 

27 

21 

38 

6 

8 

5 

96 

43 

127 
51 

34 

14 

17 

2 

9 

4 

45 

17 

152   41    34J  86,  37 

54 

5 

25 

30J     2 

10  33 

2  20 

30 

41 

300 1 300 

Table  II. — Percentage  of  Brain  Tumors  Eemovable. 


Author. 

No.  cases. 

Operable. 

Reference. 

1.  Mills  and  Llovd 

2.  Hale  White     " . 

3.  Starr  . 

4.  Knapp 

5.  Gray   . 

6.  Gray  . 

7.  Seydel 

8.  Dana  . 

9.  Starr  . 

10.  Byrom  Bramwell 

100 

100 

300 

40 

53 

49 

100 

29 

300 

50 

10 

10 

16 

2 

4 

6 

3 

5 

21 

3 

Pepper's  System,  1886.  vol.  v. 
Guv's  Hospital  Rep  ,  1888. 
Med.  News,  Jan.  12,  1889  (children). 
Intra-cranial  Growths,  1891. 
Sajous'  Annual,  1891. 
1892. 
Verhand.  Deut.  Gesell.  f.  Chir.,  1892. 
Trans.  N.  Y.  Acad.  Med.,  Jan.  1893. 
Brain  Surgery,  1S93  (adults). 
Edinburgh  Med.  Journ.,  June,  1894. 

1121 

80 

Pathology.  The  Varieties  of  Brain  Tumor.  Almost  every  variety  of 
tumor  known  has  been  found  within  the  brain.  There  are  certain  tumors, 
however,  which  are  quite  common,  and  others  which  are  very  rare.  In  the 
first  class  are  tubercular,  sarcomatous,  gliomatous,  glio-sareomatous,  cystic, 
carcinomatous,  and  gummy  tumors.  In  the  second  class  are  fibromatous, 
angiomatous,  myxomatous,  osteomatous,  and  liptomatous  tumors,  also  psam- 
moma,  cholesteatoma,  and  echinococcus  cysts. 

Tubercular  tumors  of  the  brain  are  the  most  common  of  all  the  forms  of 
tumor.  They  occur  with  greatest  frequency  in  childhood,  being  sometimes 
primary,  but  usually  secondary  to  tuberculosis  of  other  organs.  In  20  per 
cent,  of  the  cases  recorded,  tubercular  tumors  are  multiple.  This  fact  should 
not  be  forgotton  in  studying  the  symptoms  of  brain  tumor  and  in  diagnosti- 
cating the  location  of  the  tumor,  for  if  the  tumor  is  probably  tubercular, 
and  if  the  symptoms  are  not  clearly  exj)licable  upon  the  theory  of  its  loca- 
tion in  one  part  of  the  brain,  it  is  to  be  remembered  that  two  or  more  differ- 
ent tumors  in  different  locations  may  give  rise  to  a  great  variety  of  symp- 
toms. Tubercular  tumors  vary  in  size  from  a  small  collection  of  miliary 
tubercules  lying  in  a  mass  of  thickened  pia  mater  up  to  a  large  solid  circum- 
scribed mass,  with  hard,  cheesy,  or  broken-down  granular  centre  and  a  dis- 
tinct capsule.     (See  Figs.  119^  120,  and  121).     Not  infrequently  the  tumor 


472 


XEEVO US  DISEASES  AND  THEIR  TEEATJIEXT. 


is  surrounded  by  a  tubercular  infiltration  both  in  the  brain  and  its  mem- 
branes. Sometimes  irregularly-shaped  deposits  of  tubercular  tissues  are 
found  upon  the  base  of  the  brain,  in  the  meshes  of  the  pia  mater,  compressing 
the  cranial  nerv^es. 


Fig.  119. 


j^^te* 


Tubercular  tumor  in  the  pons  varolii  with  granular  mass  lying  in  a  capsule.  Sagittal  section  through 

pons  and  cerebellum. 

Tubercular  tumors  may  be  found  within  the  cerebral  tissue  at  some  dis- 
tance from  the  surface,  and  no  part  of  the  brain  can  be  said  to  be  free  from 
a  liability  to  tubercular  deposits.  But  the  large  majority  of  this  yariety  of 
tuuKjrs  is  found  in  connection  with  the  meninges  and  about  the  large  yessels 

Fig.  120. 


Tubercular  tumor  in  right  optic  thalamus.    Tubercular  meningitis  of  the  median  surface  of  the 

hemisphere. 


of  the  brain,  so  that  they  are  more  commonly  discoyered  upon  the  surface 
and  about  the  base  than  lying  deep  within  the  organ.  When  the  tumor 
arises  in  the  meninges  meningeal  thickening  by  tubercular  deposits  is  quite 


FOCAL  DISEASES  OF  THE  BRAIN. 


473 


common.  In  a  few  cases  the  cranial  bones  have  been  eroded  in  the  growth 
of  the  tumor.  Tubercular  tumors  are  sometimes  found  in  the  brain  after 
death  when  no  cerebral  symptoms  have  been  present  during  life.^ 


Section  through  cerebrum  showing  a  large  tubercular  tumor  with  thick  capsule  and  granular 
contents  lying  beneath  the  cortex  in  the  centrum  ovale  of  the  frontal  lobe. 

For  an  account  of  the  finer  patholology  of  tumors  the  reader  is  referred  to 
the  text-books  of  pathology. 

The  important  facts  to  be  considered  in  making  the  diagnosis  of  tubercu- 
lar tumors  are  (a)  hereditary  tendencies  of  the  individual  to  tuberculosis ; 
(b),  exposure  to  such  influences  as  are  known  to  favor  the  development  of 
the  disease  ;  (c),  the  history  of  symptoms  of  primary  liulmonary,  or  intes- 
tinal, or  joint,  or  glandular  affections;  and  (d),  the  presence  of  local  signs 
or  general  evidences  of  tubercular  infection. 

When  cerebral  symptoms  develop  in  an  individual  with  tubercular  disease 
the  possibility  both  of  tubercular  tumor  and  of  tubercular  meningitis  should 
not  be  overlooked. 

The  qviestion  of  operative  interference  when  a  tubercular  tumor  is  diag- 
nosticated has  given  rise  to  some  discussion ;  von  Bergmann^  being  opposed 
to  such  operations,  and  Horsley^  being  in  their  favor.  It  must  be  admitted 
that  a  permanent  cure  by  operation  is  less  likely  to  be  achieved  in  the  case 
of  a  tubercular  tumor  than  in  the  case  of  a  non-tubercular  tumor,  there 
being  not  only  the  danger  of  recurrence,  but  also  the  possibility  of  the  ex- 
istence of  undetected  tumors  elsewhere  in  the  brain,  and  the  danger  of  the 


1  Edinburgh  Hospital  Reports,  vol.  i.  p.  420. 

-  Von  Bergmann  :  Die  Chirurgische  Behandlung  von  Hirnkrankheiten,  Berlin,  1881. 

2  Horsley  :  Trans.  Internal.  Med.  Cong.,  1890. 


474 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


development  of  tubercular  meningitis  subsequently  to  the  operation.  An 
operation  is  capable  of  prolonging  life,  and  hence  should  not  be  wholly  con- 
demned. 

Sarcomatous   tumors   are   next   in   frequency  to   tubercular.     They  are 
rarely  secondary  to  sarcoma  in  other  parts  of  the  body,  and  they  are  only 


Fig.  122. 


Sarcoma,  encapsulated,  with  pedicle  attached  to  the  dura,  lying  in  the  posterior  cranial  fossa,  and 
compressing  the  left  hemisphere  of  the  cerebellum. 

multiple  when  they  appear  in  the  form  of  melanotic  nodules,  which  are  rar'fe 
in  the  brain.     (Figs.  122  and  123.) 

Sarcoma  is  usually  encaj^sulated,  round  or  oval  in  shape,  hard,  approach- 
ing fibroma  in  consistency,  and  is  easily  separable  from  the  brain  tissue,  which 


Fig.  123. 


Sarcoma  encapsulated  lying  on  the  base  of  the  brain  and  compressing  the  right  side  of  the  pons  and 
right  hemisphere  of  the  cerebellum. 

it  compresses  and  indents  more  frequently  than  it  infiltrates.     Fig.  124  shows 
a  sarcoma  removed  from  the  brain  by  McBurney.'     Round-cell  and  spindle- 

1  Amer.  Jouru.  Med.  Sci.,  April,  1893. 


FOCAL  DISEASES  OF  THE  BRA IX. 


475 


cell  sarcomata  are  more  frequently  met  with  than  myxo-sarcomata  or  giio- 
sarcomata.  These  tumors  grow  rapidly  and  produce  well-marked  symptoms 
which  do  not  vary  very  greatly  in  their  intensity.  They  are  not  vascular, 
and  hence  the  occurrence  of  apoplectic  attacks  during  their  growth  is  infre- 
quent. It  is  not  to  be  forgotten  that  a  sarcomatous  deposit  in  the  meninges 
may  occur,  producing  a  thick  layer  of  new  tissue  over  an  extensive  surface 
of  the  cortex  or  base,  and  in  such  a  case  operative  treatment  is  necessarily 
unsuccessfiil.^  Occasionally  a  sarcoma  has  no  defined  limits,  and  infiltrates 
the  tissue  of  tlie  brain.  Hence,  sarcoma  is  not  uniformly  favoral)ly  for  opera- 
tion. 

Fig.  124. 


Sarcoma  removed  from  the  cortex  of  the  frontal  lobe.    The  capsule  contained  many  vessels. 

From  the  study  of  Table  I  it  is  evident  that  sarcoma  may  l)e  found  in  any 
part  of  the  brain,  but  it  is  more  frequent  in  the  cortex  and  in  the  cerebel- 
lum than   in  any  other  localities.     It  is  the  form  of  tumor  most  easily  ex- 

FlG.  125. 


A  glioma  of  the  pons  and  medulla  infiltrating  the  tissues,  but  not  destroying  the  tracts. 
The  symptoms  were  chiefly  cerebellar. 

tracted  from  the  skull,  and  the  majority  of  the  successful  cases  of  removal  of 
brain  tumor  have  been  sarcomata.  (See  Fig.  122,  which  shows  a  sarcoma 
lying  on  the  cerebellum,  which  could  have  been  removed  very  easily.) 

1  Eskridge:  Journ.  Amer.  Med.  Assoc,  Sept.  30, 1893. 


476  XERVOUS  DISEASES  AND  THEIB  TREATMENT. 

Gliomatous  tumors  come  third  in  the  list.  This  tumor  is  a  product  of 
the  neuroglia  and  presents  the  appearance  of  a  connective  tissue  fibrillary 
network  containing  a  greater  or  less  number  of  large  branching  cells  and 
many  small  nucleated  cells. 

Glioma  of  the  brain  is  usually  primary,  but  occasionally  may  develop 
secondarily  to  glioma  of  the  retina. 

Gliomata  vary  in  density,  but  are  usually  softer  than  sarcomata,  and  are 
rarely  well  defined  or  separable  from  the  brain  tissue,  even  those  which  ap- 
pear to  have  a  definite  limit,  being  found,  on  microscopic  study,  to  be  sur- 
rounded by  a  zone  of  gliomatous  infiltration  in  the  brain.  The  usual  con- 
sistency of  a  glioma  is  about  that  of  the  brain  substance.  There  is  a 
tendency  in  all  gliomatous  tissues  to  undergo  fatty  degeneration,  to  break 
down  and  liquefy,  so  that  cavities  filled  with  clear  fluid  of  a  straw  color  or 
more  sharply-defined  cysts  are  very  frequently  found  in  and  about  a  gliomat- 

FlG.  126. 


Glioma  of  the  motor  area  infiltrating  the  cortex  and  centrum  ovale,  without  distinct  capsule, 

excepting  at  one  part. 

ous  tumor,  and,  in  fact,  some  authors  have  maintained  that  all  cysts  found 
in  the  brain,  not  the  relics  of  previous  hemorrhages  or  of  embolic  softening, 
are  due  to  gliomatous  formations.  A  similar  tendency  to  the  formation  of 
cavities  Avithin  gliomatous  tissue  is  manifested  in  the  spinal  cord  in  the  dis- 
ease syringomyelia. 

Glioma  may  appear  in  any  part  of  the  brain,  but  is  somewhat  more  fre- 
quent in  the  white  substance  of  the  brain  than  in  the  gray  matter.  As  a 
glioma  grows  it  destroys  the  brain  tissue,  its  branching  cells  surrounding  and 
annihilating  both  nerve-cells  and  nerve-fibres.  It  does  not  compress  the 
brain  as  a  sarcoma  does. 

Glioma  is  very  vascular,  and  hence  the  symptoms  which  it  produces  are 
somewhat  variable  in  intensity,  and,  in  case  the  delicate  vessels  within  it  rup- 
ture, apoplectiform  attacks  occur. 

Glio-sarcoma  is  a  variety  of  tumor  not  very  frequent,  partaking  of  the 
nature  both  of  glioma  and  of  sarcoma,  commonly  accompanied  by  cystic 
cavities.     Like  glioma,  the  tumor  cells  are  infiltrated  through  the  brain 


FOCAL  DISEASES  OF  THE  BBAIX. 


477 


tissues ;  but,  like  sarcoma,  its  constituents  are  spindle  and  round  cells,  and 
its  density  is  considerable.  It  is  rarely  encapsulated,  and,  like  glioma,  is 
much  more  difficult  of  removal  than  sarcoma. 


Fig.  127. 


Glio-sarcoma  of  frontal  lobes  and  corpus  callosum.    (Francis.) 

It  is  questionable  whether  the  origin  of  a  glio-sarcoma  is  the  development 
of  sarcomatous  cells  infiltrating  the  brain,  and  causing  an  irritation  and 
proliferation  of  the  neuroglia,  or  whether  there  is  a  development  of  haixl, 
round  connective  tissue  elements,  sarcomatous  in  character,  in  the  midst  of 
the  original  glioma. 

Fig.  128. 


-t^^^^^ 


GUo-sarcoma  of  corpus  callosum,  invading  the  frontal  lobes  chiefly  on  the  right  side,  where 
disintegration  of  the  centrum  ovale  was  produced.    (Francis.) 


The  symptoms  are  more  closely  like  those  of  glioma  tlian  of  sarcoma,  the 
same  variability  of  intensity  being  observed. 

Carcinoma  of  the  brain  is  usually  secondary  to  carcinoma  in  other  parts 


478  NEBVO US  DISEASES  AND  THEIR  TREATMENT. 

of  the  body,  either  of  the  orbit  or  retina,  or  of  the  internal  organs,  or  of 
the  breast. 

Carcinoma  is  a  variety  seldom  found  in  children,  and  usually  develops  in 
adults  above  the  age  of  fifty.  In  cases  in  which  it  has  occurred  in  children 
it  has  been  from  direct  extension  of  the  disease  from  the  orbit.  It  may  occur 
as  the  primary  development  of  carcinoma  in  the  body,  giving  rise  to  second- 
ary infection  elsewhere,  but  this  also  is  rare. 

Carcinoma  grows  rapidly  in  the  brain,  is  not  sharply  defined,  rarely  has  a 
capsule,  is  decidedly  vascular,  and,  of  all  brain  tumors,  the  one  least  open 
to  operative  treatment. 

Fig.  129. 


Glio-sarcoma  of  corpus  callosum.    (Fr.\xcis.) 

Cystic  tumors  of  the  brain  may  arise  either  in  connection  with  glioma 
and  glio-sarcoma,  as  already  described,  or  independently,  as  the  result  of 
j^arasitic  infection.  Hydatid  cysts,  echinococcus,  and  cysticercus  are  much 
more  frequently  recorded  in  German  and  Australian  medical  journals  than 
in  this  country. 

Kuchenmeister  has  made  a  collection  of  88  cases  of  this  variety,  in  all  but 
13  of  which  multi]3le  cysts  were  found.  Of  these  49  involved  the  mem- 
branes, 41  were  in  the  cortex,  19  in  the  white  substance,  19  in  the  cerebel- 
lum, 18  in  the  ventricles,  17  in  the  basal  ganglia,  and  a  few  in  the  corpora 
quadrigemina,  pons,  and  medulla.  These  are  not  included  in  the  tables,  as  it 
Avould  give  an  appearance  of  undue  frequency  of  this  form  of  tumor.  These 
parasitic  cysts  grow  slowly,  and  produce  compression  of  the  brain  tissue,  bvit 
do  not  destroy  it.  The  symptoms  which  they  produce  are  very  rarely  so 
well  marked  as  to  enable  a  diagnosis  to  be  reached,  but  in  cases  in  which  a 
diagnosis  is  possible  these  tumors  may  be  easily  removed,  as  the  cyst-wall  is 
separable  from  the  brain  tissue.  Several  such  cysts  have  been  removed  in 
Germany. 

Gummata  of  the  brain,  though  very  rare  in  childhood,  and  never  the 
result  of  inherited  syphilis,  are  very  frequent  in  adult  life,  and  may  develop 
within  a  year  of  the  original  infection.  They  may  also  appear  as  the  only 
apparent  evidence  of  tertiary  syphilis  even  twenty  years  after  the  disease 
was  acquired. 

Gumma  may  occur  as  a  soft  gelatinous  exudation  ui)()n  the  base  of  the 


FOCAL  DISEASES  OF  THE  BBAIX  479 

brain,  its  favorite  position,  or  anywhere  in  the  membranes,  or  as  a  harder 
and  more  eircnmscribed  tnmor  in  the  meninges,  especially  of  the  cortex  and 
cerebellnm.  It  grows  rapidly,  bnt  also  subsides  rajDidly,  under  specific  treat- 
ment. In  one  case  under  my  care,  where  many  symptoms,  including  double 
optic  neuritis,  were  present,  the  patient  was  perfectly  well  in  nine  "months. 
The  occurrence  of  nocturnal  headache  and  insomnia  of  an  obstinate  charac- 
ter in  any  case  presenting  the  symptoms  of  brain  tumor,  will  suggest  the 
probability  of  a  gumma ;  and,  in  fact,  in  every  case  in  which  the  diagnosis 
of  brain  tumor  is  made  it  is  well  to  subject  the  patient  to  a  course  of  treat- 
ment by  mercury  and  iodide  for  a  period  of  at  least  two  months,  in  order  to 
eliminate  the  possibility  of  gumma.  Yet  it  must  not  be  hastily  argued  that 
the  subsidence  of  symptoms  under  this  treatment  'is  positive  evidence  that 
the  tumor  is  syphilitic.  In  a  case  under  my  observation,  which  autopsy 
proved  to  be  a  small  sarcoma  with  a  large  cyst,  the  wall  of  w^hich  was  sar- 
comatous tissue,  all  symptoms,  including  optic  neuritis,  subsided  under  this 
treatment,  and  the  patient  remained  well  for  a  period  of  five  months,  and 
then  sudden  death  in  coma  occurred  unexpectedly. 

Other  varieties  of  brain  tumor,  such  as  fibroma,  angioma,  myxoma,  psam- 
moma,  osteoma,  cholesteatoma,  lipoma,  teratoma,  which  occur  in  the  brain, 
are  of  great  rarity.  They  occur  both  in  children  and  in  adults,  and  their 
diagnosis  cannot  be  made  from  other  forms  of  tumor  during  life. 

Psammoma  is  usually  the  form  of  tumor  occurring  in  the  situation  of  the 
pineal  gland,  and  gives  rise  to  symptoms  similar  to  those  produced  by  tumors 
of  the  corpora  quadrigemina. 

Tumors  of  the  pituitary  body  are  not  uncommon,  and  are  usually  of  the 
nature  of  fibroma  or  myxoma.  It  is  maintained  by  some  that  the  disease 
acromegalia  is  the  result  of  such  tumors.  It  is  not  true,  however,  that  a 
tumor  of  the  pituitary  body  always  produces  symptoms  of  acromegalia,  and 
in  one  case  of  acromegalia  under  my  observation  the  autopsy  failed  to  show 
any  change  in  the  pituitary  body. 

The  appearance  of  a  brain  in  which  a  tumor  has  developed  is  usually 
characteristic.  The  membranes  are  tense,  the  convolutions  are  flattened 
by  pressure,  the  ventricles  are  distended  by  serous  fluid,  the  brain  tissue  is 
wet,  the  weight  of  the  brain  is  increased,  and  frequently  about  the  tumor 
there  is  a  zone  of  softening  of  greater  or  less  extent,  according  to  the  variety 
of  the  tumor.  Encapsulated  tumors  are  less  likely  to  be  surrounded  by  a 
softened  tissue. 

Intra-cranial  aneurisms  present  the  same  features  as  tumor  of  the  brain. 
They  are  rarely  large  in  size,  they  appear  upon  the  larger  arteries  at  the  base 
of  the  brain  and  upon  the  Sylvian  arteries.  They  are  usually  fusiform,  occa- 
sionally round.  They  increase  in  size  more  rapidly  than  ordinary  brain 
tumors,  or  than  aneurisms  elsewhere,  and  usually  rupture  before  attaining 
any  great  size.  They  produce  symptoms  by  their  pressure,  and  are  occasion- 
ally to  be  diagnosticated  by  pulsating  headache  or  the  sensation  which  they 
produce,  or  by  a  distinct  murmur  audi]:)le  to  the  stethoscope  on  the  head. 
Such  a  murmur  is  not,  however,  j^athognomonic,  as  I  have  heard  such  a  loud 
double  murmur  over  the  vSylvian  region  in  a  case  which  proved  at  the  o])era- 
tion  to  be  one  of  extensive  softening — no  aneurism  being  found. ^  In  a 
case  recently  seen  at  St.  Luke's  Hospital  the  aneurism  developed  rai)idly 
after  a  blow  on  the  head,  producing,  first,  left-third  nerve  paralysis,  and  one 
month  later  right  hemiplegia.  The  patient  died  three  months  after  the 
injury,  having  had  all  the  general  symptoms  of  brain  tumor.  An  aneurism 
of  the  left  internal  carotid  artery  at  the  point  of  union  with  the  posterior 

'  Starr:  Brain  Surgery,  Case  xix. 


480 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


communicating  artery  was  found,  which  had  ruptured.  As  the  arteries  were 
not  diseased,  it  seemed  probable  that  the  bruise  of  the  artery  against  the 
bone  at  the  time  of  the  injury  had  weakened  the  wall  and  predisposed  to 
aneurism. 

Symptoms.  While  the  symptoms  of  brain  tumor  are  in  many  cases  very 
clear  and  characteristic,  so  that  there  need  be  little  doubt  in  regard  to  the 
diagnosis,  both  of  the  existence  of  a  tumor,  of  its  nature,  and  of  its  location, 
it  must  be  stated  that  there  are  other  cases  in  which  no  characteristic  symp- 
toms at  all  appear. 

Numerous  cases  have  been  recorded  in  which  large  tumors  have  been  found 
unexpectedly  after  death,  even  in  locations  in  the  brain  in  which  the  existence 
of  a  tumor  would  presumably  have  produced  very  marked  symptoms. 
Thus,  in  one  case  under  my  observation,  a  large  glioma  occupied  the  entire 
white  substance  of  the  frontal  lobe  upon  the  left  side,  yet  the  patient  had 
suffered  only  from  occasional  attacks  of  epileptic  convulsions,  not  jDreceded 
by  an  aura,  and  never  unilateral,  was  as  intelligent  as  ever  up  to  the  time  of 
his  death,  though  his  family  had  noticed  some  irritability  of  temper  at  times, 
and  on  this  account  had  occasionally  questioned  his  responsibility  for  certain 
peculiarities.  This  man  was  under  observation  by  most  competent  physicians 
for  several  years,  and  was  supposed  to  have  epilepsy.  His  eyes  were  exam- 
ined and  found  to  be  normal  within  a  few  weeks  of  his  sudden  death,  which 
took  place  in  a  convulsion.  He  had  never  had  the  ordinary  symptoms  of  a 
brain  tumor.     Schoenthal'  has  recorded  a  case  of  supposed  hysteria  in  which 

Fig.  130. 


Sarcoma  of  base  separating  the  crura  and  surrounding  the  optic  chiasm  and  greatly  stretching 
the  optic  nerves.    The  exit  of  the  optic  nerves  from  the  tumor  is  indicated  by  the  white  dots. 

the  variability  of  the  symptoms  were  surprising,  and  in  which  careful  exami- 
nation failed  to  reveal  any  permanent  or  tangible  physical  signs.  x'Vfter 
death  a  large  tumor  of  the  right  frontal  lobe  was  found.  Mayer'^  has  collected 
several  such  cases.     Buzzard  has  recorded  similar  cases.     BramwelP  has  de- 


1  Berlin,  kiln.  Woch.,  1891,  No.  10.    See  also  Williams  :  Lancet.  October  14,  1893. 

2  E.  Mayer:  Inaug.  Dissert.,  Berlin,  1891.  s  intra-cranial  Tumors,  p.  12. 


FOCAL  DISEASES  OF  THE  BBAIN.  481 

scribed  an  enormous  tumor  lying  in  the  central  region  upon  the  cortex  of 
the  right  side  in  which  there  were  no  symptoms  of  j^aralysis  whatever.  And 
many  tumors  have  been  found  in  and  about  the  cerebellum  which  have 
failed  to  produce  the  ordinary  symptoms  of  brain  tumor. 

Tumors  upon  the  base  of  the  brain  may  also  be  found  involving  structures, 
which,  during  life,  appear  to  have  been  capable  of  carrying  on  their  ordinary 
functions.  Thus  a  child  under  my  observation  suffered  for  five  months  from 
occasional  convulsions,  from  headache,  from  spastic  paraplegia,  but  had  no 
difficulty  whatever  of  vision,  and  no  paralysis  of  the  cranial  nerves.  The 
autopsy  showed  a  large  tumor  upon  the  base  in  the  median  line,  through 
which  both  the  optic  nerves  passed  and  in  which  the  orotic  chiasm  lay.  It 
must  have  rested  upon  all  the  motor  nerves  of  the  eyes  and  compressed  the 
fifth  nerve  on  both  sides.  This  tumor  had  grown  upward,  filling  both  the 
lateral  ventricles  and  obliterating  the  third  ventricle  entirely.^   (See  Fig.  130.) 

I  have  seen  a  tumor  of  the  medulla  oblongata,  an  infiltrating  glioma, 
which  produced  an  apparent  uniform  increase  in  size  of  the  entire  medulla 
to  double  its  ordinary  dimensions,  but  in  which  there  were  absolutely  no  signs 
of  any  disease  of  either  cranial  nerves  or  tracts  passing  through  this  impor- 
tant part  of  the  nervous  system.  The  patient  had  headaches,  slight  optic 
neuritis,  occasional  convulsions,  and  a  slightly  staggering  gait,  which  led  to 
the  diagnosis  of  tumor  of  the  cerebellum.     (See  Fig.  125.) 

It  is  thus  evident  that  tumors  in  the  various  parts  of  the  brain  substance 
may  develop  and  assume  a  considerable  size  without  producing  characteristic 
symptoms  either  of  a  local  or  of  a  general  ty^^e.  Such  cases,  however,  are 
rare,  and  the  careful  observer  will  usually  be  able  to  diagnosticate  a  brain 
tumor. 

The  symptoms  of  brain  tumor  are  very  numerous,  but  for  purposes  of  con- 
venience may  be  separated  into  two  categories. 

I.  General  symptoms  due  to  the  existence  of  a  new  growth  irrespective  of 
its  position.  These  are  headache,  general  convulsions,  double  optic  neuritis, 
and  optic  atrophy,  changes  of  disposition  and  of  mental  power,  vomiting, 
vertigo,  insomnia,  changes  in  the  pulse  rate,  attacks  of  syncope,  polyuria, 
and  progressive  malnutrition. 

II.  Focal  symptoms  of  the  disease  in  the  cortex  of  the  brain  or  beneath 
the  cortex  in  the  projection  tracts  which  join  the  cortex  to  the  various  sub- 
cortical centres.  These  symptoms  are  unilateral  spasms,  monoplegia,  or 
hemiplegia,  parsesthesia  or  anaesthesia  in  one  or  more  limbs,  hemianoi^sia,  and 
the  various  forms  of  aphasia.  Affections  of  the  cranial  nerves  and  basal 
parts  of  the  brain,  which  occur  with  tumors  in  the  basal  ganglia  and  cere- 
bral axis,  or  external  to  the  brain  upon  the  base.  These  latter  symptoms 
are  frequently  very  complex,  as  may  be  supposed,  when  it  is  remembered 
that  the  twelve  cranial  nerves  have  extensive  nuclei  of  origin  and  a  long 
course,  and  that  all  connection  between  the  external  world  and  the  brain 
passes  through  the  cerebral  axis. 

In  the  vast  majority  of  cases  of  brain  tumors  we  find  some  of  these  general 
and  focal  symptoms  present.  And  from  their  combination  and  the  order  of 
their  development  it  is  usually  possible  to  arrive  at  a  definite  diagnosis. 
These  symptoms  must  therefore  be  studied  with  care. 

I.  General  symptoms  occur  irrespective  of  the  location  of  the  tumor, 
and  depend  upon  its  rapidity  of  growth,  its  vascularity,  and  its  pathological 
character.  They  vary  in  severity  from  time  to  time,  probably  in  accordance 
with  the  activity  of  the  pathological  process  going  on  in  and  about  the  tumor 
and  with  the  condition  of  blood-supply  in  the  brain.     When  a  tumor  is 

1  Transactions  Amer.  Neurol.  Assoc,  1891.    Starr:  Brain  Tumor. 
31 


482  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

growing  rapidly  they  are  very  severe ;  if  it  remain  stationary  they  may 
almost  disappear.  They  are  often  affected  by  those  agents  which  produce  a 
temporary  cerebral  hypersemia  or  anaemia,  as  is  proved  by  the  fact  that  hot 
foot  baths  or  general  hot  baths  may  produce  marked  changes  in  the  degree 
of  general  symptoms. 

Headache  is  the  most  prominent  and  constant  symptom  of  brain  tumor. 
It  varies  in  severity,  but  is  usually  very  intense.  It  may  be  intermittent,  it 
may  recur  with  periodicity,  is  usually  worse  at  night  in  syphilitic  cases,  worse 
in  the  daytime  in  other  cases,  is  increased  by  physical  effort,  or  mental  strain, 
or  emotional  excitement.  It  may  be  a  dull,  heavy,  continuous  pain,  with 
sharp  paroxysms,  during  which  the  patient  cannot  control  his  suffering.  It 
varies  in  its  location,  is  usually  frontal  or  occipital,  and  the  situation  of  the 
pain  rarely  indicates  the  situation  of  the  tumor.  If,  however,  the  pain  is 
constantly  located  in  the  occipital  region  the  tumor  is  probably  in  the  pos- 
terior fossa.  The  pain  is  often  associated  with  indefinite  cerebral  sensations 
described  as  fulness,  pressure,  confusion,  tightness,  as  if  a  band  were  drawn 
about  the  forehead ;  and  these  give  rise  to  great  discomfort.  In  infants  the 
existence  of  headache  may  be  inferred  from  constant  motion  of  the  head, 
from  movements  of  the  hands  grasping  the  head,  or  pulling  the  hair,  and  from 
sudden  outbursts  of  screaming  without  other  ascertainable  cause.  Headache 
is  probably  less  severely  felt  in  cases  of  tumor  in  infants,  as  the  opening  of 
the  sutures  may  prevent  the  extreme  degree  of  intra-cranial  pressure  to  which 
the  headache  is  chiefly  ascribed.  In  adults  the  headache  prevents  the  patient 
from  making  any  physical  or  mental  exertion,  and  leads  to  a  desire  for  seclu- 
sion and  quiet. 

The  causes  which  are  supposed  to  produce  the  headache  are  the  increase  of 
the  intra-cranial  pressure  and  the  consequent  stretching  of  the  membranes ; 
the  existence  of  effusion  into  the  ventricles,  which  is  a  frequent  accompani- 
ment of  a  tumor ;  the  variations  in  the  cerebral  circulation  produced  by  the 
pressure  of  the  tumor,  or  the  direct  involvement  of  the  sensitive  dura  mater 
and  branches  of  the  fifth  nerve.  Such  effects  of  the  presence  of  a  tumor  are 
more  likely  to  follow  when  the  new  growth  is  in  the  posterior  cranial  fossa 
under  the  tentorium  cerebelli,  and  in  such  cases  headache  is  most  constant 
and  most  severe. 

The  headache  is  often  associated  with  a  marked  tenderness  of  the  head  to 
percussion,  and  if  this  is  not  due  to  sensitiveness  of  a  single  nerve  trunk  it 
is  a  very  valuable  sign  of  the  location  of  a  tumor.  Such  a  tenderness  to 
percussion  is  more  commonly  found  in  tumors  lying  just  beneath  the  bone, 
that  is  cortical  tumors,  than  in  tumors  deep  within  the  brain.  It  has  been 
asserted  that  a  flatness  to  auscultatory  percussion  can  be  detected  over  a 
tumor,  and  I  am  able  to  confirm  this  statement,  having  noticed  it  in  several 
cases.     It  is  not  always  present. 

General  convulsions  are  the  next  most  frequent  symptom  of  brain  tumor. 
They  are  particularly  liable  to  occur  as  an  early  symj)tom  in  children,  but 
may  also  be  the  first  symptom  of  tumor  in  adults.  Thus,  in  a  patient  of 
mine  from  whom  Dr.  McBurney  removed  a  large  sarcoma  of  the  frontal  lobe, 
the  first  symptom  was  a  general  convulsion  which  occurred  two  months  before 
the  headache  began,  and  was  never  repeated  during  the  three  years'  course  of 
the  disease.'  In  another  patient  under  my  care,  who  subsequently  developed 
all  the  general  symptoms  of  brain  tumor,  general  convulsions  occurred  at 
intervals  during  three  months  before  any  other  symptom  appeared.  A  case 
diagnosticated  as  epilepsy  has  already  been  mentioned. 

It  is  njot  uncommon  to  find  convulsions  occurring  at  irregular  intervals 

1  See  Amer.  Journ.  of  the  Med.  Sciences,  January,  1893. 


FOCAL  DISEASES  OF  THE  BRAIN.  483 

from  the  onset  of  the  disease  to  its  termination.  They  usually  occur  at  long 
intervals,  but  have  been  known  to  be  as  frequent  as  twenty  to  thirty  a  day. 
They  may  be  slight  in  degree,  almost  of  the  nature  of  petit  mal,  with  a  sudden 
loss  of  consciousness,  or  this  loss  of  consciousness  may  be  attended  by  a  little 
twitching  of  the  face  and  eyes,  with  stiffening  of  the  back  and  extremities, 
balancing  movements  of  an  automatic  kind,  which  prevent  falling,  and  then 
recovery ;  or  they  may  have  all  the  general  characteristics  of  a  general  epi- 
leptic seizure  followed  by  coma.  Sometimes  a  peculiar  general  tremor  follows 
the  attack,  and  may  last  for  an  hour  or  more. 

General  convulsions  may  be  a  culmination  of  a  local  spasm ;  hence,  wher- 
ever a  convulsion  occurs  particular  attention  is  to  be  called  to  the  manner  of 
its  beginning,  and  the  patient  is  to  be  carefully  observed  and  instructed  to 
watch  for  a  conscious  aura.  The  significance  of  local  spasms  will  be  discussed 
in  the  next  section. 

Convulsions  are  usually  indicative  of  rapid  progress  in  the  new  growth,  of 
effusion  into  the  ventricles,  of  hemorrhage  within  the  tumor  or  of  a  secondary 
affection  of  the  meninges.  They  may  occur  from  tumors  situated  anywhere, 
and  have  no  significance  as  a  diagnostic  symptom  of  its  location.  Death  not 
infrequently  occurs  in  convulsions  in  brain  tumor,  and  hence  a  development 
or  rapid  increase  of  this  symptom  is  a  sign  of  danger. 

Changes  of  disposition  and  of  mental  poiver  occur  in  the  course  of  brain  tumor 
with  considerable  frequency.  These  have  sometimes  been  explained  by  the 
existence  of  headache,  the  suffering  producing  mental  exhaustion.  But  they 
are  also  observed  quite  uniformly  with  tumors  of  the  brain,  even  when  head- 
ache is  not  severe.  In  children  this  symptom  is  quite  noticeable ;  the  child 
becomes  fretful  and  irritable,  refuses  to  notice  its  toys  or  to  play,  or,  if  it  does 
so,  soon  becomes  wearied,  and  requires  constant  attention.  It  may  become 
indifferent  to  things  in  which  it  was  formerly  interested,  prefers  to  lie  down 
and  to  keep  quiet,  in  a  manner  unnatural  to  a  healthy  child,  and  may  even 
become  somnolent  and  lethargic,  or  it  may  have  apparent  attacks  of  cause- 
less terror.  In  adults  the  mental  dulness  is  very  noticeable.  The  patient 
takes  little  interest  in  his  ordinary  surroundings  or  business,  and  is  content  to 
sit  or  lie  for  hours,  doing  nothing,  and  apparently  with  vacant  mind.  Such 
a  patient  is  easily  aroused,  and  replies  intelligently  to  questions,  but  cannot  be 
considered  in  a  normal  state  of  mental  activity.  On  the  other  hand,  such  a 
patient  is  not  demented,  although  late  in  the  course  of  the  disease  a  condition 
quite  approaching  dementia  is  often  observed,  especially  in  tumors  of  the 
frontal  lobes.  Attacks  of  maniacal  excitement  have  been  recorded,  but  are 
very  rare.  The  usual  mental  state  present  in  brain  tumor  after  it  has  existed 
for  a  period  of  six  months  may  be  described  as  one  of  apathy.  These  symp- 
toms are  probably  referable  to  the  increased  intra-cranial  pressure  and  con- 
sequent compression  of  the  brain,  which  interferes  with  the  processes  of 
association  upon  which  all  thought  depends.  The  tumor  appears  by  its 
pressure  to  hamper  the  transmission  of  impulses  throughout  the  brain. 
Somnolence  may  be  associated  with  this  apathy.  In  the  case  of  tumor  of 
the  frontal  lobes  and  corpus  callosum^  (shown  in  Figs.  128  and  129)  mental 
apathy  was  the  chief  symptom  from  beginning  to  end. 

Double  optic  neuritis  and  optic  nerve-atrophy  are  very  important  diagnostic 
symptoms  of  intra-cranial  tumor.  Neuritis  is  usually  associated  with  other 
signs  of  increased  intra-cranial  pressure,  but  may  occur  without  such  press- 
ure. It  is  present  in  80  per  cent,  of  the  cases,  and  should  be  looked  for  in 
every  case  which  presents  cerebral  symptoms.  A  marked  degree  of  optic 
neuritis  may  exist  without  any  impairment  of  vision ;  hence,  the  ophthalmo- 

1  R.  G.  Francis :  Amer.  Journ.  of  the  Med.  Sciences,  June,  1895. 


484  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

scope  should  be  used,  whether  the  defect  of  sight  be  present  or  not.  But 
when  the  patient  shows  impairment  of  visual  power,  or  limitation  of  the 
visual  field  for  colors  or  for  light,  or  is  becoming  blind,  it  will  be  found  that 
optic  neuritis  or  optic  atrophy  is  fully  developed.  Sudden  loss  of  vision 
appears  to  be  more  commonly  noted  in  histories  of  children's  cases  than  in 
those  of  adults,  possibly  because  a  gradual  loss  of  sight  is  not  detected.  It  is 
true  that  hydrocephalus  may  cause  choked  disks,  and  hence  from  this  symptom 
alone  a  tumor  cannot  be  diagnosticated.  But  in  cases  where  the  diagnosis  is 
difficult  no  more  important  objective  evidence  of  brain  tumor  can  be  found. 

Tumors  of  the  cerebellum  and  corpora  quadrigemina,  and  tumors  upon  the 
base  of  the  brain  and  in  the  basal  ganglia,  produce  optic  neuritis  more  con- 
stantly and  earlier  in  their  course  than  tumors  situated  in  the  cortex  or  cen- 
trum ovale.  Optic  neuritis  is  usually  double,  though  it  always  appears  first 
in  one  eye,  and  is  rarely  equally  intense  in  both  eyes ;  but  in  a  few  cases  it 
has  been  found  in  one  eye  only,  and  then  is  thought  to  indicate  disease  of 
the  nerve  in  the  orbit  or  in  front  of  the  optic  chiasm,  rather  than  a  distant 
tumor.  For  the  exact  changes  in  the  retina  and  for  the  pathological  causes 
of  optic  neuritis  the  reader  is  referred  to  special  text-books.  ^ 

Vomiting  is  a  symptom  of  brain  tumor  more  frequently  observed  in  chil- 
dren than  in  adults.  It  may  or  may  not  be  accompanied  by  nausea.  It  may 
occur  accidentally,  without  special  relation  to  the  time  of  meals,  or  it  may 
be  so  continuous  as  to  threaten  inanition.  It  occurs  not  infrequently  on  any 
movement  of  the  head  after  the  patient  has  been  confined  to  bed  for  some 
time,  and  then  it  is  usually  associated  with  vertigo.  It  also  frequently 
accom]Danies  severe  headache. 

Vertigo  is  sometimes  a  coincident  symptom,  but  usually  occurs  independ- 
ently of  vomiting.  The  patient  feels  dizzy,  feels  himself  turning  or  falling, 
and  things  about  him  appear  to  be  in  motion.  He  grasps  at  near  objects  for 
support,  covers  his  eyes  with  his  hands,  or  lies  down  on  the  floor  and  cries 
out  with  bewilderment  and  distress.  Like  vomiting,  vertigo  may  be  excited 
by  changes  of  position.  It  occurs  at  intervals,  in  attacks  of  short  or  long 
duration.  It  occurs  more  frequently  with  tumors  in  the  posterior  fossa,  in 
the  cerebellum,  or  pons,  or  on  the  base  involving  the  auditory  nerve,  than 
with  tumors  elsewhere.  Such  attacks  of  vertigo  are  not  to  be  confounded 
Avith  the  slight  constant  vertigo  due  to  double  vision,  and  secondary  to 
paresis  of  the  third  and  sixth  nerves. 

Insomnia  may  be  due  to  disturbances  of  the  cerebral  circulation  or  to  the 
intensity  of  the  other  general  symptoms,  and  is  much  more  rarely  com- 
plained of  in  cases  of  tumor  in  children  and  youth  than  in  adults  suflTering 
from  syphilitic  tumors. 

Fever  and  changes  in  the  rapidity  and  rhythm  of  the  pulse  have  been  ob- 
served in  the  course  of  brain  tumors.  The  former  is  ascribed  to  inflamma- 
tory changes  in  the  brain  or  meninges  as  a  complication.  The  latter  is 
regarded  as  evidence  of  increased  intra-cranial  pressure.  Slow  and  irregular 
pulse  is  the  form  usually  noted,  but  toward  the  close  of  life  very  rapid  jiulse 
has  been  observed.  Irregular  or  Cheyne-Stokes  respiration  has  also  been 
noticed  as  a  terminal  symptom. 

Occasionally  attacks  of  syncope  occur  in  patients  with  tumor  of  the  pos- 
terior fossa,  and  a  general  feeling  of  weakness  is  not  infrequently  complained 
of.  Polyuria  and  glycosuria  may  develop  in  the  course  of  brain  tumor'^  as 
a  symptom  of  increased  pressure.  It  has  been  found  also  in  small  tumoi's  of 
the  medulla'^  as  an  evidence  of  irritation  of  the  vagus  nucleus. 

1  See  especially  Knies :  The  Eye  in  General  Diseases.    William  Wood  &  Co.,  1895. 
-  See  Kothmann,  Zeitsch.  f.  kiln.  Med.,  1893,  xxiii.  p.  339. 
3  De  Jonge,  Arch,  f  Psych.,  xili.  p.  658. 


FOCAL  DISEASES  OF  THE  BBAIN. 


485 


A  rise  of  temperature  in  the  scalp  over  the  tumor  has  been  observed  in  a 
few  cases,  but  is  not  a  uniform  or  reliable  symptom  of  brain  tumor. 

The  combination  of  several  of  these  general  symptoms  in  any  case  should 
lead  to  a  strong  suspicion  of  intra-cranial  tumor.  When,  in  addition,  local 
symptoms  are  added,  the  diagnosis  should  not  be  difficult.  In  all  cases  the 
onset  of  the  general  symptoms  is  gradual,  their  intensity  increasing  as  time 
goes  on,  and  a  careful  study  of  their  mode  of  development  and  progress  is  a 
great  aid  in  the  diagnosis  of  the  kind  of  tumor  present,  of  its  size,  and  of  the 
rapidity  of  its  growth. 

The  distress  produced  by  the  general  symptoms  is  usually  much  greater 
than  that  caused  by  the  local  symptoms,  and  consequently  treatment  is  often 
required  for  their  alleviation. 

The  focal  symptoms  of  brain  tumor  depend  entirely  wpon  the  situation 
of  the  tumor. 

A  distinction  is  made  between  direct  and  indirect  focal  symptoms,  the  first 
being  due  to  irritation  or  destruction  of  a  limited  area  by  the  tumor,  the 
second  being  due  to  interference  with  the  function  of  an  area  by  disease  at  a 
distance  from  it  which  impairs  its  circulation  or  causes  pressure  upon  it. 
Thus,  a  tumor  of  the  cerebellum  may  cause  inco-ordination  and  vertigo  as 
direct  symj)toms,  and  also  cause  j)aralysis  of  the  sixth  and  seventh  cranial 
nerves  as  an  indirect  symptom  of  displacement  of  the  pons  Varolii  to  one 
side,  which  stretches  these  nerves  unduly.  Tumors  usually  cause  both  forms 
of  focal  symptoms,  and,  therefore,  much  care  must  be  given  to  the  question  of 
their  significance  in  any  case. 

Fig.  131. 


The  functional  areas  of  the  cerebral  cortex.    Left  hemisphere. 


Focal  symptoms  may  further  be  divided  broadly  into  two  classes,  those 
produced  by  tumors  in  the  cortex  and  cerebral  hemispheres,  and  those  pro- 
duced by  tumors  upon  the  base  of  the  brain  affecting  the  cranial  nerves. 
Figures  131  and  132  display  the  various  functions  performed  by  the  diiferent 
areas  of  the  cortex  of  the  brain  so  far  as  is  at  present  known.  Reference 
may  be  made  to  the  preceding  chapter  upon  localization  of  the  brain  func- 
tions. Figures  133  and  134  represent  the  tracts  and  association  fil)res  which 
lie  beneath  the  cortex  and  occupy  the  cerebral  hemispheres  above  and  in 


486 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  vicinity  of  the  basal  ganglia,  and  Figure  133  displays  the  fact  that  all 
fibres  joining  the  cortex  with  the  cerebral  axis  are  compressed  into  a  narrow 
strait — the  internal  capsule — in  their  exit  from  the  cerebral  hemispheres. 
Figure  135  shows  the  base  of  the  brain,  together  with  the  numerous  cranial 


Fig.  132. 


The  functional  areas  of  the  cerebral  cortex.    Eight  hemisphere. 


The  projection  tracts  joining  the  cortex  with  lower  nerve  centres.  Sagittal  section,  showing  the 
arrangements  of  tracts  in  the  internal  capsule,  a,  tract  from  the  frontal  lobe  to  the  pons,  thence  to 
the  cerebellar  hemisphere  of  the  opposite  side ;  b,  motor  tract  from  the  central  convolutions  to  the 
facial  nucleus  in  the  pons  and  to  the  spinal  cord  ;  its  decussation  is  indicated  at  k  ;  c.  sensory  tract 
from  posterior  columns  of  the  cord,  through  the  posterior  part  of  the  medulla,  pons,  crus,  and  cap- 
sule to  the  parietal  lobe  ;  d,  visual  tract  from  the  optic  thalamus  (ot)  to  the  occipital  lobe ;  e,  audi- 
tory tract  from  the  intergeniculate  body,  to  which  a  tract  passes  from  the  viii.  N.  nucleus  (j)  to  the 
temporal  lofee ;  f,  superior  cerebellar  peduncle ;  g,  middle  cerebellar  peduncle ;  h,  inferior  cere- 
bellar peduncle ;  cn,  caudate  nucleus ;  cq.  corpora  quadrigemina ;  vt,  fourth  ventricle.  The  nu- 
merals refer  to  the  cranial  nerves. 


FOCAL  DISEASES  OF  THE  BRAIN.  487 

nerves,  and  from  it  may  be  deduced  the  various  symptoms  that  will  arise 
when  a  tumor  involves  any  portion  of  the  base.  With  the  anatomy  of  the 
brain  in  mind  it  is  not  difficult  to  understand  the  various  local  symptoms 
that  may  arise  from  the  existence  of  brain  tumor  in  different  localities.  It 
should  also  be  remembered,  however,  that  a  tumor  of  very  slow  growth, 
which  compresses  and  does  not  infiltrate  the  brain,  may  exist  in  any  of  these 
locations  without  necessarily  producing  focal  symptoms,  until  it  has  attained 
a  considerable  size.  It  is  also  evident  that  a  single  tumor  rarely,  if  ever, 
produces  a  large  number  of  focal  symptoms,  but  that  all  tumors  lying  in  any 
given  location  will  produce  the  same  symptoms.  It  is  also  evident  that 
tumors  will  almost  always  produce  unilateral  symptoms,  inasmuch  as  they 
rarely  lie  exactly  in  the  median  line.     And  even  the  tumors  of  the  coi'pus 

Fig.  134. 


r--* 
M 


The  association  fibres,   a,  between  aujaeem  convolutions;  B,  between  frontal  and  occipital  areas 
c,  between  frontal  and  temporal  areas,  cingulum ;  d,  between  frontal  and  temporal  areas,  fasciculus 
uncinatus ;  E,  between  occipital  and  temporal  areas,  fasciculus  longitudinalis  inferior  ;  CN,  caudate 
nucleus  ;  ot,  optic  thalamus. 

callosum,  of  which  about  twenty  have  been  recorded,  have  rarely  been  so 
exactly  median  in  their  situation  as  to  give  rise  to  symmetrical  symptoms 
upon  both  sides. 

The  focal  symptoms  usually  commence  gradually  and  are  limited  in  ex- 
tent, but  increase  steadily  as  the  tumor  grows. 

The  focal  s^jmptoms  of  tumors  of  the  frontal  cortex  may  be  enumerated  as 
follows :  Mental  inactivity,  forgetfulness,  lack  of  judgment,  decided  change 
in  character,  irritability  of  temper  and  unusual  stupidity,  an  inability  to  con- 
centrate the  attention,  to  think  connectedly  and  continuously,  to  learn  easily, 
to  exercise  self-control,  lastly  a  state  approaching  mild  dementia  without  de- 
lusions, in  which  the  patient  may  become  dirty  and  disregard  all  restraints  of 
decency.  These  symptoms  are  especially  marked  in  tumors  of  the  frontal 
cortex  and  subjacent  white  matter.^  They  are  not  present  in  tumors  lying 
upon  the  base  of  the  frontal  region  on  the  orbital  bone.  They  rarely  appear 
in  tumors  in  other  regions  of  the  cortex  until  the  last  stages  of  the  disease, 
when  the  intra-cranial  pressure  is  very  great.  A  decided  mental  change  in 
character  and  disposition,  a  mental  apathy  and  a  tendency  to  somnolence 
must  be  regarded  as  a  local  sign  of  frontal  lobe  disease.  While  the  integrity 
of  the  frontal  lobes  is  necessary  to  complete  mental  action,  yet  no  special 
loss  of  mental  faculty  can  be  said  to  result  from  their  destruction.     Nor  is 

1  Ferrier :  Lancet,  June  4, 1892. 


488 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


there  any  apparent  way  to  detect  from  the  mental  symptoms  in  which  hemi- 
sphere of  the  brain  the  tumor  lies.  The  diagnosis  of  tumor  of  the  frontal 
lobes  is,  therefore,  rarely  made  from  a  study  of  direct  focal  symptoms.  It  is 
to  be  remembered,  however,  that  a  tumor  when  situated  in  other  regions  of 
the  cerebral  hemispheres,  excepting  only  the  temporo-sphenoidal  lobe,  will 


Fig.  135. 


The  base  of  the  brain  and  the  cranial  nerves,  crura,  pons,  and  medulla  (Allen  Thompson).  I  to 
XII,  the  cranial  nerves  ;  Th,  optic  thalamus;  h,  pituitary  body  ;  tc,  tuber  cinereum  ;  a,  corpora  albi- 
cantia  ;  P,  pes  pedunculi ;  i,  interior  ;  and  e,  exterior,  geniculate  body  ;  PV,  pons  Varolii ;  pa,  an- 
terior pyramid  of  medulla ;  o.  olive  ;  d,  decussation  of  anterior  pyramids  ;  ca,  anterior  column  of 
spinal  cord ;  cl,  lateral  column  of  spinal  cord ;  Ce,  cerebellum  ;  fl,  flocculus  of  cerebellum. 

produce  other  direct  focal  symptoms,  the  absence  of  which  may  lead  to  the 
suspicion  that  a  tumor  is  situated  in  the  frontal  lobe. 

Tumors  in  the  frontal  lobe  frequently  produce  irritation  of  the  cortex. 
While  such  irritation  is  limited  to  the  frontal  cortex  Ave  have  no  evidences  of 
its  occurrence,  but  there  is  a  tendency  in  the  brain  for  irritation,  starting  in 
one  part  to  radiate  outward  to  adjacent  parts,  like  the  ripple  upon  a  lake 
when  a  stone  is  thrown  in.  While  irritation  starts  from  the  frontal  region 
it  frequently  appears  to  radiate  backward,  and  thus  involve  the  central  region 


FOCAL  DISEASES  OF  THE  BRAIN.  489 

of  the  brain,  and  under  these  circumstances  symptoms  referable  to  the  cen- 
tral region  appear,  namely,  localized  spasms,  pareesthesia,  and  paralysis/ 

Bruns  has  recently  recorded'^  three  cases  of  frontal  tumor  in  which  there 
had  been  some  disturbance  in  the  balancing  power,  and  a  staggering  gait 
similar  to  that  observed  in  cerebellar  disease  ;  l)ut  this  symptom  has  not  been 
uniformly  noticed.  It  is  known  that  the  frontal  lobes  and  cerebellar  hemi- 
spheres have  a  crossed  connection,  and  it  is  possible  that  this  symptom  may 
prove  of  some  diagnostic  value  if  confirmed.  It  may  have  been  due  to  an 
irritation  of  the  cerebellum  conveyed  along  these  connecting  tracts. 

Tumors  situated  in  the  third  frontal  convolution  of  the  left  hemisphere  in 
right-handed  persons  and  of  the  right  hemisphere  in  left-handed  persons  jh-o- 
duce  motor  aphasia  with  agraphia,  the  patient  being  al)le  to  understand  lan- 
guage both  written  and  spoken,  but  being  unable  to  give  expression  to  his 
ideas.  When  this  symptom  develops  as  the  result  of  brain  tumor  the  disturb- 
ance of  speech  is  gradual  in  its  onset,  the  patient  noticing  first  a  hesitancy 
in  speech,  a  loss  of  words,  and  possibly  a  misuse  of  words  before  he  loses  the 
power  of  expression.  The  aphasia  is  less  complete  in  brain  tumor  than  in 
those  apoplectic  conditions  which  are  the  common  cause  of  aphasia. 

Tumors  involving  the  motor  area  of  the  brain  give  rise  to  well-marked  and 
distinctive  symptoms.  The  special  functions  of  the  motor  area  are  displayed 
in  Figures  131  and  132,  and  the  symptoms  that  are  produced  by  a  tumor 
beginning  in  any  portion  of  this  area  are  easily  deduced  from  reference  to 
these  figures.  If  the  tumor  is  cortical  in  its  situation  it  almost  inevitably  gives 
rise  to  local  symptoms ;  these  may  be  in  the  form  of  tonic  or  clonic  convul- 
sions, occurring  at  intervals,  either  limited  to  one  part  of  the  body,  such  as  the 
face,  or  hand,  or  foot,  or  extending  from  the  part  first  invaded  to  other  parts 
in  a  definite  order  of  succession  ;  the  extension  being  commonly  from  face  to 
arm,  to  body,  and  then  to  leg,  or  in  the  reverse  order.  Such  attacks,  first  de- 
scribed by  Hughlings  Jackson,  are  known  as  attacks  of  Jacksonian  epilepsy. 
If  it  be  remembered  that  the  irritation  starting  from  one  part  of  the  cortex 
and  radiating  outward  to  other  parts  jiroduces  a  spasm  beginning  in  the 
muscles  represented  in  the  centre  first  irritated,  and  extending  to  other  mus- 
cles represented  in  adjacent  centres,  it  will  be  evident  that  the  exact  order  of 
the  spasm  aids  one  to  determine  the  situation  of  the  tumor,  for  it  is  evident 
that  a  spasm  beginning,  we  Avill  say,  in  the  thumb  and  extending  then  to  the 
fingers,  to  the  hand  and  up  the  arm  to  the  shoulder,  will  indicate  an  initial 
irritation  of  the  thumb-centre  of  the  cortex,  extending  then  to  the  centre  for 
the  fingers,  hand,  and  arm.  A  convulsion  beginning  with  the  turning  of 
the  head  and  eyes  to  one  side  indicates  a  tumor  situated  in  the  anterior  mid- 
dle portion  of  the  motor  zone,  and  if  that  irritation  extends  from  this  point 
backward  or  downward  the  spasm  will  extend  from  head  and  eyes  to  arm 
or  face  respectively.  Thus  the  point  of  Ijeginning  of  a  spasm  and  its  order 
of  extension  are  the  most  important  localizing  symptoms  of  brain  tumor  in 
the  motor  area.  Such  a  spasm  is  usually  followed  by  temporary  paralysis, 
and  as  the  tumor  increases  in  size  and  the  spasms  increase  in  frequency  and 
extent,  the  paralysis  may  remain  permanent  between  the  spasms.  Spasms 
due  to  cortical  irritation  are  almost  invariably  attended  by  numbness  and 
tingling  in  the  part  first  affected  by  spasms,  so  that  such  a  tingling  is  often  a 
valuable  indication  of  the  location  of  irritation  in  the  cortex.  This  tingling 
may  even  precede  the  spasm,  and  ha.s  been  termed  h\  Seguin  the  "  signal 
symptom  "  of  a  cortical  irritation.  AVhen  such  a  parsesthesia  is  a  permanent 
symptom  the  tumor  is  more  likely  to  he,  situated  behind  the  fissure  of  Rolando 

1  See  a  case  of  mv  own,  American  Journal  of  the  Medical  Sciences,  Jan.,  1893. 
-  Deut.  Med.  Wochen.,  1892,  p.  138. 


490  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

than  in  front  of  it.  When  the  irritation  produced  by  a  tumor  in  the  motor 
zone  is  very  intense,  the  local  spasm,  after  extending  from  one  limb  to  the 
entire  side  of  the  body,  may  even  become  general,  be  associated  with  loss  of 
consciousness,  and  terminate  as  a  general  convulsion.  While  such  an  order 
of  extent  preceding  the  general  convulsion  is  of  great  diagnostic  importance, 
a  general  convulsion  beginning  suddenly,  with  loss  of  consciousness  and  with- 
out any  local  spasm,  is  not  to  be  regarded  as  indicative  of  disease  in  the  motor 
area.  There  are  cases  of  brain  tumor  in  which  the  motor  area  has  been 
generally  compressed  and  destroyed  without  the  production  of  these  local 
spasms,  but  with  a  progressive  and  increasing  paralysis  alone.  It  is  thought 
that  such  a  paralysis  not  associated  with  spasms  indicates  that  the  situation 
of  the  tumor  is  in  the  white  matter  beneath  the  cortex  and  not  in  the  cortex 
itself,  and  that  the  symptoms  are  due  to  an  invasion  of  the  motor  tract  in  its 
passage  toward  the  internal  capsule.  Some  ataxia  is  commonly  associated 
with  the  paralysis  produced  by  tumors,  and  a  marked  inco-ordination  or  dis- 
turbance of  the  muscular  sense,  like  anaesthesia,  points  to  a  situation  of  the 
tumor  behind  the  fissure  of  Kolando.  The  condition  of  the  deep  reflexes  is 
altered  in  all  cases  of  tumor  in  the  motor  area ;  a  marked  increase  in  the 
tendon  reflexes  at  the  elbow,  wrist,  knee  and  ankle  is  one  of  the  early  signs 
of  paralysis.  There  is  no  atrophy  in  the  paralyzed  muscles,  but  merely  a 
slight  wasting  from  disuse,  and  there  is  no  change  in  the  electric  reaction  of 
the  muscles.  There  should  be  no  difficulty  in  differentiating  a  cerebral  paraly- 
sis, even  of  the  monoplegic  type,  from  spinal  or  nerve-trunk  paralysis,  even  in 
infancy,  because  of  these  points  of  contrast.  The  careful  study  of  the  localiz- 
ing symptoms  of  tumors  of  the  motor  region  has  resulted  in  successful  locaK- 
zation  of  such  tumors  and  in  their  successful  removal  fi-om  the  brain ;  in 
fact,  there  is  no  region  in  the  brain  in  which  a  tumor  is  more  easily  access- 
ible or  more  possible  of  early  diagnosis  than  in  the  motor  area. 

Tumors  of  the  parietal  region,  including  the  superior  and  inferior  parietal 
lobules  are  not  uniforinly  attended  by  distinctive  and  local  symptoms,  but  in 
a  considerable  number  of  cases  disturbances  of  sensation  and  of  muscular 
sense  in  the  limbs  of  the  opposite  side  have  been  observed.  It  has  been 
stated  already  that  tumors  in  the  posterior  central  convolution  are  more  liable 
to  produce  sensory  symj^toms  than  those  in  the  anterior  central  convolution. 
And  it  is  possible  that  tumors  lying  in  the  parietal  region  have  caused  sen- 
sory symptoms  by  pressure  upon  the  sensory  tracts  on  their  way  from  the 
posterior  portion  of  the  internal  capsule  to  the  central  region  of  the  brain.  If 
this  is  so,  then  ataxia  and  anaesthesia  appearing  in  connection  with  a  tumor 
of  the  parietal  region  would  be  an  indirect  local  symptom  rather  than  a  re- 
sult of  a  lesion  in  the  sensory  centres  themselves.  This  is  not  the  place  to 
enter  upon  the  discussion  with  regard  to  the  existence  of  a  muscular  sense  as 
distinct  from  the  sensory  centres  and  the  motor  centres,  yet  there  are  many 
facts  which  indicate  the  existence  of  muscular  sense  centres  in  the  parietal 
lobes  of  the  brain. ^ 

The  symptom  of  word-bHndness,  to  be  discussed  later  in  connection  with 
aphasia,  is  almost  uniformly  due  to  a  lesion  of  the  inferior  parietal  lobule  in 
the  left  hemisphere  in  right-handed  people  and  in  the  right  hemisphere  in 
left-handed  people. 

Tumors  lying  in  the  lower  half  of  the  parietal  region  are  necessarily  near 
to  the  visual  tract  Avhich  passes  outward  from  the  internal  capsule  to  the 
occipital  lobe,  and  hence,  defects  of  vision  of  the  form  of  bilateral  homonymous 
hemianopsia  have  been  recorded  in  connection  with  tumors  in  this  locality. 

1  Starr  and  ilcCosh  :  American  Journal  of  the  Medical  Sciences,  August,  1894,  A  Contribution  to 
the  Localization  of  the  Muscular  Sense. 


FOCAL  DISEASES  OF  THE  BEAiy. 


491 


Tumors  of  the  occipital  region  of  the  brain  given  rise  to  the  important  hjcal 
symptoms  of  lateral  homonymous  hemianopsia.     (See  Fig.  136.)     Recent 


Fig.  136. 


Uft  Erje 


Visual  Fielr? , 


The  Visual  Tract.  The  result  of  a  lesion  anywhere  between  the  chiasm  and  the  cuneus  is  to  pro- 
duce homonymous  hemianopsia.  H,  lesion  at  chiasm  causing  bilateral  temporal  hemianopsia  ;  N, 
lesion  at  chiasm  causing  unilateral  nasal  hemianopsia  ;  T,  lesion  at  chiasm  causing  unilateral  tem- 
poral hemianopsia ;  SX,  substantial  nigra  of  crus  ;  L,  lemniscus  in  crus  ;  RX,  red  nucleus  ;  III,  third 

nerves. 

researches  by  Henschen^  have  proven  conclusively  that  the  visual  area  of  the 
coilex  to  which  all  impulses  from  the  eyes  are  sent  lies  in  the  calcarine  fissure 

1  Pathologic  des  Gehirns.    Upsala,  1892  to  1894.    Bd.  1,  2,  and  3. 


492  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

upon  the  median  surface  of  the  hemispheres  and  inchides  the  cuneus  and  the 
cortex  beneath  it,  which  lies  within  the  calcarine  fissure.  In  oi'der  to  reach 
this  situation  the  visual  tract  makes  a  wide  curve  from  the  internal  capsule 
backward  almost  semi-circular  in  shape  with  its  convexity  outward.  (Fig.136.) 
The  apex  of  the  occipital  lobe  is  narrow  and  the  calcarine  fissure  is  deep, 
hence,  at  its  termination  there  is  little  lateral  expansion  of  this  tract,  and 
therefore  a  lesion  in  almost  any  part  of  the  occipital  lobe  at  its  apex  or  even 
its  convexity  is  quite  liable  to  invade  the  visual  tract  and  to  produce  the  same 
symptom  as  is  caused  by  a  limited  lesion  in  the  calcarine  fissure  or  its  adja- 
cent cortex. 

Henschen's  researches  show  that  a  lesion  at  almost  any  portion  of  the  occi- 
pital lobe,  or  even,  as  has  already  been  seen  in  the  parietal  lobe,  if  sufficiently 
deep  to  compress  the  white  matter  of  this  region  will  produce  hemianopsia ; 
and  it  is  to  be  expected  that  in  any  lesion  of  the  nature  of  a  tumor  in  which 
small  areas  of  tissue  are  not  destroyed,  but  considerable  areas  are  primarily 
affected  and  adjacent  regions  are  strongly  compressed,  symptoms  of  hemi- 
anopsia will  be  frequent. 

The  occipital  lobe  is  easily  accessible  to  the  surgeon,  and  therefore  it  is  im- 
portant that  tumors  here  should  be  discovered  as  early  as  possible.  It  is  not 
generally  appreciated  that  hemianopsia  is  a  symptom  often  entirely  over- 
looked by  a  patient,  a  case  having  been  recently  reported  by  Bleuler^  in 
which,  though  well-marked  hemianopsia  existed,  the  patient  was  entirely 
unaware  of  any  visual  defect.  It  is  therefore  exceedingly  important  that  the 
extent  of  the  visual  field  in  both  eyes  should  be  carefully  tested  in  every  case 
of  suspected  brain  disease,  each  eye  being  tested  separately. 

Fig.  137. 


Gliosarcoma  of  right  temporo-occipital  region,  causing  hemianopsia,  and  later  hemiplegia. 

Lesions  of  the  occipital  lobe  are  capable  of  producing  a  disturbance  known 
as  blindness  of  mind,  in  which  the  patient,  though  seeing  an  object  no  longer 
recognizes  it  as  having  been  previously  known.  This  is  a  condition  allied  to 
word-blindness,  in  which  the  patient  is  suddenly  deprived  of  the  power  of 
reading.  This  condition  appears  to  be  more  frequent  in  lesions  upon  the  left 
side  of  the  brain  in  right-handed  persons,  and  upon  the  right  side  of  the 
brain  in  left-handed  persons.     It  may  also  occur  when  a  lesion  is  entirely 

1  Arehiv  fiir  Psychiatrie,  vol.  xxv.  p.  39. 


FOCAL  DISEASES  OF  THE  BRAIi^.  493 

sub-cortical,  as  well  as  when  it  is  in  the  cortex  of  the  occipital  lobe.  This 
symptom  will  be  discussed  further  in  connection  with  aphasia. 

Tumors  of  the  temporal  lobes  or  tumors  lying  upon  the  base  of  the 
cerebral  hemispheres  above  the  tentorium  or  upon  the  petrous  portion  of  the 
temporal  bone  give  rise  to  few  recognizable  symptoms.  In  a  few  such  tumors 
disturbance  of  taste  and  smell  seems  to  have  been  present  when  the  apex  of 
the  temporal  lobe  had  been  invaded  by  the  growth,  and  Avhen  the  uncinate 
gyrus  had  been  destroyed.  There  are  no  known  symptoms  produced  by  dis- 
turbance of  the  lingual  lobule. 

Tumors  invading  the  first  and  second  temporal  convolution  upon  the  left 
side  in  right-handed  persons  and  upon  the  right  side  in  left-handed  persons 
produce  the  form  of  aphasia  known  as  worcl-deafuess,  in  which  the  person  is 
unable  to  recall  the  names  of  places  or  persons,  and  cannot  understand  what 
is  said  to  him. 

It  is  believed  that  the  first  and  second  temporal  convolutions  are  the 
termination  of  the  auditory  tract,  and  that  each  hemisphere  is  related  to 

Fig.  138. 


-J^'. 


Glioma  of  left  temporo-occipital  lobe  obliterating  the  ventricle.    The  distention  of  the  ventricle 
in  the  left  hemisphere  is  seen. 

botli  ears.  Deafness  of  cerebral  origin  is,  however,  rare,  and  is  not  often 
observed  in  tumors  of  these  convolutions. 

Tumors  lying  within  the  Sylvian  fissure  and  upon  the  island  of  Reil 
produce  numerous  symptoms  on  account  of  their  pressure  upon  adjacent 
parts  ;  thus,  by  pressing  the  third  frontal  convolution  they  cause  motor 
aphasia  ;  by  invading  the  operculum  they  produce  facial  paralysis  ;  by 
pressing  upon  the  inferior  parietal  lobule,  or  the  superior  temporal  convolu- 
tion they  may  produce  various  symptoms  of  sensory  aj)hasia  ;  and  by  direct 
pressure  upon  the  island  of  Reil,  and  upon  the  underlying  external  capsule, 
they  may  cause  paraphasia.  If  this  pressure  is  transmitted  more  deeply 
to  the  internal  capsule,  symptoms  of  tumor  in  this  region  may  also  be 
caused. 

Tumors  lying  on  the  median  surface  of  the  brain,  upon  the  gyrus  forui- 
catus,  gyrus  marginalis,  or  upon  the  hypocampal  convolution  are  not  easily 
diagnosticated.  Ferrier  believes  that  in  the  latter  convolution  are  situated 
the  tactile  centres.  The  majority  of  physiologists  (Munk,  Horsley,  Sclireffer) 
and  of  pathologists  deny  this,  and  recently  a  case  of  glioma  of  tliis  region 
without  sensory  symptoms  has  been  reported  by  Humphrey.^    Tumors  in  this 

1  Humphrey  :   Brit.  Med.  Journ.,  Aug.  27,  1893. 


494  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

region  are  of  rare  occurrence,  and  no  focal  symptoms  can  be  assigned  to 
them  as  yet. 

Tumors  of  the  corpus  callosum  are  not  at  all  common,  only  twenty  cases 
being  so  far  recorded  in  literature.^ 

The  symptoms  in  a  majority  of  these  cases  have  been  chiefly  general 
symptoms,  viz :  headache,  vomiting,  optic  neuritis,  epileptiform  attacks, 
j)hysical  inertia,  hemiparesis,  disturbance  of  intelligence — principally  in  the 
form  of  dementia.  These  were  the  symptoms  in  one  case  under  my  obser- 
vation. The  last-named  symptom  is  the  only  one  that  appears  to  be  of 
constant  occurrence  in  these  cases,  and  in  many  of  them  it  has  been  pre- 
ceded by  symptoms  quite  comparable  to  those  of  hysteria.  The  majority 
of  cases  of  tumor  of  the  corpus  callosum  have  therefore  resembled  tumor  of 
the  frontal  lobes.  When  tumors  occur  in  the  corpus  callosum  they  are  more 
likely  to  be  situated  far  forward  about  its  knee,  rather  than  in  its  thinner 
posterior  part.     (See  Fig.  128.) 

Our  knowledge  of  the  function  of  the  corpus  callosum  is  very  imperfect, 
though  it  is  evident  from  its  structure  that  it  associates  the  action  of  the  two 
hemispheres.  The  corpus  callosum  has  been  wholly  wanting  in  the  brain  in 
a  few  cases,  and  although  this  is  occasionally  associated  with  imbecility  it  is 
a  condition  which  has  been  found  in  persons  who  presented  no  symptoms 
during  life.'^  It  is  evident,  therefore,  that  tumors  in  this  localty  cannot  be 
positively  diagnosticated,  and  the  situation  of  such  tumors  deep  between  the 
hemispheres  forbids  the  possibility  of  their  removal. 

In  the  enumeration  of  the  symptoms  produced  by  lesions  in  the  different 
parts  of  the  brain  cqjJiasia  is  an  important  one,  in  fact  there  are  few  tumors 
in  the  left  hemisphere  of  the  brain  in  right-handed  persons,  excepting  those 
situated  in  the  apex  of  the  frontal  lobe  or  at  the  summit  of  the  central  region 
which  do  not  cause  more  or  less  disturbance  of  speech.  Our  present  knowl- 
edge of  the  mechanism  of  speech  has  advanced  far  beyond  the  point  attained 
by  Broca,  who  located  speech  in  the  third  frontal  convolution,  the  so-called 
Broca's  centre,  or  even  by  that  reached  by  Wernicke,  who  made  the  dis- 
tinction between  sensory  and  motor  aphasia,  the  first  due  to  lesions  of  the 
temporal  region,  the  second  to  lesions  of  Broca's  centre. 

It  is  now  known  that  as  the  physical  basis  of  any  word,  be  it  noun  or 
verb,  there  exists  a  number  of  mental  images  acquired  through  different 
senses  located  in  different  regions  of  the  brain,  and  joined  together  in  a 
conscious  unit  by  a  series  of  association  tracts.  The  word  "  concept,"  long 
used  by  psychologists  to  denote  a  congeries  of  mental  images  making  up  an 
idea,  may  be  adopted  by  the  pathologist  to  indicate  this  collection  of  mental 
images.  To  be  complete  such  a  concept  must  have  all  its  parts  intact  and  the 
connection  between  those  parts  also  intact.  If  we  take  as  an  example  a  word 
such  as  "bell"  or  "rose,"  and  if  we  study  the  process  in  the  mind  of  the 
child  as  it  acquires  its  j^rimary  knowledge  of  some  particular  bell  or  rose, 
we  at  once  see  that  this  particular  concept  has  a  very  limited  extent,  consist- 
ing of  the  mental  images  of  the  object  (1)  as  seen,  (2)  as  felt — shape,  size, 
temperature,  hardness,  (3)  as  smelt,  (4)  as  tasted,  if  the  object  has  odor  or 
taste,  (5)  as  heard,  if  the  object  is  audible.  These  five  mental  pictures  com- 
prise the  mental  image  of  the  object,  and  the  separate  mental  images  ai'e 
united  with  all  the  others,  so  that  when  one  rises  in  memory  it  inevitably 
recalls  all  the  rest. 

1  Bruns  :  Berlin  klin.  Woch.,  1886,  Nos.  21  and  22.  Bristow  :  Dis.  of  the  Nervous  System,  p.  271. 
Lutzenberger  :  Keurol.  Centralb.,  1890,  p.  251.  Berkley:  American  Journal  of  the  Medical  Sciences, 
June,  1890.  Oliver  :  University  Medical  Magazine,  April,  1891.  Francis  ;  Amer.  Journal  of  the  Med- 
ical Sciences,  June,  1895. 

-  Bruce:   Brain,  xii.  p.  171. 


FOCAL  DISEASES  OF  THE  BRAIN. 


495 


As  another  illustration,  we  may  take  the  verbs  "  to  run,"  "  to  sew."  We 
call  up  to  the  mind  memory  pictures  of  some  individual  in  action,  or  of  some 
act  of  our  own,  with  its  attendant  sensations,  and  thus,  as  the  basis  of  the 
verb  "run,"  as  well  as  of  the  noun  "rose,"  we  must  think  of  a  congeries  of 
mental  images  closely  associated  with  one  another.  So  far  our  analysis  of 
thought  would  apply  equally  well  to  a  child  who  had  not  learned  to  speak,  to 
a  deaf  and  dumb  person,  or  to  a  healthy  man ;  but  in  the  man  it  is  evident 
that  there  is  added  to  this  mental  image  a  "  word  image "  quite  distinct 
in  ts  parts  from  the  mental    image,  and  consisting  of  memory  pictures  of 


Fig.  139. 


Diagram  to  illustrate  the  concept  "  bell "  and  to  show  the  varieties  ot  apraxia  and  aphasia.  The 
memory  pictures  are  relics  of  past  perceptions  received  through  different  senses.  The  association 
makes  up  the  mental  image  bell.  The  word  image  is  made  up  of  the  memories  of  the  sound 
and  appearance  of  the  word,  and  of  the  uttering  and  writing-effort  memories  ;  these  are  joined 
together.  The  mental  image  and  the  word  image  are  also  joined  with  one  another,  making  up 
the  concept  "bell." 

the  word  as  heard,  as  seen  in  print  or  writing,  as  pronounced  by  muscular 
effort,  or  as  produced  in  writing  by  movements  of  the  hand.  Each  of  these 
separate  word-pictures  is  joined  with  the  others  and  forms  a  "  word-concept ;  " 
each  part  of  this  word-concept  is  also  connected  with  every  j)art  of  the  mental 
concept  which  the  word  enables  us  to  convey  to  others.  Thus  it  becomes 
evident  that  the  psychological  term  "concept"  (German,  "Begrifl'")  is  not 
a  simple  thing,  but  is  a  very  complex  thing,  implying  as  its  physical  basis  an 
activity  of  widely  distant  cortical  areas  in  each  of  which  a  separate  memory 
picture  is  located,  and  of  long  or  short  association  tracts  running  in  every 
conceivable  direction  between  these  various  areas.  Now  if  such  is  the  com- 
jilexity  of  the  physical  basis  underlying  such  simple  concepts  as  a  particular 
bell  or  rose,  or  a  simple  act,  like  running  or  sewing,  it  is  eyident  that  the 
physical  basis  of  more  complex  concepts,  such  as  the  class  books  or  vases,  or 
the  complex  acts  implied  by  the  verbs  "to  educate,"  "to  civilize,"  are  in- 
numerable.   It  becomes  equally  evident  that  for  the  conduct  of  thought,  for 


496  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  perfect  action  of  the  mind  in  dealing  with  concepts,  be  they  simple  or 
complex,  an  integrity  of  the  entire  brain  is  necessary  both  in  its  cortical  ex- 
tent and  in  the  white  subjacent  association  tracts.  With  these  facts  in  mind 
it  is  absurd  to  speak  of  intellectual  centres  in  the  brain,  or  to  suppose  that 
such  faculties  as  memory  or  imagination  can  be  obliterated  by  a  single  lesion. 

Small  lesions  of  the  cortex  in  various  parts  may  injure  these  concepts  by 
depriving  them  of  some  constituent  mental  image,  and  small  lesions  in  the 
white  matter  may  disturb  the  use  of  these  concepts  by  dissociating  images 
which  should  be  closely  bound,  and  hence  it  is  evident  that  lesions  in  various 
parts  of  the  cerebral  hemisphere  will  produce  disturbance  in  the  use  of  our 
mental  concepts,  which  may  be  manifest  as  an  inability  to  recognize  places 
or  objects,  the  condition  of  mind-blindness  and  mind-deafness,  or  mind- 
paralysis,  or  a  condition  of  aphasia,  word-blindness,  word-deafness,  inability 
to  speak  or  to  write. 

When  the  lesions  of  the  brain  in  certain  situations  are  considerable  in 
extent,  involving  an  entire  convolution,  the  symptoms  of  aphasia  are  very 
well  marked.  Thus,  a  lesion  involving  the  third  frontal  convolution  pro- 
duces motor  aphasia,  the  patient  being  unable  to  articulate  distinctly,  to 
pronounce  words,  to  talk  voluntarily,  to  read  aloud,  or  to  repeat  a  word 
after  another.  Agraphia  is  usually  associated  with  this  form  of  aphasia,  the 
patient  being  unable  to  write  voluntarily,  or  copy,  or  write  from  dictation. 
In  two  or  three  cases,  however,  agraphia  alone  has  been  noticed,  and  the 
lesion  has  been  limited  to  the  posterior  portion  of  the  second  frontal  convo- 
lution. 

Word-deafness  is  produced  by  a  lesion  involving  the  first  and  second 
temporal  convolutions,  and  in  this  condition  the  patient  is  unable  to  recall 
the  spoken  name  of  objects,  to  understand  speech,  and  hence,  is  often  unable 
to  say  what  he  wishes. 

Word-blindness  is  due  to  a  lesion  situated  in  the  inferior  parietal  lobule, 
including  the  supramarginal  gyrus  and  the  angular  gyrus.  _  It  is  true  that  a 
lesion  in  this  situation  almost  inevitably  divides  an  association  tract,  passing 
from  the  occipital  to  the  temporal  lobe,  and  joining  the  memory  picture  of 
words  seen  with  that  of  words  heard.  Hence,  it  is  somewhat  uncertain 
whether  word-blindness  is  due  to  the  lesion  of  the  cortex  or  to  the  lesion  of 
the  subjacent  white  tract ;  but  a  lesion  in  this  situation  always  produces  a 
loss  of  power  to  understand  printed  or  written  words,  to  read  aloud,  and  to 
copy. 

But  while  these  various  well-marked  forms  of  aphasia  indicate  large  lesions 
in  these  various  situations,  it  must  be  admitted  that  the  majority  of  cases  of 
aphasia  are  not  easily  assigned  to  one  of  these  particular  types,  that  they  - 
partake,  in  some  degree,  of  all  the  various  types,  and  that  some  in  fact,  while 
they  present  the  features  of  each  type  in  slight  degree,  do  not  present  all  the 
features  of  any  one  type  completely.  Such  cases  of  aphasia  Ave  must  ascribe 
to  very  small  lesions  involving  only  certain  portions  of  the  speech  cortex,  or 
involving  a  few  of  the  many  association  tracts.  When,  for  example,  a 
patient  cannot  read,  but  can  copy  what  he  sees,  and  in  the  act  of  copying 
becomes  conscious  of  the  meaning  of  the  words  which  he  has  copied,  thus 
being  able  to  read  by  the  aid  of  his  muscular  sense,  when  he  cannot  read  by 
mere  vision,  it  is  evident  that  he  has  not  lost  the  power  of  recalling  printed 
words,  because,  through  the  aid  of  his  muscular  memories  he  is  able  to 
awaken  these  memory  pictures,  but  that  some  lesion  in  an  association  tract 
has  cut  off  the  impulses  that  ordinarily  reach  the  word-memory  picture  by 
the  way  of  the  eye  and  the  occipital  cortex.  This  may  be  hkened  to  a  break 
in  a  railroad  which  compels  the  passenger  to  take  a  round-about  route,  with 
several  changes,  to  reach  his  destination. 


FOCAL  DISEASES  OF  THE  BBAIN.  497 

We  are  not  yet  able  to  locate  exactly  the  various  lesions  producing  these 
complex  forms  of  so-called  association  aphasia  or  transcortical  aphasia.  But 
we  must  not  be  too  hasty  in  our  localization  in  aphasic  symptoms,  unless 
they  present  well-marked  characters  and  belong  to  one  of  the  chief  clinical 
types. 

These  are  the  chief  symptoms  produced  by  disease  in  the  cortex  of  the 
brain  or  in  the  subjacent  white  matter  of  the  centrum  ovala 

Tumors  of  the  basal  ganglia,  including  the  lenticular  and  caudate  divisions 
of  the  corpus  striatum  and  the  optic  thalamus,  are  not  very  rare.  Our 
knowledge  of  the  functions  of  these  ganglia  is  very  imperfect,  and  the  neces- 
sary loss  of  function  which  must  occur  when  they  are  destroyed  by  softening 
cannot  be  detected  during  life.  It  has  been  suggested  that  these  ganglia  are 
to  be  regarded  as  vestigial  bodies,  like  the  apj)endix  vermiformis,  without 
active  function  in  man.  Tumors,  however,  in  this  region,  almost  always 
produce  pressure  upon  the  internal  capsule  through  which  pass  the  most  im- 
portant motor  and  sensory  tracts,  and  which  lies  between  these  ganglia,  and 
hence  symptoms  of  the  nature  of  hemiplegia,  hemiataxia,  hemianpesthesia, 
and  hemianopsia  are  observed  when  the  tumor  invades  one  or  more  of 
these  tracts.  It  may  even  be  possible  to  detect  the  progressive  growth  of  a 
tumor  here  by  the  succession  of  symptoms  2:)roduced,  one  tract  after  another 
being  invaded  by  the  disease.  Motor  symptoms  are  more  common  in  cases 
of  tumors  of  the  corpora  striata.  Sensory  symptoms  occur  in  cases  of  tumors 
of  the  optic  th-alami.  When  a  tumor  invades  the  posterior  part  of  one  thala- 
mus, homonymous  hemianoiDsia  is  an  invariable  symptom.  This  will  be  easily 
understood  by  reference  to  Fig.  136. 

It  has  been  supposed  that  lesions  in  the  optic  thalamus  give  rise  to  dis- 
turbances in  the  recognition  of  the  position  of  the  limbs  of  the  opposite  side, 
and  that  in  consequence  awkward  positions  are  assumed,  and  awkward  move- 
ments, athetoid  in  character,  are  made  (Meynert).  It  has  also  been  affirmed 
that  a  tremor  quite  similar  to  that  of  multiple  sclerosis  may  be  caused  by  a 
tumor  of  the  thalamus.'  It  has  been  noticed  that  disturbances  in  facial  ex- 
pression and  in  the  natural  play  of  facial  feature  in  speech  and  thought  have 
been  noticed  in  patients  suffering  from  disease  of  the  optic  thalamus.^  The 
face  is  affected  on  the  side  opposite  to  the  lesion,  and  does  not  act  in  smiling, 
but  can  be  moved  voluntarily.  It  has  been  thought  that  certain  inhibitory 
functions  are  exercised  by  the  thalamus,  and  that  undue  emotional  reactions 
occur  when  it  is  diseased.  Disturbances  in  the  body-temperature  have  been 
observed  in  a  few  cases. ^  Cases  are  on  record  to  sujoport  each  of  these  state- 
ments, yet  it  must  be  admitted  that  numerous  negative  cases,  that  is,  cases 
of  tumor  of  the  thalamus  in  which  these  symptoms  were  wanting  throw 
much  doubt  on  the  diagnostic  significance  of  the  effects  mentioned.*  My  own 
view  of  the  functions  of  these  ganglia  is  that  they  preside  over  many  acts 
which  are  commonly  performed  in  a  purely  automatic  manner,  for  example, 
the  posture  of  the  body,  the  ordinary  gait,  the  facial  expression,  and  probably 
emotional  control ;  that  these  acts  can,  however,  be  performed  voluntarily 
as  well  as  automatically,  and  hence,  when  the  automatic  mechanism  fails,  a 
volitional  act  takes  its  place,  which  practice  soon  perfects,  leaving  the  indi- 
vidual quite  unconscious  of  his  defect,  and  hence,  causing  few  or  no  synq^toms. 
It  is,  therefore — on  this  theory — clear  that  tumors  of  the  basal  ganglia  cause 
few  recognizable  symptoms. 

1  D.  H.  Cooke  :  Lancet,  Mav  28, 1892. 

2  Kirilzew  :  Neurol.  Centralb.,  1891,  p.  310.    Nothnagel:  Zeitsch  f.  klin.  Med.,  1889.    Bechterew  : 
Neurol.  Centralbl.,  1884,  p.  102. 

3  Cowan  :  Lancet,  December,  1892.    Lloyd  :  Med.  News,  January,  1892. 
*  Wharton  Sinkler  :  University  Med.  Mag.,  October,  1893. 

32 


498  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Tumors  of  the  corpora  quadrigemnia  present  symptoms  of  a  focal  char- 
acter which  are  diagnostic'  These  consist  of  a  staggering  gait  similar  to 
that  seen  in  cerebellar  disease  and  symptoms  of  paralysis  or  paresis  in  the 
muscles  controlled  by  the  ocular  nerves.  The  co-ordination  in  movements 
of  the  eyes,  the  reflex  motions  of  the  eyes  in  following  a  light,  or  turning 
toward  a  sound,  and  the  power  of  steady  gazing  at  an  object  are  controlled 
by  automatic  centres  in  the  corpora  quadrigemina.  Disease  here  frequently 
produces  nystagmus  and  interferes  with  these  automatic  movements.  The 
symptoms  are  not  referable  to  a  disease  of  one  third  nerve  alone,  for  the 
pupils  are  often  unaffected.  They  are  often  bilateral  and  more  nearly  resemble 
the  symptoms  of  ophthalmoplegia  externa.  Hence,  it  is  possible  to  distin- 
guish lesions  of  the  corpora  quadrigemina  from  lesions  in  the  crus  cerebri, 
w^hich  cause  true  third-nerve  paralysis.  The  eyeballs  are  not  often  equally 
afiected,  one  moving  more  than  the  other ;  but,  on  the  other  hand,  neither 
eyeball,  as  a  rule,  is  totally  paralyzed.  The  superior  and  inferior  recti  are 
more  commonly  affected  than  the  lateral  muscles.  It  is  the  combination  of 
these  ocular  symptoms  with  the  reeling  gait  which  will  lead  to  the  diagnosis 
of  tumor  of  the  corpora  quadrigemina  when  the  other  (general)  symptoms 
of  brain  tumor  are  present : 

The  focal  symptoms  of  tumors  at  the  base  of  the  brain  are  necessarily 
very  complex.  Suffice  it  to  say  that  tumors  lying  upon  the  base  of  the  brain 
will  necessarily  compress  one  or  more  of  the  cranial  nerves,  either  upon  one 
side  alone  or  uj)on  both  sides,  in  case  the  tumor  is  near  the  median  line.  The 
situation  of  the  tumor  can  usually  be  determined  by  noting  the  order  in  which 
the  various  cranial  nerves  are  invaded  from  first  to  twelfth.  The  reader  is 
also  referred  to  Chapters  XV.  and  XXIV.  for  the  consideration  of  lesions  at 
the  base,  and  to  Chapters  XXVI.  and  XXVII.  for  lesions  of  the  cranial  nerves. 
Tumor  of  the  crus  cerebri  is  characterized  by  the  combination  of  hemi- 
plegia of  one  side  with  third-nerve  paralysis  of  the  opposite  side.  The 
tumor  lies  on  the  side  on  which  the  third  nerve  is  aflTected.  To  this  combi- 
nation bilateral  hemianopsia  may  be  added  if  the  tumor  compresses  the  op- 
tic tract.^ 

Tumors  in  the  upper  part  of  the  pons  or  in  the  crus  cerebri  affect  the 
third  and  fifth  nerves,  producing  external  strabismus,  with  dilatation  of  the 
pupil  and  ptosis,  and  also  tingling  pain  and  anaesthesia  of  the  face  with 
ulceration  of  the  cornea,  and  sometimes  grating  of  the  teeth  during  sleep. 
Tumors  in  or  near  the  lower  half  of  the  pons  involve  the  sixth  and  sev- 
enth and  eighth  nerves,  causing  internal  strabismus  with  contracted  pupil 
paralysis  of  the  face,  including  inability  to  close  the  eyes,  and  deafaess,  Avith 
vertigo.  Alternating  hemiplegia  is  also  produced  by  a  lesion  in  this  region. 
Tumors  invading  the  medulla  may  disturb  the  action  of  the  glosso-pharyngeal, 
pneumogafetric,  spinal  accessory  and  hypoglossal  nerves,  producing  difficulty 
in  deglutition,  irregular  respiration,  irregular  pulse,  flushing  of  the  skin,  with 
sweating,  sometimes  unilateral,  projectile  vomiting,  polyuria  or  glycosuria, 
retraction  of  the  head  or  rolling  of  the  head  upon  the  pillow,  and  lastly, 
paralysis  of  the  tongue,  with  inability  to  articulate  distinctly  or  to  swallow. 
When  the  tumoi"  lies  upon  the  base  of  the  brain,  it  not  only  invades 
the  cranial  nerves,  but  it  presses  upon  the  various  tracts  which  traverse  the 
crura,  pons,  and  medulla.  Thus  it  may  give  rise  to  hemiplegia  or  hemiataxia 
or  hemian^esthesia,  according  to  the  tract  invaded.  These  symptoms  are 
easily  understood  by  reference  to  Fig.  133. 

Tumors  of  the  pons,  producing  pressure  upon  the  middle  peduncle  of  the 

1  Nothnagel :  Brain,  xii.  21.    Hall :  Heidelberg  Dissert,  1892. 

2  Venal :  Bullet  de  la  Soc.  Anat.,  Paris,  .Jan.,  1891. 


FOCAL  DISEASES  OF  THE  BEAIX.  499 

cerebellum,  produce  a  tendeucy  to  stagger  in  walking.     The  patient  usually 
staggers  toward  the  side  opposite  the  tumor,  but  this  is  not  an  invariable  rule. 

Tumors  of  the  pons  quite  uniformly  produce  a  loss  of  the  tendon  reflexes 
at  the  knee.  The  control  of  the  bladder  and  the  rectum  is  also  frequently 
impaired. 

Tumors  of  the  cerebellum  are  exceedingly  frequent,  both  in  children  and 
in  adults,  and  present  almost  all  of  the  characteristic  general  symptoms  of 
brain  tumor.  The  situation  of  the  cerebellum  held  down  in  a  small  cavity 
by  the  tentorium  cerebelli  is  such  that  a  small  growth  in  the  posterior  fossa 
is  capable  of  producing  an  increase  of  intra-cranial  pressure  quite  early  in 
the  course  of  the  case.  The  tumor  in  the  posterior  fossa  will  also  compress 
the  fourth  ventricle  by  displacing  its  floor  or  roof,  and  as  a  result  of  such 
compression  an  accumulation  of  fluid  in  the  ventricle,  and  subsequently  in 
the  lateral  ventricles,  is  usual.  Hence,  symptoms  appear  earlier  in  the  course 
of  the  disease  in  tumors  about  the  cerebellum  than  in  tumors  elsewhere  in 
the  brain.  Headache,  occipital  or  frontal,  is  usually  the  first  symptom,  and 
optic  neuritis  appears  very  early  in  the  course  of  the  case.  The  percentage 
of  cases  having  optic  neuritis  is  much  greater  in  tumors  of  the  cerebellum 
than  in  tumors  in  the  cerebral  hemispheres. 

The  focal  symptoms  of  tumors  of  the  cerebellum  are  not  very  numer- 
ous. They  are  first  staggering  in  walking,  sometimes  attended  by  a  strong 
tendency  to  stagger  or  to  fall  in  a  particular  direction ;  secondly,  symptoms 
referable  to  a  compression  or  displacement  or  stretching  of  the  cranial  nerves 
lying  in  the  posterior  fossa. 

Tumors  in  the  middle  lobe  of  the  cerebellum  uniformly  produce  cerebellar 
ataxia  or  a  staggering  gait.  Tumors  in  the  hemispheres  of  the  cerebellum 
near  to  and  compressing  the  middle  lobe  are  attended  by  the  same  symp- 
toms. So  also  are  tumors  which  compress  the  peduncles  of  the  cerebellum, 
especially  the  middle  peduncles  in  their  course  to  the  pons,  or  the  superior 
peduncles  on  their  way  toward  the  corpora  quadrigemina.  Tumors  lying 
within  the  hemispheres  which  do  not  invade  these  parts  do  not  always  pro- 
duce a  staggering  gait.  Hence,  a  diagnosis  of  a  tumor  of  the  cerebellum 
is  easy  when  the  tumor  lies  near  to  the  median  line,  but  is  impossible  when 
it  lies  near  the  surface  in  the  lateral  portion  of  the  hemispheres.  Thus  in 
the  tumor  shown  in  Fig.  122  there  was  no  staggering.  The  early  appearance 
of  staggering  as  related  to  the  general  symptoms  is,  therefore,  an  important 
sign  in  favor  of  a  cerebellar  tumor;  while  the  appearance  of  staggering 
many  months  after  the  development  of  optic  neuritis  will  merely  indicate 
that  a  tumor  in  the  hemisphere  has  finally  reached  or  encroached  upon  the 
middle  lobe. 

The  early  appearance  of  cranial  nerve  symptoms,  such  as  paralysis  of  the 
face,  deafness,  disturbance  in  swallowing,  symptoms  referable  to  the  vagus 
nerves  or  paralysis  of  one-half  of  the  tongue,  indicates  that  the  tumor  lies 
near  to  the  medulla  and  pons,  that  is,  upon  the  inferior  sui'face  of  the  cere- 
bellum. The  appearance  of  these  symptoms  late  in  the  disease,  long  after 
the  development  of  optic  neuritis,  will  indicate  tliat  the  growth  has  finally 
reached  the  inferior  surface,  or  more  probably  that  its  size  is  so  great  as  to 
have  displaced  the  cerebral  axis.     Such  a  tumor  is  shown  in  Fig.  123. 

The  characteristics  of  cerebellar  ataxia  are  a  staggering  gait  with  steps  of 
irregular  length  and  j^osition,  the  body  swaying  like  that  of  a  person  intoxi- 
cated. This  ataxia  of  the  legs  and  of  the  body  is  attended  by  a  decided 
sense  of  vertigo,  and  does  not  usually  persist  when  the  patient  lies  down. 
These  characteristics,  together  with  the  fact  that  the  knee-jerks  are  exagger- 
ated in  cerebellar  tumor,  will  enable  any  one  to  distinguish  this  disturb- 
ance of  gait  from  that  appearing  in  locomotor  ataxia.     Cerebellar  ataxia  is 


500  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

due  to  a  disturbance  in  the  meclianism  of  equilibrium  in  so  far  as  this  de- 
pends upon  impressions  coming  to  the  brain  from  the  muscles  of  the  trunk 
and  legs.  When  the  staggering  is  in  one  direction  only  it  is  an  indication 
that  the  middle  peduncle  of  the  cerebellum  is  invaded  by  the  tumor.  This 
unilateral  staggering  is  not  a  common  symptom.  In  four-fiftks  of  the  cases 
recorded  the  patient  has  staggered  away  from  the  side  on  which  the  tumor 
lies  ;  in  the  remaining  fifth  the  patient  has  staggered  toward  the  tumor. 
The  direction  of  staggering  is  not,  therefore,  an  absolute  sign  of  the  side  on 
which  the  tumor  lies.  When  the  middle  peduncle  of  the  cerebellum  is  in- 
vaded there  are  usually  cranial  nerve  symptoms  produced,  and  these  are 
always  upon  the  side  on  which  the  tumor  lies.  Hence,  the  combination  of 
the  staggering  toward  one  side  with  cranial  nerve  symptoms  of  the  opposite 
side  will  indicate  inevitably  which  peduncle  of  the  cerebellum  is  involved. 
Thus  in  the  case  shown  in  Fig.  123  the  diagnosis  was  made  before  death  from 
this  combination  of  symptoms.  When  the  superior  peduncles  of  the  cerebel- 
lum are  invaded,  nystagmus,  paralysis  of  the  ocular  motor  muscles,  and 
blindness  are  developed.  In  fact  it  is  impossible  to  differentiate  a  tumor  in- 
vading the  superior  peduncles  of  the  cerebellum  from  a  tumor  of  the  corpora 
quadrigemina. 

Diagnosis.  The  review  of  the  symptoms  just  described  will  convince  the 
reader  that  in  the  majority  of  cases  of  tumor  of  the  brain  there  are  suificient 
evidences  of  the  existence  of  disease  within  the  cranial  caAaty,  and  that  the 
gradual  development  and  progress  of  the  disease  will  enable  the  physician  to 
come  to  the  conclusion  that  it  is  of  the  nature  of  a  tumor.  If  in  any  case 
these  symptoms  which  are  present  are  careflilly  classified,  the  general  symp- 
toms being  separated  from  the  local  symptoms,  and  the  order  of  appearance 
of  the  local  symptoms  fully  determined,  it  will  usually  be  possible  to  reach  a 
conclusion  as  to  the  situation  of  the  tumor.  The  combination  of  local  symp- 
toms is  sometimes  as  characteristic  as  their  order  of  appearance  and  method 
of  extension,  as,  for  examj^le,  in  cases  of  tumors  of  the  cms  or  of  the  cor- 
pora quadrigemina. 

It  is  not  to  be  forgotten,  however,  that  tumors  of  the  frontal  lobes  and 
tumors  of  the  temporal  lobes,  especially  those  situated  in  the  right  hem- 
isphere, often  fail  to  cause  any  local  symptoms.  The  absence  of  distinct  local 
svmptoms,  therefore,  will  point  to  these  localities  as  the  probable  position  of 
the  suspected  tumor. 

It  is  not  to  be  forgotten  that  many  local  symptoms  are  produced  indirectly 
by  pressure  upon  parts  not  far  from  the  tumor,  but  yet  not  directly  invaded 
in  its  growth. 

It  is  also  to  be  remembered  that  tumors  pressing  upon  large  vessels  of  the 
brain  may  so  disturb  the  circulation  as  to  produce  symptoms  quite  similar  to 
those  of  thrombosis,  and  these  symptoms  may  be  due  to  suspension  of  func- 
tion of  a  part  lying  at  some  distance  from  the  tumor. 

The  diagnosis  of  the  variety  of  the  tumor  present  can  only  be  reached  by 
careful  study  of  the  general  history  of  the  patient  and  by  a  consideration  of 
those  facts  which  have  been  already  mentioned  in  the  discussion  of  the  vari- 
eties of  brain  tumor. 

It  is  therefore  evident  that  in  the  diagnosis  of  the  disease  there  are  always 
three  questions  to  be  settled :  first,  the  existence  of  a  tumor ;  secondly,  its 
situation  ;  thirdly,  its  variety.  A  study  of  the  symptoms  will  usually  enable 
the  physician  to  reach  an  answer  to  the  first  two  questions,  but  the  answer  to 
the  last  question  will  always  remain  uncertain. 

The  symptoms  of  brain-abscess  may  be  the  same  in  kind  as  those  of  brain- 
tumor,  since  both  produce  an  increase  of  intra-cranial  pressure  and  a  pro- 
gressive destruction  of  brain  tissue.     In  their  origin,  mode  of  development, 


FOCAL  DISEASES  OF  THE  BRAIN.  501 

progress,  and  termiuatiou,  liOAvever,  there  are  not  infrequently  marked  differ- 
ences. Brain  abscess  develops  most  commonly  after  severe  injuries  or  in  con- 
junction with  suppurative  affections  of  the  inner  ear  and  of  the  nasal  and 
orbital  cavities,  and  with  caries  of  any  of  the  cranial  bones  which  lie  in 
contact  with  the  membranes.  These  rarely  occur  prior  to  the  development 
of  brain-tumor.  The  symptoms  common  to  tumor  and  abscess  may  develop 
after  a  blow  on  the  head,  but  Avhen  the  condition  is  one  of  abscess  the  symp- 
toms appear  in  more  rapid  succession,  with  greater  severity,  and  more  fre- 
quently with  fever  than  when  the  condition  is  that  of  tumor.  Furthermore, 
the  symptoms  of  abscess,  after  appearing  suddenly,  often  subside,  the  abscess 
becoming  latent,  and  all  symptoms  disappearing  for  months  or  years,  and 
then  breaking  out  again  with  suddenly  fatal  termination.  This  course  con- 
trasts markedly  with  that  in  a  case  of  a  tumor,  where  a  gradual  progress 
w^ith  slowly-increasing  intensity  of  all  the  symptoms  is  found.  The  constant 
addition  of  new  symptoms  is  usual  in  tumors,  and  a  temporary  remission 
rather  than  intermission  of  the  symptoms  is  the  rule  when  the  i:)rogress  is 
not  continuous.  There  may  also  be  some  points  of  distinction  found  in  the 
individual  symptoms.  Thus,  headache  is  more  severe  and  paroxj^smal  with 
tumor ;  optic  neuritis  is  much  more  conmionly  found  with  tumor ;  mental 
changes  are  more  gradual  and  constant  with  tumor  ;  and  local  symptoms  are 
slower  in  onset  and  more  apt  to  develop  with  tumor.  A  complication  of 
tumor  not  infrequent  is  cerebral  hemorrhage.  Meningitis  is  the  usual  com- 
plication of  abscess.  Lastly,  a  duration  of  from  one  to  two  years,  with 
symptoms  constantly  present,  points  directly  to  tumor. 

Tubercular  meningitis  is  under  certain  circumstances  easily  mistaken  for 
cerebral  tumor.  This  is  not  true  of  the  ordinary  cases  of  tubercular  menin- 
gitis with  acute  hydrocephalus,  which  develop  marked  symptoms  rapidly  and 
terminate  fatally  wdthin  four  or  six  weeks.  But  there  are  a  number  of  cases  of 
tubercular  meningitis  which  present  a  chronic  course  with  gradual  progress, 
and  in  which  the  diagnosis  from  tubercular  tumor  is  almost  impossible.  It 
is  true  that  the  symptoms  often  develop  rapidly  in  these  cases,  and  yet  this 
is  sometimes  apj)arently  the  case  in  tumor ;  for,  unless  a  patient  is  carefully 
watched,  the  early  symptoms  of  tumor  may  escape  notice  for  some  time. 
The  symptoms  of  chronic  tubercular  meningitis  may  be  the  same  as  those 
described  as  general  symptoms  of  brain  tumor ;  but  the  headache  is  more 
severe  in  meningitis  and  more  continuous ;  there  is  more  likely  to  be  hyper- 
sensitiveness  to  light,  sound,  or  touch  in  meningitis ;  and  optic  neuritis 
develops  less  frequently,  less  rapidly,  and  with  less  intensity  than  in  tumor. 
Tubercles  upon  the  choroid  are  found  more  frequently  in  meningitis  than  in 
tubercular  tumor.  It  is,  of  course,  understood  that  a  localized  meningitis 
may  give  rise  to  the  same  symptoms  as  a  small  tumor,  and  then  the  differen- 
tiation is  impossible.  This  is  more  common  about  the  base  of  the  brain,  in 
the  region  of  the  cranial  nerves,  than  elsewhere.  It  is  also  to  be  remem- 
bered that  a  chronic  progressing  meningitis  may  develop  in  the  vicinity  of  a 
tumor.  Here,  again,  the  diagnosis  will  be  impossible.  A  gradual  subsi- 
dence of  the  symptoms,  with  recovery,  will  point  to  meningitis  rather  than 
to  tumor. 

Chronic  hydrocephalus,  while  not  infrequently  the  result  of  tumor  or  men- 
ingitis, may  be  due  to  a  chronic  inflammation  of  the  ependyma  of  tlie  ven- 
tricles. It  then  advances,  and  the  fluid  within  the  ventricles,  producing 
pressure  upon  the  brain,  causes  atrophy.  The  course  is  chronic,  and  the 
general  symptoms  are  those  of  cerebral  tumor.  The  local  symptoms,  how- 
ever, differ  in  some  I'espects  from  those  of  tumor.  Spastic  paralysis  devel- 
ops with  chronic  hydrocephalus  without  localized  spasms,  and  is  always 
bilateral ;  the  lower  limbs  are  affected  more  intensely  than  the  upper.     The 


502  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

child  presents  the  extended,  adducted,  stiff  legs,  with  overlapping  knees, 
rigid  muscles,  increased  tendon  reflexes,  and  the  spastic  gait  so  familiar  in 
infantile  diplegia  (see  Chapter  XVII) ;  and,  in  addition,  the  hands  move 
without  proper  co-ordination.  As  the  disease  progresses  the  crura  cerebri  and 
pons  may  be  displaced  by  the  pressure  of  the  fluid,  and  irregular  symptoms  due 
to  stretching  of  the  cranial  nerves  may  appear.  These,  with  the  paraplegia, 
may  lead  to  a  suspicion  of  a  tumor  of  the  pons  or  base  of  the  brain,  and  only 
by  the  order  of  development  of  the  symj)toms  can  the  differentiation  be  made. 

The  diagnosis  between  cerebral  tumor  and  cerebral  hemorrhage  will  be 
necessary  only  in  a  few  cases  in  which  the  onset  of  the  symptoms  has  been 
very  sudden.  There  are  a  few  cases  of  tumor,  chiefly  glioma,  in  which  the 
growth  has  been  latent  for  some  time,  and  has  then  given  rise  suddenly,  after 
a  blow  on  the  head,  or  exposure  to  the  sun,  or  some  other  accidental  influ- 
ence, to  well-marked  symptoms.  These  are  usually  both  general  and  local, 
more  noticeably  the  latter.  The  suspicion  of  a  tumor  will  be  aroused  if,  after 
such  an  apoplectic  stroke,  the  symptoms  persist  and  increase  instead  of  sub- 
siding, and  if  headache,  convulsions,  and  optic  neuritis  appear.  Hemor- 
rhage alone  never  gives  rise  to  the  last-named  symptom. 

There  are  a  few  general  diseases  which  present  certain  symptoms  some- 
what similar  to  those  occurring  in  brain  tumor,  and  these  should  always 
be  kept  in  mind.  They  are  extreme  ansemia,  with  defective  vision,  from 
myopia  or  hypermetropia ;  chronic  lead-poisoning  and  chronic  diffuse  ne- 
phritis or  contracted  kidneys.  The  knowledge  that  these  diseases  may  sim- 
ulate brain  tumor  will  lead  the  physician  to  be  njjon  his  guard.  It  is  not 
necessary  to  mention  the  numerous  points  of  the  differential  diagnosis  which 
will  enable  a  definite  conclusion  to  be  reached  in  any  case. 

The  Course  of  the  Disease.  The  general  history  of  the  progress  of  a 
patient  suffering  from  brain-tumor  has  to  some  extent  been  indicated  in 
the  discussion  of  the  symptoms.  SuflEice  it  to  say  that  a  gradual  increase  in 
the  number  and  intensity  of  the  various  symptoms  is  usual.  In  some  cases 
the  general  symptoms  precede  the  local  symptoms  by  several  months,  and 
optic  neuritis  does  not  often  appear  within  three  months  of  the  beginning  of 
the  symptoms,  unless  the  tumor  is  in  the  cerebellum  or  on  the  base  of  the 
brain.  In  some  cases  the  local  symptoms  appear  before  the  general  symp- 
toms, especially  if  the  tumor  is  located  in  the  motor  cortex,  when  the  case 
may  be  regarded  for  some  time  as  one  of  cortical  epilepsy  until  the  genei^al 
symptoms  of  brain-tumor  supervene.' 

As  the  case  goes  on,  and  both  local  and  general  symptoms  become  more 
numerous,  the  suffering  of  the  patient  becomes  more  intense. 

If  the  case  is  one  of  gumma  it  may  be  possible  to  relieve  the  symptoms, 
and,  by  a  progressive  course  of  treatment,  to  cure  the  patient  entirely.  Undei* 
these  circumstances  the  symptoms  gradually  subside  and  become  less  in  inten- 
sity up  to  recovery.  In  other  cases  it  is  possible  to  locate  the  tumor  abso- 
lutely in  a  position  accessible  to  the  surgeon  and  to  remove  it  by  operation, 
and  under  these  circumstances  the  recovery  of  the  patient  is  gradual  but 
progressive  after  the  operation  is  over.  The  brain  resumes  its  functions 
after  the  pressure  of  the  tumor  is  removed,  or  when  a  portion  of  the  brain 
has  been  injured  in  the  removal  of  the  tumor  a  recovery  may  be  imperfect, 
with  some  defects  of  sight,  or  motion,  or  sensation  remaining.  In  those 
cases  which  are  not  subject  to  specific  treatment,  and  in  which  the  tumor 
cannot  be  removed,  the  course  is  progressively  downward,  the  patient  suffer- 
ing more  and  more  intensely  as  the  tumor  grows,  and  finally  passing  into  a 
state  of  coma  or  dying  in  convu.lsions. 

J  Kocher :  Zeitsch.  fiir  Chirurgie,  June,  1893. 


FOCAL  DISEASES  OF  THE  BRAIN.  503 

The  average  duration  of  the  symptoms  is  said  to  be  three  years,  but  indi- 
vidual cases  vary  greatly. 

There  are  a  few  cases,  however,  in  which,  either  spontaneously  or  under 
specific  treatment,  a  tumor  has  ceased  to  grow,  and  the  patient  "has  api)ar- 
ently  recovered  and  remained  quite  well  for  some  months  or  even  years,  the 
brain  apparently  resuming  its  function.  Two  such  cases  have  come  under 
my  observation.  In  one  the  recovery  lasted  four  months,  sudden  death  fol- 
lowing, due  to  the  rupture  of  a  cyst  which  lay  at  the  side  of  a  sarcoma.  In 
the  other  an  interval  of  eight  years  occurred,  after  which  the  symptoms  re- 
turned and  caused  death.  In  the  last  case  optic  neuritis,  which' was  present 
at  the  first  attack,  subsided  entirely,  but  recurred  at  the  second  attack.  The 
tumor  was  a  sarcoma  in  the  cerebellum.  In  both  cases  there  was  no  evidence 
of  syphilis,  yet  the  treatment,  which  was  apparently  successful,  was  inunctions 
of  mercury  and  large  doses  (300  to  400  grains  daily)  of  iodide  of  potassium. 

Prognosis.  It  is  evident  from  this  statement  of  the  course  of  the  disease 
that  the  general  prognosis  in  brain  tumore  is  unfavorable.  We  have  seen 
from  a  table  on  page  471  that  but  7  per  cent,  of  tumors  of  the  brain  are  open 
to  operation.  It  is  therefore  evident  that  in  the  vast  majority  of  the  cases 
we  cannot  give  the  patient  any  hope. 

Treatment.  1.  Medical  Treatment.  In  the  course  of  the  case  it  is  usually 
necessary  to  treat  the  symptoms  of  the  disease.  Headache  can  usually  be 
very  much  relieved  by  a  free  use  of  phenacetin,  antipyrin,  or  antifebrin. 
The  doses  of  these  drugs  which  must  be  used  are  larger  than  those  commonly 
employed,  and  it  is  my  practice  to  begin  with  the  ordinary  dose,  and  rapidly 
increase  the  number  of  doses  given,  combining  with  the  drug  any  heart 
stimulant,  cafieine  being  the  one  preferred.  If  the  patient  be  carefully 
watched  while  this  is  being  done  it  will  soon  be  found  possible  to  give  safely 
twenty  grains  of  antipyrin,  fifteen  to  twenty  grains  of  phenacetin,  or 
ten  grains  of  antifebrin  at  a  dose,  and  this  dose  may  be  repeated  after 
three  hours,  provided  the  headache  returns.  In  a  few  cases  the  headache 
may  be  benefited  by  ice-bags  to  the  head,  by  hot  baths,  or  by  ergot.  If 
these  remedies  are  useless,  resort  must  be  had  to  morphine,  but  this  drug  is 
especially  unsatisfactory  in  the  treatment  of  headache  from  brain  tumors 
unless  very  large  doses  are  given.  Vomiting  and  vertigo  in  brain  tumor  are 
best  relieved  by  the  use  of  bromide  of  sodium  or  by  hydrobromate  of  hyo- 
cine  in  j--^q  gr.  dose  repeated  every  four  hours. 

The  course  of  optic  neuritis  cannot  be  arrested,  though  it  may  be  somewhat 
delayed  by  cupping  the  temples.  While  strychnine  will  at  any  time,  when 
given  hypodermically,  improve  temporarily  the  power  of  vision,  yet  it  does  no 
permanent  good,  and  is  thought  by  some  to  hasten  the  progress  of  the  disease. 

Epileptiform  convulsions  may  be  reduced  in  frequency  by  the  free  use  of 
bromides,  but  cannot  be  arrested  as  long  as  the  disease  goes  on.  It  is  thus 
evident  that  the  treatment  of  the  general  symptoms  of  brain  tumor  is  ex- 
ceedingly unsatisfactory.  There  is  no  treatment  known  that  will  in  any  Avay 
affect  the  local  symptoms,  massage  and  electricity  to  paralyzed  limbs  being 
mere  palliatives,  capable  only  of  maintaining  the  nutrition  of  the  muscles. 

There  is  always  a  possibility  in  every  case  of  brain  tumor  that  the  disease 
may  be  syphilitic  in  oi'igin.  It  is  always  imperative,  therefore,  as  soon  as 
the  diagnosis  is  established,  to  try  the  effect  of  specific  treatment.  My  pref- 
erence is  for  the  use  of  inunctions  of  mercury,  one  drachm  of  blue  ointment 
being  rubbed  in  at  night  after  a  hot  bath,  a  different  part  of  tlie  Iwdy  being 
selected  for  each  application,  and  after  the  application  being  covered  with 
bandages  so  that  the  process  of  absorption  of  the  ointment  remaining  upon 
the  skin  may  occur  during  the  night.  At  least  two  ounces  of  blue  ointment 
should  thus  be  used,  and  if  improvement  is  evident  the  iininctions  may  be 


504  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

repeated  after  an  interval  of  two  weeks.  The  occurrence  of  salivation  will 
necessitate  the  cessation  of  the  use  of  mercury  temporarily.  At  the  same 
time  large  doses  of  iodide  of  potash  should  be  given,  beginning  with  twenty 
grains  three  times  a  day,  and  increasing  the  dose  one  or  more  grains  daily 
until  100  grains  three  times  a  day  have  been  reached.  The  iodide  may  be 
given  in  Vichy  water  or  in  milk,  before  or  after  meals,  according  to  the  con- 
dition of  digestion.     My  preference  is  to  give  it  before  meals. 

Care  in  the  regulation  of  the  diet,  the  use  of  simple  and  nutritious  food, 
frequent  massage  to  aid  digestion,  and  a  daily  hot  bath  of  temperature  of 
100^  continued  for  fifteen  to  twenty  minutes  are  essential  during  the  taking 
of  these  large  doses  of  iodide. 

When  the  tumor  is  of  a  gummatous  nature  a  decided  improvement  in  all 
the  symptoms,  and  particularly  in  insomnia  and  headache,  should  be  observed 
within  a  month.  Such  improvement  may,  however,  occur  in  cases  of  either 
sarcoma  or  glioma  or  cystic  tumors.  It  is  therefore  necessary  to  keep  up  this 
treatment  for  two  months  longer.  If  the  improvement  continues  and  the 
patient  gradually  recovers  it  is  probable  that  a  gumma  has  been  absorbed. 
In  a  case  recently  under  my  observation  in  which  the  symptoms  in  January, 
1893,  were  intense  headache,  insomnia,  mental  apathy,  staggering  gait,  great 
general  weakness,  optic  neuritis  in  both  eyes,  with  partial  blindness  in  the 
right  eye  and  total  paralysis  of  the  right  third  nerve,  partial  anaesthesia  of 
the  right  side  of  the  face,  and  paresis  of  the  right  sixth  and  seventh  nerves, 
there  was  by  November,  1893,  a  complete  recovery,  which  still  persists,  an 
occasional  nocturnal  headache  being  the  only  symptom  remaining.  Five 
courses  of  inunction  have  been  employed,  and  iodide  has  been  given  to  the 
extent  of  250  grains  a  day,  the  dose  being  varied  from  time  to  time  When 
symptoms  of  intolerance  appeared.  Thus  in  ten  months  a  basal  gumma  of 
considerable  size  has  been  absorbed  by  persistent  treatment. 

If  the  tumor  present  is  a  sarcoma  or  glioma,  and  an  improvement  has  oc- 
curred during  the  first  months  of  treatment,  such  improvement  will  not 
always  persist,  and  therefore  a  return  of  the  symptoms  during  the  course  of 
specific  treatment  is  a  pretty  sure  proof  that  the  tumor  is  not  of  the  nature 
of  a  gumma.  It  is  useless  to  continue  specific  treatment  after  three  months  of 
thorough  trial;  it  is  better  to  refuse  medical  treatment  or  to  depend  entirely 
upon  palliatives  under  these  circumstances. 

2.  The  surgical  treatment  of  brain  tumors  is  a  subject  which  has  aAvakened 
much  interest  of  late,  inasmuch  as  over  130  tumors  have  been  operated 
upon  within  the  past  six  years.  Tumors  in  which  surgical  treatment  is 
applicable  are  those  which  are  situated  in  or  near  the  cortex  of  the  hemi- 
spheres, tumors  of  the  cerebellum,  though  accessible  being  particulary  un- 
favorable for  operation. 

Space  does  not  permit  of  an  analysis  of  these  operations  for  brain  tumor, 
and  this  subject  will  be  discussed  in  another  chapter.  Sufiice  it  to  say  that 
47  per  cent,  of  the  cases  in  which  operation  has  been  attempted  have  proved 
successful,  the  tumor  having  been  accurately  located  and  successfully  removed, 
with  recovery  of  the  patient.  Considering  that  this  operation  is  a  new  one, 
that  it  has  been  attempted  rashly  in  some  cases  as  a  last  resort,  where  there 
was  no  probability  of  success,  and  where  failure  was  inevitable,  it  may  be 
expected  that  the  percentage  of  recoveries  will  in  the  future  be  much  higher. 
It  is,  of  course,  a  discouraging  feature  that  but  7  per  cent,  of  tumors  of  the 
brain  are  open  to  operation,  and  these  statistics  would  indicate,  therefore, 
that  but  three  brain  tumors  in  a  hundred  will  probably  be  cured  by  surgical 
treatment.  iNTevertheless  this  treatment  should  be  carefully  considered,  and 
Avhenever  the  diagnosis  of  a  tumor  in  an  accessible  location  can  be  made  the 
surgeon  should  be  called  in  as  early  as  possible  to  remove  it. 


FOCAL  DISEASES  OF  THE  BRAIN.  505 

Horsley  has  recently  advised  that  in  cases  in  which  the  tumoi-  is  inaccessi- 
ble a  large  opening  be  made  in  the  skull  and  that  a  drainage-tube  be  passed 
within  the  dura  to  relieve,  if  possible,  the  intra-cranial  pressure.  I  have 
seen  this  done  ;  but  it  seems  to  me  of  problematical  value,  as  it  merely  pro- 
longs the  misery  in  a  hopeless  condition. 

The  varieties  of  brain  tumor  which  are  most  favorable  to  surgical  treat- 
ment are  sarcoma  and  fibroma.  These  tumors  are  encapsulated,  are  easily 
separable  from  the  brain  substance,  and  can  be  removed  without  any  lacer- 
ation of  the  brain  tissue.  Figure  124  shows  such  a  tumor  removed  from  the 
frontal  region  by  Dr.  McBurney  at  my  suggestion. 

Glioma  and  glio-sarcoma  are  not  as  easily  removed,  they  usually  infiltrate 
the  brain  substance,  penetrating  into  the  white  matter  even  when  they  arise 
in  the  cortex,  and  it  is  necessary  in  their  i-emoval  to  incise  the  brain  tissue. 
They  are  very  vascular,  and  often  contain  cysts  filled  with  fluid,  and  hence 
their  removal  is  much  more  difficult.  Both  varieties  of  tumor,  however, 
have  been  successfully  removed.  After  removal  they  are  liable  to  return, 
but  in  two  or  three  cases  operations  have  been  done  a  second  and  even  a 
third  time,  with  the  result  of  prolonging  life.^  When  a  gumma  does  not 
yield  to  specific  treatment  there  is  no  reason  why  it  should  not  be  removed, 
provided  it  is  accessible,  and  it  is  not  unlikely  that  if  a  gumma  were  very 
large  and  were  removed  that  specific  treatment  subseqviently  administered 
would  eventually  prove  curative.  The  chief  difficulty  in  the  way  of  such 
removal  is  the  infiltration  of  the  pia  with  gummatous  material  and  the  diffi- 
culty of  getting  this  away  without  great  hemorrhage ;  this  difficulty  is  not, 
however,  insuperable. 

Carcinoma  of  the  brain  is  the  most  unfavorable  tumor  for  operation,  both 
because  of  the  fact  that  it  is  usually  secondary  to  carcinoma  elsewhere,  which 
is  bound  to  kill  the  patient,  or  because  of  its  liability  to  return.  The  same 
difficulties  which  attend  a  removal  of  glioma  are  met  with  in  operating  upon 
carcinoma. 

Cysts  of  the  brain  are  easily  emptied  when  found,  but  the  mere  abstrac- 
tion of  the  fluid  gives  no  permanent  relief,  as  it  is  bound  to  reaccumulate. 
It  is  necessary  therefore  either  to  drain  the  cyst,  and  thus  secure  its  closure 
from  the  bottom  by  the  approximation  of  its  walls,  or  else  to  remove  the 
whole  of  the  cyst  by  dissecting  it  out  from  the  brain.  The  latter  is  a  dan- 
gerous process,  and  is  sure  to  be  followed  by  the  formation  of  scar  tissue, 
which  in  itself  is  a  constant  irritant  to  the  brain.  Drainage,  therefore,  appears 
to  me  to  be  the  best  form  of  treatment  for  cysts.^  If,  however,  the  cyst  is 
merely  a  part  of  a  glioma  the  removal  of  its  wall  and  adjacent  tissue  gives 
most  hope. 

The  removal  of  tubercular  tumors  has  been  already  discussed  in  the  sec- 
tion upon  that  subject. 

I  cannot  but  believe  that  the  operation  for  tumor  of  the  brain  will  be 
more  widely  performed  in  the  future,  that  cases  will  be  operated  upon  earlier 
in  the  disease  as  our  knowledge  of  diagnosis  increases,  and  that  the  day  will 
come  when  as  little  fear  will  be  felt  in  opening  the  cranial  cavity  as  is  at 
present  felt  in  the  opening  of  the  abdomen.  And  I  believe  that  the  statis- 
tics at  present  available,  which  would  seem  to  indicate  that  but  3  per  cent, 
of  brain  tumors  can  be  successfully  removed,  will  be  materially  changed 
within  the  next  ten  years. 

For  details  of  the  operation,  the  rules  of  guidance  in  finding  various  areas 
of  the  brain,  and  a  general  discussion  of  the  subject,  the  reader  is  referred  to 
the  chapter  upon  Surgery  of  the  Brain. 

1  Czerny  :  Verhand.  Deut.  Gessel.  fur  Chirurg.,  1892. 
-  SeeKocher:  Zeitsch  fur  Chirurg.,  April,  1893. 


CHAPTER    Xyil. 
FOCAL  DISEASES  OF  THE  BRAIN. 

(Continued.) 
By  F.  X.  DERCUM,  M.D. 

THE  CEREBRAL  PALSIES  OP  CHILDHOOD. 

Children,  as  a  result  of  diverse  pathological  causes,  operating  both  in 
intra-uterine  life  and  in  early  childhood,  and  of  various  accidents  to  which 
they  are  exposed  during  birth,  are  subject  to  a  variety  of  palsies  presenting 
special  clinical  features.     These  palsies  constitute  a  group  by  themselves. 

Etiology  and  Pathology.  As  the  name  "  cerebral  palsy  "  implies,  there  is 
in  every  case  a  lesion  in  the  motor  area  of  the  cortex,  or  at  some  point  in  the 
encranial  portion  of  the  motor  tract,  that  is,  in  the  white  matter  subjacent  to 
the  motor  area,  in  the  motor  portion  of  the  internal  capsule,  in  the  crus, 
pons,  or  pyramidal  tracts.  Clinically  the  cases  resolve  themselves  into  two 
groups ;  first,  those  in  which  the  lesion  is  widely  diffused  and  involves  both 
sides  of  the  brain,  producing  paralysis  on  both  sides  of  the  body,  that  is, 
diplegia ;  and  secondly,  those  in  which  the  lesion  is  limited  to  one  side  of  the 
brain,  producing  unilateral  palsy  or  hemiplegia.  As  might  be  conjectured, 
the  detailed  symptoms  in  a  given  case  depend  upon  the  location  of  the  lesion 
and  but  little  upon  iis  nature.  Similar  symptoms  may  be  produced  by 
Avidely  different  causes,  anything,  in  fact,  that  interferes  with  the  nutrition  or 
the  development  of  the  motor  area  or  tract,  such  as  inflammation,  hemor- 
rhage, thrombosis,  neoplasm,  etc.  Unfortunately,  our  knowledge  of  the 
various  morbid  processes  at  work  depends  more  upon  inference  than  upon 
observation.  It  is  very  common  to  find  at  the  autopsy  atrophy  and  sclerosis 
of  the  convolutions,  together  with  large  cysts,  but  these  changes  are  in  the 
majority  of  cases  the  outcome  of  some  pre-existing  and  acute  process.  They 
are  evidently  terminal  in  character,  and  must  be  regarded  as  a  result  rather 
than  as  a  cause. 

With  reference  to  their  etiology,  cerebral  palsies  resolve  themselves,  first, 
into  those  beginning  in  intra-uterine  life ;  secondly,  those  occurring  as  the 
result  of  accidents  during  birth ;  and  thirdly,  those  acquired  in  infancy. 

The  first  group  presents  the  following  etiological  features.  In  some  of  the 
prenatal  cases  simple  developmental  arrest  is  the  causal  factor.  The  brain 
in  such  cases  is  embryonically  defective  and  growth  fails  to  take  place,  either 
because  of  lack  of  formative  power  or  because  of  some  gross  anomaly  in  the 
vascular  supply.  A  certain  number  of  these  cases,  however,  are  due  to  gross 
pathological  conditions,  such  as  meningo-encephalitis,  ependymitis,  and,  per- 
haps, hemorrhage  and  thrombosis.  In  syphilis  and,  perhaps,  other  infectious 
processes,  we  have  a  possible  cause  of  prenatal  vascular  lesions,  though  the 
evidence  upon  this  point  is  meagre. 

Trauma  of  the  abdomen  of  the  mother,  in  rare  instances,  plays  an  im- 
portant part.     This  is  proven  by  the  interesting  case  reported  by  Gibbs.^ 

1  Cited  by  McNutt :  Apoplexia  Neanotorum,  Amer.  Journ.  of  Obstetrics  1885,  xviii.  p.  73. 


FOCAL  DISEASES  OF  THE  BBAIK  507 

The  child,  which  was  stillborn,  presented  the  symptoms  of  hemiplegia  with 
atrophy  and  contractures,  the  latter  being  so  marked  that  they  could  not  be 
overcome  without  cutting  the  tendons.  On  the  j)arietal  bone  of  the  oppo- 
site side  was  found  an  ecchymosis,  while  the  hemisphere  showed  the  remains 
of  an  old  clot.  There  was  a  history  of  a  severe  blow  to  the  abdomen  of  the 
mother  during  her  pregnancy. 

At  times,  and  probably  with  truth,  prenatal  arrest  of  development  has 
been  attributed  to  a  maternal  impression,  such  as  fright  or  other  great  emo- 
tional disturbance. 

Occasionally  children  born  prematurely  present  later  on  the  symptoms  of 
spastic  palsy.  Here  feeble  development  of  the  motor  cortex  and  tracts  offers 
the  most  probable  explanation.  We  should  remember  in  this  connection, 
however,  that  the  crania  of  premature  children  are  imperfectly  developed, 
and  that  as  a  consequence  they  are  less  able  to  protect  the  brain  from  injury 
at  birth.  The  two  causes  should  not  be  confounded.  In  the  one  instance, 
there  would  be  a  history  of  a  gradually  acquired  paLsy  ;  in  the  other,  the  his- 
tory of  a  palsy  dating  from  bii'th.  In  another,  though  rare  class  of  cases, 
the  children  are  apparently  normal  at  birth,  but  there  is  such  an  extreme 
feebleness  of  development  or  instability  of  the  motor  tract  that  early  degen- 
erative changes  take  place.  Freud  ^  records  two  cases  of  cerebral  diplegia 
in  the  children  of  a  physician  who  had  married  his  niece.  The  three  re- 
markable cases  of  hereditary  infantile  spastic  paraplegia  recorded  by  Gee,^ 
also  belong  to  this  group ;  father,  daughter,  and  son  were  affected.  As 
Freud  points  out,  thei'e  is  here  a  relation  to  Friedreich's  ataxia.  There  is 
the  same  tendency  to  premature  death — premature  wearing  out — of  nerve 
tracts. 

The  mcoml  group,  which  includes  cases  having  their  origin  in  trauma 
during  birth,  is  quite  large.  The  head  of  the  child  in  its  passage  through 
the  pelvis  is,  as  we  know,  exposed  to  varying  conditions  of  pressure,  and  it 
cannot  cause  surprise  that  under  certain  circumstances,  e.  g.,  when  this  pres- 
sure has  been  excessive  or  unduly  prolonged,  that  encranial  lesions  ensue. 
The  first  to  properly  appreciate  these  facts  and  to  recognize  their  relation  to 
the  spastic  palsies  of  childhood  was  Little.'^  He  tells  us  that  the  "  severe 
lesions  caused  by  the  mechanical  compression  and  laceration  and  extensive 
hemorrhage  within  the  skull,  when  they  do  not  destroy  life,  give  rise  to  per- 
manent deformity  of  the  cranium,  to  atrophy  of  the  injured  portions  of  the 
brain,  and  are  the  causes  of  many  cases  erroneously  described  as  congenital 
idiocy."  It  has  been  repeatedly  demonstrated  that  the  lesion  in  these  cases 
is  meningeal  hemorrhage,  and  to  Sarah  McNutt  *  belongs  the  credit  of  clearly 
establishing  the  relation  of  these  hemorrhages  to  the  cerebral  palsies  (see 
Fig.  140).  She  showed,  furthermore,  that  hemorrhages  are  apt  to  occur  at 
the  base  of  the  brain  in  vertex  presentations,  and  at  the  vertex  in  breech 
presentations.  It  is  exceedingly  probable  when  they  occur  at  the  base 
that  vital  structures  are  interfered  with,  and  that  as  a  consequence,  the 
child  promptly  dies,  while  when  they  occur  at  the  vertex  the  child  lives 
but  later  presents  the  Avell-known  symptoms  of  chronic  sf)astic  paralysis. 
The  hemorrhage  appears  to  come  from  the  veins  of  the  pia,  and  even  at 
times  from  the  longitudinal  sinus.  The  effused  blood  causes  compression, 
and  possibly,  also,  inflammation  of  the  central  portions  of  the  vertex.     As 

1  Freud  :  Ueber  Familien  Formen  des  Cerebralen  Diplegia,  Neurolog.  Centralbl.,  1893,  xii.  pp. 
512,  542. 

-  Gee  :  Hereditary  Infantile  Spastic  Paraplegia,  St.  Bartholomew  Hosp.  Reports.  1889.  xxv.  p.  81. 

3  Little:  On  the"lnfluence  of  Abnormal  Parturition,  Difficult  Labors,  Premature  Birth,  and  As- 
phyxia Neonatorum  on  the  Mental  and  Physical  Condition  of  the  Child,  Especially  in  Relation  to 
Deformities.    Obstetrical  Transactions,  1862,  vol.  iii.  p.  263. 

•1  Loc.  cit. 


508  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

already  stated,  the  lesions  commonly  found  are  those  of  atrophy  and  sclerosis 
with  or  without  the  formation  of  cysts  (porencephalus),  changes  which  can 
certainly  be  regarded  as  terminal  to  meningeal  hemorrhage.  The  lesion  most 
frequently  involves  both  sides  of  the  brain,  though  it  may  be  limited  to  one 
hemisphere.     According  to  Sachs,^  the  congenital  cases  of  hemiplegia  almost 

Fig.  140. 


Showing  the  location  of  a  meningeal  hemorrhage  occurring  at  birth.    (McNbtt.) 

equal  in  number  the  congenital  cases  of  diplegia,  and  there  can  be  no  ques- 
tion that  both  forms  are  frequently  the  outcome  of  similar  causes.  It  is  not 
imiDossible,  flirther,  that  the  prolonged  asphyxia  to  which  children  are  some- 
times exposed  during  birth  is  a  factor  in  the  subsequent  cortical  degenera- 
tion. Finally,  the  fact  that  the  majority  of  congenital  cerebral  palsies  occur 
in  first-born  children  is  a  confirmation  of  the  importance  of  birth  traumata 
as  etiological  factors.  A  few  cases  of  cerebral  palsy  have  been  traced  to 
injury  by  the  forceps.  Thus,  Osier  ^  found  nine  cases  of  such  injury  in  one 
hundred  and  twenty  infantile  hemiplegias,  all  told.  It  is  certain,  however, 
as  Gowers  ^  points  out,  that  the  injury  is  due  less  frequently  to  the  forceps 
than  to  the  dystochia  which  renders  their  employment  necessary. 

In  the  third  group,  which  includes  the  acquired  cases,  a  number  of  causes 
are  found,  and  among  these  the  infectious  diseases  play  the  dominant  role. 
Cerebral  palsies  have  been  observed  to  occur  during  or  just  after  scarlet 
fever,  measles,  whooj)ing-cough,  typhoid  fever,  diphtheria,  and  even  vaccinia. 
In  a  certain  number  of  autopsies  in  more  recent  cases  unmistakable  evi- 
dences of  hemorrhage,  thrombosis,  embolism,  and  other  changes  have  been 
found.  In  children,  we  should  remember,  meningeal  and  cortical  hemor- 
rhage are  far  more  frequent  than  in  adults,  and  this  is  probably  true  of 
other  vascular  derangements.  Vascular  lesions  were  present  in  sixteen  out 
of  ninety  autopsies  of  hemiplegia  collected  by  Osler.^  In  what  manner  these 
lesions  are  produced  is  not  definitely  known.  It  is  probable  that  in  some 
instances  a  local  arteritis  results  in  tlirombosis  and  in  othei^s  in  hemorrhage, 
w^hile  in  infectious  diseases  complicated  by  endocarditis,  embolism  is  the 

1  B.  Sachs  :, Cerebral  Paralvsis.of  Early  Life.    Trans,  of  the  Tenth  Internal .  Med.  Congress,  vol.  iv. 
p.  128. 
-  Osier  :  The  Cerebral  Palsies  of  Children.    London,  1889. 
3  Growers :  Dis.  of  the  Nervous  System,  1894,  ii.  p.  414.  ■*  Loc.  cit. 


FOCAL  DISEASES  OF  THE  BRAIX.  509 

factor  at  work.  StriimiDel  lias  advanced  the  theory  that  some  of  these  cases 
are  due  to  an  inflammation  of  the  cortex,  the  lesion  being  similar  to  that 
which  takes  place  in  acute  poliomyelitis.  That  a  polioencephalitis  corticalis 
acuta  actually  exists  as  a  pathological  entity  remains  to  be  proved.  The 
symptoms,  however,  often  suggest  this  lesion.  This  was  the  case,  for  instance, 
in  twenty  cases  out  of  one  hundred  and  sixty  collected  by  Sachs  and  Petei*- 
son.^  In  a  large  number  of  cases  the  paralysis  is  ascribed  to  convulsions. 
Thus,  twentv-one  out  of  sixty-four  cases  in  the  collection  of  Sachs  and  Peter- 
son, in  which  the  causes  had  been  ascertained,  presented  convulsions  as  the 
initial  symptom.  It  Ls  exceedingly  difficult  to  estimate  properly  the  value 
of  these  facts,  as  it  is  probable  that  the  convulsions  are  more  frequently  the 
result  of  the  lesion  than  a  primary  cause.  It  is  not,  however,  inconceivable 
that  a  toxic  agent  acting  upon  the  cortex  should  produce  convulsions,  and 
that  these,  if  sufficiently  intense  and  prolonged,  should  lead  to  permanent 
changes  in  the  nutrition  of  the  cortex.  Trauma  also  plays  a  role  in  some  of 
the  acquired  cases.  Thus,  penetrating  wounds  and,  more  especially,  falls 
upon  the  head  are  occasionally  followed  by  the  symptoms  of  cerebral  palsy. 
In  one  instance,  in  a  patient  in  the  Pennsylvania  Institution  for  Feeble- 
Minded  Children,  hemiplegia  followed  ligation  of  the  carotid  artery.  As  the 
reader  has  probably  inferred,  acquired  palsies  are  most  often  hemiplegic  in 
t}q)e.  Thus,  of  ninety-one  cases,  according  to  Sachs  and  Peterson,  eighty- 
three  presented  the  symptoms  of  hemiplegia. 

As  the  reader  has  already  learned  (see  Chapter  XV.)  lesions  of  the 
motor  area  of  the  cortex  are  followed  by  a  degeneration  in  the  fibres  of  the 
motor  tract.  In  various  autopsies  in  the  cerebral  palsies  of  childhood  these 
degenerations  have  been  traced.  Occasionally,  however,  all  evidence  of 
these  secondary  scleroses  is  wanting.  Thus  Gierlich^  found  an  atrophy  of 
the  motor  tracts  in  the  j^ons,  the  medulla  and  in  the  sj^inal  cord  down  to  the 
lumbar  region,  but  there  was  no  degeneration.  Such  nerve  fibres  as  were 
present  were  normal  in  appearance.  The  number  of  fibres,  however,  was 
diminished,  esjoecially  in  the  pons.  Gierlich  offers  as  an  explanation  that  in 
destruction  of  the  motor  centres  in  embryonal  or  infantile  life  the  encasing 
of  the  axis  cylinders  with  myelin  ceases,  and  that  the  axis  cylinders  thus  un- 
protected degenerate  and  are  absorbed  through  the  active  metabolic  processes 
of  childhood  without  any  reactive  inflammation  taking  place  in  the  intersti- 
tial tissue.  This  ingenious  theory  has  much  to  commend  it.  It  renders  clear 
facts  which  otherwise  seem  inexplicable. 

Hemiplegia  and  diplegia,  as  we  have  seen,  may  be  due  to  the  same  morbid 
process,  and  either  form  may  be  congenital  or  acquired.  However,  the  large 
majority  of  the  congenital  palsies  are  diplegic,  while  the  acquired  palsies  are 
most  frequently  hemiplegic  ;  and,  though  a  sharp  distinction  cannot  be  drawn 
between  them,  each  form,  notwitkstanding,  presents  an  average  of  peculiari- 
ties which  renders  a  separate  consideration  desirable. 

Hemiplegia.  The  relative  frequency  of  hemiplegia  may  be  inferred  from 
the  statistics  of  Osler,^  who  in  a  collection  of  151  cases  of  all  forms  found 
120  presenting  this  symptom.  That  it  Ls  only  infrequently  congenital  is 
proven  by  the  collection  of  Sachs  and  Peterson,*  Avho  found  only  22  congeni- 
tal out  of  105  cases.  As  regards  sex.  Osier  found  iu  lo5  cases  75  girls  and 
60  boys,  while  Sachs  and  Peterson  in  140  cases  found  42  girls  and  63  boys. 
It  cannot  be  said,  therefore,  that  either  sex  predominates.  Again,  as  regards 
the  side  affected,  Osier  found  it  occurred  79  times  on  the  right  side  and  oQ 

1  Sachs  and  Peterson  :  Journ.  of  Nervous  and  Mental  Diseases,  1890,  xvii.  p.  295. 
-  Gierlich  :  Ueber  secundare  Degeneration  bei  cerebraler  Kinderliihmung.    Archiv  f.  Psychiatrie, 
1891,  vol.  xxiii.  p.  201. 
3  Loc.  cit.  *  Loc.  cit. 


510 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


times  on  the  left  side,  while  Sachs  found  it  to  occur  52  times  on  the  right 
side  and  53  times  on  the  left  side.  It  is  fair,  therefore,  to  assume  that  neither 
side  is  especially  predisposed.  The  great  majority  of  the  acquired  hemiple- 
gias occur  within  the  first  two  or  three  years  of  childhood.  This  statement 
is  borne  out  by  both  the  statistics  of  Osier  and  by  Sachs  and  Peterson. 

The  morbid  anatomy  of  hemiplegia  based  on  90  autopsies  collected  by 
Osier,  is  as  follows :  Sixteen  cases,  none  of  which  survived  the  attack  long, 
suffered  from  thrombosis,  embolism  or  hemorrhage.  In  seven  there  was  plug- 
ging of  the  Sylvian  artery,  in  nine  hemorrhage.  Three  were  congenital,  one 
was  under  three  years,  six  were  over  ten  years.  In  50  cases  atrophy  and 
sclerosis  were  found.  I'he  sclerosis  was  usually  diffuse  and  involved  either 
an  entire  hemisphere  or  a  single  lobe,  or  it  was  confined  to  one  or  two  convo- 
lutions. In  a  few  cases  it  was  found  in  patches.  ^Nodular  projections  of 
sclerosed  tissue,  that  is,  hj^Dcrtrophic  scleroses,  were  sometimes  found.  In  24 
cases  porencephalus  (see  Fig  141)  was  found  ;  that  is,  cysts  filling  up  space 

Fig.  141. 


A  case  of  porencephalus.    (Lloyd.) 

normally  occupied  by  brain  tissue,  and  extending  down  from  the  surface  of 
the  brain  to  a  variable  depth  into  its  substance.  (For  a  detailed  account 
of  this  condition  see  page  319.)  In  six  the  paralysis  was  congenital;  in 
eighteen  it  was  acquired ;  in  eleven  of  these  it  came  on  in  early  life  and 
after  convulsions.  The  extent  of  the  lesion  varied  from  a  few  convolutions 
to  half  of  the  hemisphere.  In  all  of  the  cases  the  lesions  involved  the 
motor  area.  In  some  instances  the  primary  lesion  is  undoubtedly  a  menin- 
gitis. Oliver^  has  reported  one  such  instance.  In  rare  instances  the  symp- 
toms of  infantile  hemiplegia  are  the  result  of  a  tumor  involving  the  motor 
area.  Such  a  case  is  recorded  by  Donkin'^  in  which  a  tuberculous  tumor 
involved  the  Rolandic  region.  Another  instance  is  shown  in  Fig.  142,  in 
which  the  left,  motor  area  was  invaded  by  an  extensive  angiolithic  sarcoma. 
There  was  marked  contracture  and  retardation  of  growth  of  the  right  arm  and 
also  some  arrest  of  growth  in  the  leg. 

Diplegia.     This  form,  as  we  will  presently  see,  resolves  itself  into  two  sub- 
groups ;  first,  diplegia  proper,  that  is  those  cases  in  which  both  upper  and 

1  Oliver  :  British  Medical  Journal,  1890,  vol.  i.  p.  284. 

-  Doukin  :  Westminster  Hospital  Reports,  1891,  vol.  vii.  p.  1. 


FOCAL  DISEASES  OF  THE  BEAIN. 


511 


Fig.  142. 


lower  limbs  are  affected  on  each  side  of  the  body  ;  and,  secondly,  paraplegia, 
in  which  the  paralysis  is  limited  to  the  legs,  or  in  which  it  is  very  slightly 
marked  in  the  arms.  Though  congenital  in  the  large  majority  of  cases  diple- 
gia may  also  be  acquired.  Thus  Sachs  and  Peterson^  present  twenty  cases  of 
congenital  diplegia,  seven  of  congenital  paraplegia,  and  but  four  each  of 
acquired  diplegia  and  paraplegia.  The  causes  of  congenital  diplegia  we  have 
already  sufficiently  considered.  In  the  ac- 
quired cases  Sachs  found  that  one  resulted 
from  convulsions,  two  followed  measles,  one 
began  with  fever,  one  followed  cerebro-spinal 
meningitis,  two  hydrocephalus,  while  in  still 
another  the  cause  was  unascertained.  The 
morbid  anatomy  of  cerebral  diplegia  proper 
is  based  upon  sixteen  autopsies,  also  collected 
by  Osier.  All  of  the  cases  revealed  destruc- 
tive lesions  of  the  motor  centres  of  the  cortex, 
difflise  atrophic  sclerosis  being  most  common. 
Descending  degeneration  was  present  in  some 
cases,  not  noted  in  others,  and  absent  in  one 
when  searched  for.  Rarely  extensive  internal 
hydrocephalus  gives  rise  to  the  symj)toms  of 
spastic  diplegia.  Such  an  instance  is  pre- 
sented in  Fig.  143. 

But  one  record  of  autopsy,  that  of  Foerster, 
was  found  by  Osier  in  cerebral  paraplegia.  In 
this  there  was  general  cortical  sclerosis,  slight 
dilatation  of  the  lateral  ventricles  and  some 
descending  degeneration.  To  this  we  must 
add  another  autopsy  recorded  by  Ferguson,^ 
who  found  a  patch  of  sclerosis  at  the  upper 
end  of  each  fissure  of  Rolando,  with  descend- 
ing degeneration  in  the  motor  tracts,  except  in 
the  columns  of  Tiirck. 

Symptoms.  The  symptoms  and  course  of 
the  affection  vary  in  accordance  with  the  mode 
of  origin,  that  is,  whether  prenatal,  congenital 
or  acquired,  and  also  in  accordance  with  the 
extent  and  distribution  of  the  lesion.  In  the 
prenatal  cases  where  there  has  been  marked 
arrest  of  development,  such  striking  features 
as  microcephaly  or  other  deformity  of  the 
cranium,  with  more  or  less  markecl  hemiplegia,  single  or  double,  with  or 
without  contractures,  may  be  observed  at  birth. 

In  the  cases  due  to  trauma  at  birth,  we  have  generally  the  history  of  a  pro- 
tracted or  difficult  labor  of  a  first  birth.  When  born  the  child  may  present 
symptoms  more  or  less  marked  of  asphyxia,  and  frequently  it  suffers  from 
convulsions.  Owing  to  the  child's  general  condition,  the  paralysis  may  not 
be  noticed,  and  indeed  several  days  may  elapse  before  it  attracts  attention. 
Sooner  or  later,  however,  it  becomes  very  evident.  Convulsive  seizures,  if 
they  occur  at  this  time,  are  oft  repeated,  and  may  be  general  or  limited  to 
one  side.  After  these  symptoms  disappear,  and  as  time  passes,  we  observe 
that  the  development  of  the  child  does  not  follow  a  normal  course.  Thus,  it 
does  not  learn  to  walk  at  the  proper  time.     Walking  is  very  much  delayed, 


Spastic  hemiplegia  from  angiolithic 
sarcoma  of  tlie  brain,  the  symptoms 
dating  from  five  years  of  age.  Jefferson 
Hospital. 


1  Log.  cit. 


-  Ferguson :  American  Journal  of  Obstetrics,  1891,  vol.  xxiv.  p.  928. 


512 


NERVOUS  DISEASES  AND  THEIR  TREATMENT 


Fig.  143. 


and  in  many  instances  never  acquired.  If  the  cliild  be  closely  examined  it 
is  found  that  there  is  more  or  less  marked  rigidity  in  both  arms  and  legs,  and 
that  there  is  a  tendency  in  the  arm  to  assume  the  position  of  contracture  seen 
in  adult  hemiplegics  in  whom  secondary  degeneration  has  occurred,  while  the 
legs  become  extended  and  firmly  adducted.  Often  one  leg  is  crossed  over 
the  other.     In  diplegias,  to  which  this  description  especially  applies,  the  legs 

sufier,  as  a  rule,  more  severely  than  the  arms. 
Indeed,  as  already  stated,  the  arms  are  occa- 
sionally very  little  involved,  and  in  some  cases 
not  at  all,  the  disease  then  constituting  the 
sub-group  above  mentioned  as  cerebral  para- 
plegia. 

If  a  hemiplegia  has  resulted,  the  symptoms 
are  likewise  those  of  a  sj)astic  palsy ;  but  in 
this  instance,  contrary  to  what  we  find  in  the 
diplegias,  the  arm  is  much  more  aflfected  than 
the  leg.  Further,  we  notice  as  the  child  de- 
velops, that  the  limbs  on  the  hemiplegic  side 
fail  to  grow  as  rapidly  as  their  fellows,  and 
that,  when  compared  Avith  these  as  time  pro- 
gresses, they  appear,  in  addition  to  the  con- 
tractures which  they  present,  much  smaller. 
As  could  be  expected  upon  a  jyriori  grounds, 
the  tendon  reactions  are  markedly  increased, 
that  is,  if  the  contractures  are  not  so  severe 
as  to  prevent  motion  of  the  limbs.  Thus  in 
hemiplegia  the  knee-jerks  are  plus,  Avhile 
ankle  clonus  is  often  obtained.  In  the  di- 
plegic  form,  while  the  knee-jerks  are  plus  it  is 
impossible  often  to  obtain  an  ankle  clonus, 
owing  to  the  rigid  fixation  of  the  foot. 

In  the  acquired  forms  the  symptoms  may,  as 
ah'eady  stated,  come  on  as  a  result  of  various 
infectious  diseases  and  trauma,  but  may  also 
make  their  appearance  in  the  midst  of  apparent  health.  The  onset,  as  a  rule, 
is  sudden,  generally  with  convulsions,  which  may  be  intermittent  and  repeated. 
Some  fever,  though  this  is  generally  slight,  may  accompany  the  attack.  Occa- 
sionally, however,  the  rang*  of  temperature  may  be  very  high,  107°  F.  being 
mentioned  by  Sachs.'  During  the  convulsion  the  child  is  in  a  condition  of 
coma,  and  paralysis  may  not  be  noted  until  consciousness  returns.  At  times, 
however,  the  convulsion  is  more  marked  on  or  limited  to  one  side — the  side 
which  afterward  reveals  paralysis.  The  lesion  having  been  produced,  the 
symptoms  follow  the  course  pursued  by  other  cerebral  palsies.  Most  fre- 
quently, as  we  have  seen,  a  hemiplegia  is  established,  though  sometimes  a 
diplegia  results. 

A  number  of  symptoms  pertaining  more  or  less  to  all  forms  remain  to  be 
noted.  Mental  defects  are  present  in  many  cases.  That  they  are  especially 
marked  in  the  prenatal  forms,  those  in  which  there  has  been  cortical  agenesis, 
is  not  to  be  wondered  at.  That  they  should  also  be  frequent  in  the  congeni- 
tal forms  and  in  those  acquired  cases  in  which  the  affection  has  come  on  in 
the  earliest  years  of  infancy,  is  merely  what  we  would  expect  to  find.  Thus 
Sachs  and  Peterson^  in  their  statistics  of  eighty  cases  found  that  fourteen  pre- 

1  Sachs :  Cerebral  Hemorrhage,  Thrombosis  and  Embolism,  Keatiug's  Cyclopaedia  of  Diseases  of 
Children,  1890,  vol,  iv.  p.  537. 
-  Loc.  cit. 


Diplegia  from  internal  hydrocephalus, 
Philadelphia  Hospital. 


FOCAL  DISEASES  OF  THE  BRAIN  513 

sented  idiocy,  fifteen  imbecility  aiid  six  feeble-mindedness.  Of  those  in  which 
the  palsy  had  been  acquired  under  three  years,  six  presented  idiocy,  eighteen 
presented  imbecility  and  ten  feeble-mindedness.  Of  those  from  three  ^o  five 
years  none  presented  idiocy,  three  imbecility,  and  two  feeble-mindedness ;  of 
those  from  five  to  ten  years,  three  presented  imbecility  and  two  feeble-minded- 
ness, while  of  six  acquired  after  ten  years  of  age,  but  one  presented  feeble- 
mindedness. The  inference  from  these  figures  is  obvious.  The  earlier  the 
onset  the  greater  the  mental  impairment.  Further,  the  proportion  of  grave 
mental  defects,  such  as  idiocy  and  imbecility,  is  greater  in  those  cases  in  which 
the  lesion  has  been  most  extensive.  Thus  in  seventeen  cases  of  diplegia,  eight 
presented  idiocy,  seven  imbecility  and  two  feeble-mindedness.  In  nine  cases 
of  paraplegia  again,  more  than  half  (five)  presented  idiocy,  one  iml^ecility  and 
three  feeble-mindedness.  Of  forty-five  cases  of  hemiplegia,  but  seven  pre- 
sented idiocy,  thirty-one  presented  imbecility  and  sixteen  feeble-mindedness. 
In  another  case  there  existed  epileptic  insanity. 

Cerebral  palsies  are  frequently  complicated  by  epilepsy.  This  is  present, 
especially  in  the  hemiplegic  form.  Most  frequently  it  does  not  make  its 
aj)pearance  until  one  or  more  years  have  elapsed  after  the  onset  of  the  paral- 
ysis. It  shows  a  disposition,  further,  to  persist  and  often  to  increase,  and  is  of 
itself  in  many  cases  responsible  for  the  imbecility  present.  It  may  begin  in  and 
may  be  limited  to  the  limbs  of  the  affected  side,  or  it  may  be  general.  In  di- 
plegic  palsies  convulsive  seizures  frequently  occur  at  birth  or  for  a  brief  period 
thereafter.  The  tendency  is  to  an  early  cessation  of  the  attacks.  In  but 
few  instances  do  they  develop  into  epilepsy.  On  the  other  hand,  about  50 
per  cent,  of  all  hemiplegics  are  epileptics. ^ 

In  addition  to  the  various  symptoms  thus  far  detailed  various  disorders  of 
motion  may  be  added  to  the  paralysis.  Thus  there  may  be  tremor,  chorea, 
spasms  or  athetosis.  (See  p.  264.)  In  Osier's  collection,  thirty-one  cases  of 
hemiplegia  presented  such  disorders.  One  presented  tremor,  twenty-four 
presented  chorea,  and  six  cases  presented  mobile  spasms  with  athetosis.  In 
diplegic  cases  ataxic  and  athetoid  movements  most  exaggerated  in  kind  may 
be  present.  When  spasm  and  chorea  are  equally  associated  it  has  been 
been  termed  chorea  spastica.  When  the  hands,  fingei's  and  toes  present 
slow,  irregularly  recurring  movements  the  condition  is  termed  athetosis,  and 
W'hen  they  are  present  in  diplegic  cases  the  condition  is  termed  double  athe- 
tosis. (See  Fig.  144.)  Post-hemiplegic  disorders  of  movements  were  first 
described  by  Weir  Mitchell.  No  change  has  ever  been  observed  in  the 
electrical  conditions  of  the  muscles.  Sensation  is  never  lost  or  even  impaired 
in  the  cerebral  palsies  of  childhood.  In  a  few  cases  there  is  hj'persensitive- 
ness  to  touch  (hypereesthesia).'' 

As  we  have  seen,  the  various  forms  of  cerebral  palsies  present  many  symp- 
toms in  common.  Each  form,  however,  presents  a  number  of  special  fea- 
tures. Some  of  these  have  abeady  been  alluded  to,  but  our  purpose  Avill  be 
served  best  by  rehearsing  bx'iefly  the  symptoms  especially  pertaining  to  each 
group. 

Hemiplegia.  This,  as  we  have  seen,  is  most  frequently  acquired.  The 
onset  is  characterized  by  convulsions  and  coma.  In  a  few  cases  these  symp- 
toms are  absent.  When  present  they  are  associated  with  fever,  which  may 
be  transient  or  persistent,  usually  not  very  high.  At  times  the  onset  is  asso- 
ciated with  delirium.     Vomiting  is  also  occasionally  noted,  and  sometimes 

1  Because  of  the  intimate  relation  existing  between  cerebral  palsies  and  epilepsy  Freud  goes  so 
far  as  to  consider  common  epilepsy  as  a  congenital  or  acquired  disease  (not  a  neurosis)  in  which 
the  diplegia  or  hemiplegia  pertaining  thereto  has  disappeared.  This  he  claims  is  also  true  of  many 
cases  of  imbecility  and  idiocv.    Revue  Xeurolog.,  1893,  i.  p.  177. 

-'  Railton  :  British  Med.  Joiirn.,  1891,  i.  p.  1382. 

33 


514 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


there  is  soreness  of  the  general  surface.  When  consciousness  returns  the 
hemiplegia  is  discovered.  It  is  usually,  though  not  always,  profound.  It  is 
marked  in  the  arm,  leg,  and  sometimes  in  the  face.     In  the  latter  the  lower 


Fig.  144. 


Illustrating  the  walk  of  a  young  girl  presenting  spastic  diplegia  with  choreiform  and  athetoid 
movements.  From  serial  photographs  made  simultaneously  from  three  different  points  of  view  by 
Eadweard  Muybridge  from  a  patient  of  the  writer. 


half  only  is  involved,  the  orbicularis  palpebrarum  and  brow  muscles  escap- 
ing. The  hemiplegia  is  thus  of  the  type  met  with  in  the  adult.  After  a 
time  signs  of  recovery  set  in.     The  paralysis  in  the  majority  of  cases  dis- 


FOCAL  DISEASES  OF  THE  BRAIN. 


515 


appears  from  the  face  altogether,  becomes  less  pronounced  in  the  leg,  but 
remains  marked  in  the  arm.  In  rare  instances  the  facial  paralysis  persists. 
Thus  in  a  case  reported  by  Koenig^  it  persisted  in  the  face,  while  it  disap- 
peared from  the  limbs. 

After  a  time  the  child  recovers  sufficiently  to  resume  walking,  but  the  gait  is 
hemiplegic.     Sooner  or  later  rigidity  of  the  paralyzed  side  makes  its  appear- 
ance.    In  a  few  cases  (in  two  noted  by  Sachs)  it  fails  to 
appear.     The  arm  assumes  the  position  seen  in  the  sec-  f^'^-  i^o. 

ondary  contracture  of  the  hemiplegia  of  the  adult.  The 
leg  suffers  less  from  rigidity  than  the  arm,  but  the  ten- 
dency is  for  it  to  assume  the  position  of  extension.  The 
knee-jerks  are  exaggerated,  and  ankle-clonus  is  often 
present.  Choreiform  or  athetoid  movements  may  also 
make  their  appearance.  In  one  instance  Fere^  noted  a 
peculiar  intermittent  contraction  in  the  fascicles  of  the 
large  muscles  of  the  paralyzed  limbs.  The  arm  grows 
at  a  lessened  rate  than  its  fellow.  This  is  also  true  of 
the  leg,  though  to  a  less  extent.  By  the  time  adult  life 
is  reached  the  difference  in  the  limbs  of  the  two  sides 
is  generally  very  great,  the  arm  appearing  when  com- 
pared with  its  fellow  as  though  atrophied.  The  differ- 
ence in  the  length  of  the  legs  is  generally  sufficient  to 
cause  a  more  or  less  marked  limp  in  the  gait.  In  some 
cases  vasomotor  disturbances,  such  as  coldness  and  blue- 
ness  of  the  extremities  is  noted.  Often  the  hemiplegia 
is  accompanied  by  aphasia.  This  is  frequently  tem- 
porary, but  at  other  times  the  power  of  speech  returns 
only  after  months  and  years.  The  tremor,  choreifox"m 
movement  and  athetosis  which  appear  in  the  paralyzed 
limbs  in  some  of  these  cases  have  already  been  con- 
sidered. These  disorders  of  movements  are,  however, 
much  less  common  than  in  the  diplegic  form.  They 
Avere  present  in  but  thirty-two  cases  out  of  one  hundred 
and  twenty  collected  by  Osier.  The  relation  of  mental 
defects  and  of  epilepsy  to  hemiplegia  have  already 
been  considered. 

The  student  naist  remember  that  the  above  description  is  applicable  to  the 
vast  majority  of  cases.  In  rare  instances  aberrant  symptoms  are  met  with, 
due  doubtless  to  peculiarities  in  the  location  of  the  lesion.  Thus  Menz^  re- 
ports a  case  of  the  sudden  paralysis  of  one  side  occurring  in  a  child  of  ten 
months,  followed  by  slow  improvement,  but  with  the  appearance  of  hemi- 
chorea  and  hemiatlietosis.  Associated  with  these  phenomena  was  the  very 
unusual  one  of  bilateral  oculo-motor  palsy  most  marked  on  the  side  opposite 
the  hemiplegia.  The  lesion  is  supposed  by  Menz  to  have  been  in  the  left 
crus.     Wallenburg  reported  a  similar  case. 

Diplegia.  This  group,  as  already  stated,  falls  naturally  into  two 
sub-groups,  the  dipiegias  jyroper  and  the  paraplegias;.  There  is  usually  a 
history  of  injury  at  birth  or  of  difficult  labor.  Shortly  after  birth,  or  per- 
haps at  the  time  of  birth,  it  is  noted  that  the  limbs  of  the  child  on  both 
sides  are  not  moved  as  freely  as  they  should  be,  and  that  they  are  more  or 
less  rigid.  Occasionally  these  symptoms  are  observed  to  follow  a  febrile 
attack  or  a  convulsion.     There  is  no  local  wasting  observable  in  any  ca.>*e. 


^■j>* 


Spastic  hemiplegia  with 

epilepsy. 
(Philadelphia  Hospital.) 


Koenig  :    Deutsche  Med.  Wochenschr,  1893,  xix.  p.  lOH. 
Nouvelle  Iconograph.  de  la  Salpetriere.  1890,  iii.  p.  82. 
Menz  :    Wiener  klin.  Wochenschrift,  1892,  v.  p.  604. 


516  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

However,  there  is  usually  a  general  retardation  of  growth.  The  paralysis  is 
always  accentuated  in  the  legs.  The  latter  are  firmly  adducted,  extended, 
and  frequently  crossed  at  the  knees,  while  the  feet  assume  the  position  seen 
in  talipes  equinus  or  equino-varus.     The  knee-jerks  can  be  elicited  in  most 

Fig.  146. 


Spastic  diplegia,  congenital ;  presenting  choreiform  movements.    (Philadelphia  Hospital.)  . 

eases,  and  are  much  exaggerated.  The  ankle,  as  a  rule,  is  so  fixed  by  con- 
tracture that  no  clonus  is  obtained.  The  arms  present,  in  addition  to  marked 
rigidity,  spasm,  exaggerated  and  choreiform  movements.  The  condition  is 
further  complicated  by  an  association  of  movement.  When  a  child  makes 
an  attempt  to  grasp  an  object  with  one  hand  the  oj^posite  member  usually 

Fig.  147. 


Spastic  diplegia,  congenital ;  presenting  choreiform  and  athetoid  movements. 
(Philadelphia  Hospital.) 

opens  and  closes  in  unison.  The  majority  of  these  patients  ai'e  unable  to 
walk.  When  walking  is  possible  the  movements  are  very  irregular,  the 
tendency  to  adduction  producing  a  gait  known  as  cross-legged  progression, 
whilst  the  effort  is  attended  by  an  increase  in  all  of  the  choreiform  and  athe- 
toid movements.    These  movements  affect  not  only  the  legs  and  arms,  but  may 


FOCAL  DISEASES  OF  THE  BRAIN. 


517 


also  affect  the  face,  so  that  the  latter  is  constantly  distorted  by  rapidly  chang- 
ing and  grotesque  grimaces.  Among  rare  motor  disturbances  should  be 
mentioned  intention  tremor.  Railton^  reports  a  case  in  which  such  a  tremor 
was  present  in  the  arms  and  legs,  the  resemblance  to  disseminated  sclerosis 
being  quite  marked.  As  already  pointed  out,  the  mental  defects  in  these 
cases  are  generally  profound.  They  have  already  been  considered.  Speech 
when  acquired  is  usually  drawn,  hesitating  and  spasmodic  in  character. 
Frequently  these  patients  can  with  difficulty  be  understood. 

Paraplegia.  Here  the  symptoms  of  spastic  diplegia  are  met  with  as 
before,  but  on  the  whole,  to  a  much  less  marked  degree.  As  the  name 
implies,  the  condition  is  limited  to  the  legs,  though  in  a  small  number  the 
arms  are  slightly  involved.  The  legs  present  the  phenomena  of  rigidity  with 
exaggerated  knee-jerk.  The  condition  may  be  noted  at  birth  or  may  make 
its  appearance  shortly  after.     A  history  of  difficult  labor  is  often  present. 


Fig.  148. 


Fig.  149. 


Fig.   148.— Marked  plastic  paraplegia;    walking  or  staudiug  alone  impossible.     Infirmary  for 
Nervous  Diseases,  Philadelphia. 
Fig.  149.— Spastic  paraplegia  ;  crossed-legged  progression.    (Jefferson  Hospital.) 

Occasionally  the  para2:)legia  is  acquired.  The  tendency  to  extension  is  so 
marked  that  the  feet  assume  the  position  noted  in  diplegia  proper,  namely, 
talipes  equinus  or  equino-varus  with  marked  adductor  spasm.  (See  Fig.  148.) 
The  condition  may  be  comparatively  slight  or  very  pronounced.  Many  of 
these  patients  are  able  to  walk  with  comparatively  little  difficulty.     The 


1  Loc  cit. 


518  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

limbs  being  more  or  less  adducted,  the  patient  tends  to  throw  one  leg  in 
front  of  the  other  as  he  walks.  (See  Fig.  149.)  In  other  words,  there  is 
cross-legged  progression.  Intelligence  is  often  impaired,  but  to  a  much  less 
extent  than  in  diplegia  proper. 

Diagnosis.  Cerebral  palsies  present  symptoms  so  characteristic  that  error  in 
diagnosis  is  not  likely  to  occur.  Difficulty  can  only  arise  in  the  early  stages  of 
the  acquired  forms.  As  pointed  out  by  Striimpel,  poliomyelitis  and  acute 
cerebral  palsy  are  frequently  ushered  in  by  similar  symptoms ;  but  in  such 
cases  the  progress  of  the  case  and  the  hemiplegic  type  of  the  symptoms  will 
enable  us  to  make  the  differential  diagnosis.  It  is  also  easy,  as  a  rule,  to 
relegate  a  given  case  to  its  proper  group,  namely,  to  decide  whether  it  is 
hemiplegic,  diplegic,  or  paraplegic.  It  is  not,  however,  by  any  means  easy 
to  form  an  opinion  in  most  cases  regarding  the  nature  of  the  lesion.  It  is 
important,  first,  to  determine  whether  the  lesion  in  a  given  case  was  pre- 
natal, whether  it  is  due  to  trauma  at  birth,  or,  lastly,  whether  it  was  acquired. 
Here  the  history  and  special  symptoms  already  detailed  come  greatly  to  our 
assistance,  and  if  they  can  be  relied  upon  the  facts  determined  are  often  of 
great  value  to  the  family  of  the  patient.  Thus,  if  it  be  shown  that  a  given 
case  is  acquired  the  fact  is  of  far  less  significance  in  the  family  history  than 
if  the  evidence  points  to  a  prenatal  origin. 

Cortical  lesions  predominate  largely  in  the  cerebral  palsies  of  childhood. 
If  in  a  given  case  we  have  coma,  convulsions  or  delirium,  the  inference  is 
generally  justified  that  the  lesion  is  cortical.  However,  as  is  well  known, 
extensive  intra-cerbral  hemorrhage  may  also  give  rise  to  coma  and  initial 
convulsions,  but  the  convulsions  are  not  repeated.  In  meningeal  hemorrhage 
the  convulsions  recur  with  great  frequency.  The  differential  diagnosis  be- 
tween thrombosis,  hemorrhage,  and  embolism  must  be  made  upon  general 
principles,  the  symptoms  not  diffei'ing  in  children  from  those  in  adults,  and 
for  the  consideration  of  these  the  reader  is  referred  to  Chapter  XV.  It 
should  also  be  remembered  that  at  most  this  differential  diagnosis  can  only 
be  raised  to  a  degree  of  probability.  Fortunately,  these  distinctions  have 
but  little  practical  value. 

Care  should  be  taken  not  to  overlook  tumors  in  the  Rolandic  region,  which 
in  children,  as  we  have  ah-eady  seen,  may  give  rise  to  symptoms  closely 
resembling  those  of  ordinary  infantile  hemiplegia.  This  point  is  of  especial 
importance,  because  tumors  in  the  Rolandic  area  are  surgically  readily  acces- 
sible. If  in  a  given  case  a  legitimate  doubt  exists,  there  is  no  objection  to  an 
exploratory  trephining. 

Prognosis.  The  prognosis  differs  somewhat  in  the  various  forms.  Thus, 
diplegia  proper,  the  result  either  of  prenatal  or  congenital  causes,  offers  but 
little  prospect  of  improvement.  It  will  be  remembered  that  grave  mental 
defects  are  apt  to  occur,  idiocy  being  indeed  very  common.  Striking  excep- 
tions to  this  rule  are,  however,  occasionally  met  with,  and  the  physician 
should  make  his  prognosis  with  due  caution.  It  is  impossible  in  a  given  case 
to  say  just  to  what  extent  the  intellect  will  be  affected.  In  the  paraplegic 
form  the  prognosis  is  distinctly  less  unfavorable  than  in  diplegia  proper. 
From  what  we  know  of  the  morbid  anatomy  the  brain  lesion  is  far  less 
extensive,  and  in  keeping  with  this  fact  the  disturbance  of  the  intelligence 
is  much  less  marked.  Many  paraplegic  children  present  no  appreciable 
defect. 

As  regards  the  paralysis,  considerable  can  be  accomplished  in  some  cases. 
Every  now  and  then  a  child  unable  to  walk  acquires  this  power  with  increas- 
ing development.  In  this  i"espect  the  prognosis  is  much  more  favorable  in 
paraplegia'. 

As  regards  the  acquired  form,  the  prognosis  must  be  considered  under  two 


FOCAL  DISEASES  OF  THE  BBAIN.  519 

separate  heads :  first,  the  prognosis  of  the  affection  at  the  time  of  the  onset ; 
and,  secondly,  at  the  time  of  the  established  disease. 

Inasmuch  as  cerebral  lesions  so  often  follow  convulsions,  and  are  so  often 
the  outcome  of  infectious  diseases,  the  physician  should,  when  attending  a 
child  suffering  from  sudden  grave  cerebral  symptoms,  especially  convulsions 
and  coma,  state  to  the  family  the  possibility  of  a  paralysis  resulting.  He 
should  be  especially  careful  not  to  belittle  an  attack  of  infantile  convulsions, 
nor  should  he  feel  justified  in  an  entirely  favorable  prognosis,  even  if  no 
paralysis  be  discovered  at  the  time,  as  its  appearance  may  be  somewhat 
delayed.  A  paralysis  having  been  once  established,  and  involving,  as  it 
most  frequently  does,  the  face,  arm,  and  leg,  it  is  safe  to  assume  that  the 
paralysis  of  the  face  will  disappear,  and  that  the  paralysis  of  the  leg  will 
grow  so  much  less  that  the  child  will  in  time  again  be  able  to  walk.  How- 
ever, the  physician  should  not  neglect  to  state  to  the  relatives  that  this  result 
does  not  invariably  follow,  and,  further,  he  should  lay  emphasis  upon  the  fact 
that  recovery  is  rarely  complete.  It  is  generally  accompanied  by  a  dimin- 
ished rate  of  growth  in  the  limbs  of  the  affected  side,  so  that  the  leg  will  not 
only  be  stiff  and  awkward  in  its  movements,  but  in  course  of  time  will  be 
shorter  than  its  fellow.  The  arm  especially  will  be  small  and  contracted. 
Absolute  frankness  on  the  part  of  the  jDhysician  to  the  patient's  family  often 
saves  him  from  unjust  criticism.  Paralysis  and  contractures  having  been 
once  established,  the  pi'Ognosis  differs  in  no  respect  from  that  in  the  diplegic 
forms.  The  paralysis,  dejoending  upon  structural  change,  can  be  but  slightly 
improved.  The  contractures,  however,  may  be  materially  benefited  by  treat- 
ment. 

Treatment.  Little  can  be  said  in  regard  to  preventive  treatment,  except 
in  those  forms  due  to  traumata  at  birth.  The  relation  of  prolonged  and  diffi- 
cult labor  to  cerebral  palsies  has  already  been  considered.  Too  often  in 
works  upon  obstetrics  the  dangers  to  the  mother  alone  are  considered,  Avhile 
the  equally  grave  dangers  to  the  child  are  neglected — dangers  which  are  not 
only  immediate,  but  which  have  the  most  profound  bearing  upon  the  ftiture 
intellectual  and  physical  well-being  of  the  child.  There  can  be  no  doubt 
that  in  a  number  of  cases  labor  should  be  hastened  for  the  sake  of  the  child, 
and  it  is  probably  true  that  more  cases  of  cerebral  palsy  are  due  to  hesitation 
in  the  application  of  the  forcej)s  than  could  possibly  be  attributed  to  injury 
by  these  much  decried  instruments. 

Hemorrhage  having  occurred  in  the  trauma  of  childbirth,  the  propriety  of 
trephining  for  the  purpose  of  removing  the  clot  suggests  itself.  This  proce- 
dure was  first  advocated  by  Sarah  McNutt,  and  later  by  Sachs,  though  it  has 
never,  to  the  writer's  knowledge,  been  attempted,  probably  because  the 
symptoms  of  paralysis  do  not  immediately  make  their  appearance.  Although 
it  is  probable  that  the  clot  having  once  formed,  has  done  extensive  damage 
to  the  cortex,  no  px'ocedure  can  be  too  radical  that  promises  benefit  to  these 
unfortunate  diplegic  and  imbecile  children. 

The  treatment  of  the  acquired  form  resolves  itself  into  the  treatment  of 
the  initial  period  and  of  the  established  disease. 

A  child  in  convulsions  should  be  actively  treated,  cold  should  be  applied 
to  the  head,  bromides  should  be  given  by  the  mouth,  while  mercurials  should 
be  used  to  produce  free  purgation.  In  short  the  practitioner  should  be 
guided  by  general  principles.  The  following,  however,  should  be  especially 
borne  in  mind,  inasmuch  as  it  is  exceedingly  probable  that  in  some  cases 
the  convulsion  is  itself  the  direct  cause  of  the  later  oncoming  hemiplegia. 
Every  effort  should  be  made  to  prevent  the  recurrence  of  the  attack,  and  to 
attain  this  end  we  should  not  hesitate  to  resort  to  the  careful  use  of  chloroform. 
Sachs  insists  that  the  physician  should  remain  with  the  child  for  a  number  of 


520  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

hours  until  all  danger  of  a  repetition  of  the  convulsion  has  disappeared.  If 
the  onset  of  a  cerebral  palsy  be  due  to  trauma  prompt  surgical  interference 
is  indicated.  No  harm  can  be  done  by  an  exploratory  trephining,  and  if  a 
meningeal  clot  be  found  great  good  may  follow  its  removal.  (See  also  Chap- 
ters XIII.  and  XXXIII.) 

The  treatment  of  the  established  condition  resolves  itself  into  the  manage- 
ment of  the  paralysis  and  of  the  mental  state.  In  diplegia  proper  the 
various  remedies  at  our  disposal  have  but  little  influence  on  the  paralysis  or 
the  contractures.  However,  they  should  always  be  resorted  to  when  possible. 
They  consist  of  massage,  passive  movements,  and  faradism.  While  in  severe 
cases  but  little  impression  is  made  by  these  remedies,  in  the  less  marked  forms, 
especially  those  which  approach  in  character  paraplegia  and  in  simple  para- 
plegia itself,  great  good  is  often  accomplished  by  persistence  in  their  use.  The 
parts  should  be  gently  kneaded  and  rubbed  for  a  specified  time  daily,  while 
the  contractures  should  be  overcome  as  much  as  possible  by  gentle  movements. 
It  is  well  in  these  cases  to  use  some  lubricant,  as  olive  oil.  Xot  only  does  the 
oil  render  the  treatment  more  pleasant  to  the  child,  but  it  is  not  impossible  that 
a  small  percentage  may  be  absorbed.  Faradism  is  a  remedy  which  at  times 
enables  us  to  accomplish  decided  results.  Some  judgment  must,  however,  be 
exercised  in  its  use.  The  rule  that  I  lay  down  to  the  nui'se  or  to  the  mother  who 
has  been  instructed  in  the  employment  of  the  slowly  interrupted  faradic  cur- 
rent, is  to  apply  the  poles  to  those  muscles  which  are  overstretched  and  weak- 
ened by  the  contractures.  That  is,  in  the  arm  they  should  be  applied  to  the 
extensor  muscles,  both  of  the  arm  and  forearm,  whilst  in  the  leg  they  would  be 
ajDplied  especially  to  the  flexor  group,  i.  e.,  posteriorly  to  the  thigh,  anteriorly 
to  the  leg.  The  unskilful  use  of  faradism,  I  have  reason  to  believe,  at  times 
increases  the  contracture.  Used  according  to  the  method  I  have  described,  the 
contractures  are  generally  diminished.  In  hemiplegia  there  can  be  no  doubt 
that  the  persistent  use  of  massage  and  faradization  actually  accelerates  the 
growth  of  the  limb  besides  markedly  diminishing  the  contractures. 

The  problems  presented  by  defective  intelligence  are  to  be  met  by  slow  but 
persistent  efforts  at  education.  These  it  is  not  necessary  to  detail  here.  (See  p. 
335.)  The  principles  laid  down  by  the  elder  Seguin  still  hold  good.  They 
consist  of  the  methodical  education  of  the  limbs,  first  by  passive  and  later 
by  voluntary  motion.  Finally,  the  case  permitting,  systematic  gymnastics 
should  be  instituted.  As  the  same  time,  an  elementary  kindergarten  method 
of  instruction  should  be  pursued.  Great  care  should  be  taken  not  to  attempt 
too  much  in  too  short  a  time.  This  is  especially  true  of  attempts  to  teach 
the  child  to  walk  or  to  perform  other  simple  movements.  Some  cases,  indeed, 
are  benefited  by  prolonged  periods  of  rest  in  bed,  with  but  little  time  devoted 
to  walking  or  other  exercise.  It  is  frequently  necessary  to  divide  various 
tendons  in  order  that  the  foot  may  assume  a  normal  position.  Orthopedic 
surgery  sometimes  yields  here  brilliant  results.  For  the  methods  pursued  the 
reader  is  referred  to  the  chapter  on  Surgery. 


CHAPTEK   XYIII. 
DISEASES  OF  THE  SP^AL  CORD. 

By  JAMES  HENDRIE  LLOYD,  M.D. 

MALFORMATIONS  OP  THE   SPINAL  CORD. 

Malfoemations  of  the  spinal  cord  are  either  congenital  or  acquired. 
The  former  are  comparatively  few  in  number ;  the  latter  are  not  so  uncom- 
mon, and  they  embrace  a  variety  of  pathological  conditions.  Of  the  former, 
the  best  example  is  that  deformity  of  the  cord  seen  in  spina  bifida ;  of  the 
latter,  the  most  conspicuous  is  syringomyelia.  Yet  even  in  these  two  ex- 
amples the  distinction  between  congenital  and  acquired  deformities  is  some- 
what arbitrary,  because  syringomyelia,  while  a  disease  usually  of  adult  life, 
depends  probably  upon  an  inherent  developmental  weakness  in  the  cord.  It 
may  be  claimed  similarly  that  Friedreich's  ataxia  and  the  various  dystrophies 
which  have  as  their  base  a  gliomatous  or  degenerative  change  in  the  spinal 
cord,  due  to  heredity,  are  examples  of  malformations  of  the  cord ;  but  ob- 
viously they  do  not  fall  within  the  accepted  definitions  of  the  term,  and  will 
not  be  described  here.  So,  too,  the  defects  of  the  spinal  cord,  sometimes  seen 
in  idiocy,  might  with  justice  be  included  among  congenital  defects ;  they 
are  usually,  however,  of  the  nature  of  fine  histological  changes  and  system- 
lesions  which  do  not  come  naturally  under  the  head  of  deformities. 

True  malformations  of  the  spinal  cord  of  developmental  origin  are  exceed- 
ingly rare.  Spurious  cases,  due  to  bruises  and  cuts  inflicted  post-mortem, 
are  not  so  rare,  and  have  given  rise  of  late  years  to  a  quite  voluminous  litera- 
ture. These  malformations  may  be  included  under  the  one  term,  heterotopia, 
which  signifies  a  misplacement  of  either  the  gray  or  white  matter.  Accord- 
ing to  Van  Gieson,^  of  the  thirty-one  cases  of  alleged  malformations  of  the 
spinal  cord  now  on  record,  only  six  are  genuine  examples.  The  most  com- 
mon form  of  true  heterotopia  is  that  in  which  a  small  portion  of  gray  matter 
or  of  the  gelatinous  substance  of  Rolando  is  separated  from  the  rest  of  the 
gray  matter  and  lies  imbedded  in  the  white  tracts.  The  accompanying  illus- 
tration of  a  case  of  Pick's  (Fig.  150)  is  an  example  of  this.  Such  an 
anomaly  is  insignificant,  and  would  give  rise  to  no  symptoms  during  life.  The 
same  is  true  of  the  very  few  instances  of  anomalous  distribution  of  white 
tracks  which  have  been  observed,  especially  in  the  isthmus. 

The  examples  of  spurious  or  pseudo-heterotopia  include  a  great  variety  of 
displacements  of  gray  and  white  matter,  or  both,  giving  rise  to  the  appear- 
ances of  extraordinary  malformations.  The  most  striking  of  these  is  the 
so-called  doubling  of  the  cord,  examples  of  which  have  been  honestly  reported 
and  seriously  discussed.  Illustrations  from  a  case  are  given  here  to  serve  as 
a  warning  (Figs.  151,  152,  153,  154).     Such  cases  have  been  reported  as 

1  "  A  Study  of  the  Artefacts  of  the  Nervous  Svstem,"  etc.    N.  Y.  Med.  Journ.  1892,  vol.  ii.  pp.  337  , 
365,  and  421. 


522 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


"  rudimentary  cords  "  and  "  duplications."  There  can  be  no  doubt  that  thev 
are  artefacts,  i.  e.,  that  they  are  produced  post-mortem  by  accidents  and  by 
rough  handling.  Van  Gieson  has  studied  critically  all  recorded  cases  in  his 
elaborate  paper.     Similar  mistakes  are  no  longer  excusable. 


Fig.  150. 


Heterotopia  of  the  spinal  cord.    The  shaded  circular  area  in  the  posterior  column  indicates  the 
heterotopic  fragment  of  gray  matter.    (Pick.) 

A  number  of  monstrosities  of  the  cord,  incompatible  with  life,  have  been 
observed.  Among  these  are  congenital  absence  of  the  cord,  or  amyelia,  which 
is  usually  associated  with  absence  of  the  brain ;  atelomyelia,  or  partial  ab- 
sence of  the  cord ;  diastemato-myelia,  in  which  the  cord  is  divided  into  two 
halves,  each  surrounded  by  its  membrane — a  condition  probably  allied  to 


Fig.  151. 


Fig.  152. 


Fig.  153. 


Fig.  154. 


Artificial  duplication  of  the  spinal  cord.    (FCrstner  and  Zachee.) 

some  forms  of  spina  bifida ;  and,  finally,  diajilomyelia,  a  union  of  two  cords, 
as  seen  in  some  kinds  of  double  monster  (to  be  distinguished  from  the  pseudo 
duplications  or  artefacts  already  referred  to). 


DISEASES  OF  THE  SPINAL  CORlJ. 


523 


There  are  some  varieties  of  asymmetry  of  the  spiual  cord,  associated 
especially  with  defective  development  or  amputation  of  a  liml),  and  these 
may  be  congenital.     They  need  not  be  described  in  detail  here. 


SPINA   BIFIDA. 

The  one  conspicuous  example  of  malformation  of  the  spinal  cord  is  that 
which  is  an  accompaniment  of  spina  bifida.     This  will  now  be  described. 

Morphological  Note.  In  order  to  understand  clearly  the  exact  nature 
and  the  mode  of  formation  of  spina  bifida,  it  is  necessary  to  know  the  suc- 
cessive stages  in  the  development  of  the  spinal  cord  and  the  vertebral  canal. 

In  the  embryo-chick  the  elementary  spinal  cord,  or  medullary  groove,  has 
already  become  a  conspicuous  object  before  the  end  of  the  first  day.  In 
transverse  section,  at  about  the  eighteenth  hour,  the  l^lastoderm  presents  the 
following  appearances  (Fig.  155)  :  Its  three  layers — epiblast,  mesoblast,  and 


Fig.  155. 


Transverse  section  of  a  blastoderm  incubated  for  eighteen  hours.  The  section  passes  through  the 
medullary  groove  (mc)  at  some  distance  behind  its  front  end.  A,  epiblast ;  B,  mesoblast ;  C,  hypo- 
blast ;  mc,  medullary  groove ;  mf,  medullary  fold ;  ch,  notochord.    (Balfovr.) 

hypoblast — have  become  differentiated.  The  medullary  groove,  which  is  to 
form  eventually  the  spinal  cord,  is  marked  by  a  depression,  at  the  base  of 
which  is  a  dense  group  of  mesoblastic  cells.  The  groove  itself  is  formed 
exclusively  of  the  epiblast,  which  lines  its  involuted  surface  ;  in  other  words, 
the  groove  is  an  involution  of  the  epiblast.  The  group  of  mesoblastic  cells 
at  the  base  of  the  groove  is  the  notochord,  which  in  time  gives  place  to  the 
bodies  of  the  vertebrpe.  On  either  side  of  the  groove  is  a  fold  of  epiblast, 
the  medullary  fold.  These  are  the  simple  elements  which  eventually  form 
the  spinal  cord. 

Before  the  end  of  the  twenty-four  hours  these  medullary  folds  increase  in 
every  dimension,  and,  growing  in  elevation,  lean  over  toward  each  other,  thus 
tending  to  form  an  arch,  which,  of  course,  encloses  a  long  canal,  the  neural 
canal  (Fig.  156.)  These  folds  coalesce  first  near  the  head,  and  last  at  the 
caudal  end. 

Before  the  end  of  the  second  day  the  medullary  folds  in  the  chick  have 
coalesced  to  form  this  neural  canal  or  tube  (Fig.  157).  The  neural 
tube  thus  formed  becomes  gradually  separated  from  the  epil)lastic  layer, 
which  coalesced  externally  to  it,  and  which  forms  henceforth  the  epithelial 
layer  of  the  skin  of  the  back.  In  the  meantime  there  has  been  formed  on 
either  side  of  the  neural  tube  a  dense  body,  composed  of  mesoblastic  cells, 
and  known  as  a  mesoblastic  somite  (not  shoAvn  in  the  illustrations). 
From  this  somite  is  formed  eventually  the  vertebra  and  the  trunk  muscles. 
This  mesoblastic  tissue  is  gradually  prolonged  between  the  neural  tube 
and  the  external  epiblastic  layer,  and  thus  forms  the  arches  of  the  ver- 
tebrae. From  this  mesoblastic  tissue  are  formed  also  the  deeper  layers 
of  the  skin,  the  connective  tissue  and  the  bloodvessels,  and  the  meninges 


524 


NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 


of  the  cord.  It  is  important,  in  order  to  understand  the  genesis  of 
the  various  types  of  spina  bifida,  to  keep  in  mind  the  fact  that  the  neural 
tube  is  primarily  a  mere  infolding  of  the  epiblast,  or  external  epithelial 
layer,  and  that  its  enclosure  by  bone  and  couuective  tissue  is  a  secondary  or 
later  process. 


Fig.  156. 


Section  of  a  rabbit-embryo  at  the  ninth  day, 
showing  open  neural  tube,  e,  epiblast  invagina- 
ted  and  thickened  within  the  neural  canal  (n) ; 
Til,  the  mesoblast ;  h,  the  body  cavity ;  g,  still 
open  gut,  lined  with  hypoblast.    (Pieesol.) 


Section  oi  a  rabbit-embryo  at  the  tenth  day, 
showing  closed  neural  tube,  n,  neural  canal: 
s,  segmental  or  posterior  ganglia ;  m,  mesoblast ; 
g,  gut-tube  ;  I'l'.  primitive  aorta ;  p,  thoracic  cav- 
ity.     (PlERSOL.) 


The  walls  of  this  neural  tube,  formed  entirely  of  epiblast,  gradually  un- 
dergo great  increase  in  thickness  by  proliferation  of  their  cell-elements,  and 
from  these  walls  is  formed  the  entii'e  cerebro-spinal  system.  The  central 
canal  of  the  cord  persists  through  life  as  a  minute  tube,  lined  with  epithelial 
cells. 

In  the  early  embryo  the  neural  tube,  or  future  spinal  cord,  is  as  long  as 
the  primitive  organ  mapped  out  by  the  somites,  which  will  eventually  form 
the  vertebral  column.  In  the  course  of  development,  however,  this  vertebral 
column  grows  faster  than  the  neural  tube,  so  that  in  the  fully  developed 
man,  for  instance,  the  spinal  cord  is  not  nearly  so  long  as  the  vertebral 
canal,  but  extends  to  only  the  level  of  the  .second  lumbar  vertebra.  In  spina 
bifida  of  the  lumbo-sacral  region,  however,  it  is  common  to  find  the  cord 
extending  down  to  that  low  level,  which  extension  is  readily  understood  by 
reference  to  the  facts  of  embryology.  It  illustrates  the  fact,  too,  that  spina 
bifida  dates  from  almost  the  earliest  period  of  development. 

Morbid  Anatomy.  Spina  bifida  is  a  developmental  defect,  dating  from  a 
very  early  period  of  embryonic  growth.  It  is  caused  by  a  failure  of  the  ver- 
tebral arches,  wdiich  grow  from  the  mesoblastic  somites,  as  just  described,  to 
coalesce  dorsad  to  the  spinal  cord  and  between  it  and  the  suj^erficial  epithelial 
layer  of  the  skin  of  the  back.  This  failure  is  accompanied  in  various  degrees, 
according  to  the  case,  by  a  failure  of  the  other  tissues,  which  also  spring  from 
this  mesoblastic  tissue,  notably  the  corium  of  the  skin  and  the  meninges  of 
the  spinal  canal,  likewise  to  coalesce.  Hence,  there  results  a  cleft  or  aper- 
ture in  the  vertebral  column,  through  which  protrudes,  as  a  hernia,  a  sac 
which  contains,  according  to  its  type,  one  or  more  of  the  contents  of  the 
spinal  canal. 

The  types,  or  varieties,  of  spina  bifida  may  be  grouped  in  four  classes,^ 
according  to  the  degree  of  deformity.     While  they  are  identical  in  origin, 

1  Bland  Sutton  (Lancet,  Feb.  25, 1888),  in  his  admirable  discussion  on  "  Evolution  in  Pathology,'' 
makes  six  classes.  The  Committee  on  Spina  Bifida  of  the  London  Chnical  Society  (Trans.,  vol. 
xviii.;  recognizes  only  three.  I  think  that  four  classes  can  properly  include  all  varieties.  There 
are  sub-types  which  merge  into  each  other,  but  which  do  not  require  special  designations. 


DISEASES  OF  THE  SPINAL  CORD. 


525 


they  differ  widely  in  extent  and  character  of  tissue  involved,  and  these  differ- 
ences are  of  vital  importance  clinically,  and  especially  with  reference  to 
treatment. 

1.  Meningocele.  In  this  variety,  Avhich  is  the  sirnplest  and  least  disabling, 
one  or  more  of  the  vertebral  arches  have  failed  to  coalesce.  The  skin  of  the 
back,  however,  is  usually  perfect,  and  covers  the  sac.     The  meninges  also 


Fig.  158. 


Memljrane. 


Nerves. 


Skin. 


Cord. 


Diagram  of  a  meningocele. 


are  well  formed,  but  protrude  into  the  sac,  or,  more  correctly,  they  consti- 
tute the  sac,  so  that  its  cavity  is  continuous  with  the  subarachnoid  space. 
The  cord,  and  consequently  the  nerves,  do  not  extend  into  the  sac  (Fig.  158). 
The  meningocele  has  a  tendency  to  become  pedunculated,  and  sometimes 
it  is  cured  spontaneously.  It  is  not  dangerous  to  life,  and  usually  does  not 
cause  paralysis  nor  deformity  of  the  legs.     It  is  a  rare  form. 

2.  Meningomyelocele.     This  is  the  most  common  form  of  spina  bifida,  and 
is  not  unusually  fatal.    When  the  patient  survives,  it  usually  causes  paralysis 

Fig.  159. 

Epitlielial  layer  of  skin. 

Spinal  cord. 

Skin. — 

Meninges. — 

Nerves.  -'-'- 


Spinal  canal. 
Diagram  of  a  meningomyelocele. 


and  deformities  in  the  legs  and  feet.  In  this  form  not  only  have  the  verte- 
bral arches  failed  to  coalesce,  but  often  the  corium  of  the  skin  and  the  spinal 
meninges,  wdiich  are  likewise  products  of  the  mesoblast,  have  fiiiled  to  develoj) 
dorsad  to  the  cord.  Hence,  in  the  worst  of  these  cases  there  is  no  meningeal 
cavity  and  no  true  skin  behind  the  cord,  which  lies  in  immediate  contact  with 
the  epithelial  layer  of  the  surface  of  the  back  (Fig.  159).  It  thus  appears  that 
in  the  primitive  involution  of  the  epiblast  to  form  the  cord,  the  latter  never 
liecame  sepai-ated  from  the  epithelial  or  epiblastic  layer.     Therefore,  as  the 


526 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


sac  protruded  and  distended  more  and  more  it  drew  the  attached  cord  with 
it,  so  that  the  cord  extends  through  the  cleft  in  the  vertebral  wall,  and  is 
firmly  imbedded  in  the  wall  of  the  sac.  In  this  position  its  shape  is  usually 
deformed  ;  it  exists,  indeed,  as  a  layer  of  neural  tissue  over  the  posterior  and 
inner  surface  of  the  sac.  On  transverse  section  in  some  cases  the  central 
canal  may  be  seen  in  this  layer  (Fig.  159).  The  nerve-trunks  of  the  seg- 
ments of  the  cord  involved  are  seen  springing  from  this  layer  of  nerve-tissue 
and  coursing  forward  through  the  sac  to  gain  the  intervertebral  foramina. 
Thus  it  is  seen  that  the  cord  is  pulled  into  the  sac,  and  the  nerves  run,  not 
into  the  sac,  but  out  of  it  (Fig.  160). 


Fig.  160. 


\t 


- —     d 


Dissection  of  the  parts  concerned  in  a  lumbo-sacral  spina  bifida,  sliowing  the  typical  anatomical 
disposition  in  cases  of  meningomyelocele.  A  portion  of  the  sac-wall  has  been  cut  away  to  show  the 
interior,  o,  surface  of  cord,  covered  with  arachnoid,  exposed  by  removal  of  portion  of  dura  mater ; 
b,  dura  mater  entering  into  the  tormation  of  the  sac- wall :  c,  arachnoid  lining  the  sac  ;  d,  lower  por- 
tion of  the  spinal  cord,  crossing  the  interior  of  the  sac ;  some  of  the  nerve-roots  pass  forward  upon  it, 
toward  the  intervertebral  foramina ;  the  other  nerve-roots  arise  from  the  posterior  wall  of  the  sac 
in  a  vertical  series  and  traverse  the  space  horizontally  ;  e,  falciform  process  continuous  with  the  pia 
mater,  separating  the  anterior  and  posterior  roots  of  the  nerves  of  the  left  side ;  there  is  a  corre- 
sponding process  on  the  right  side.    (London  Clinical  Society.) 

In  meniugonn^elocele,  because  of  the  defective  development  of  the  coriuin 
in  some  cases,  the  extreme  posterior  surface  of  the  sac  is  covered  with  an  ex- 
ceedingly thin  membrane,  devoid  of  hair  and  sebaceous  glands  and  of  any  of 
the  characteristics  of  true  skin.  This  thin  membrane  represents  the  epiblast. 
In  some  cases,  however,  the  skin  is  better  developed.     Occasionally  there 


DISEASES  OF  THE  SPINAL  CORD.  527 

exists  a  small  pit-like  depression,  or  umbilicus,  on  the  posterior  surface  of  the 
sac.  This  marks  the  point  of  attachment  of  the  spinal  cord  to  the  inner 
surface  of  the  sac,  and  is  a  sign  of  some  value  in  diagnosis. 

In  this  form  of  spina  bifida  there  usually  is  destruction  or  failure  of  devel- 
opment of  some  elements  of  that  portion  of  the  cord  that  is  within  the  sac, 
and  some  degeneration  of  the  nerve-trunks  arising  from  it.  Hence  there 
result  various  degrees  of  paraplegia,  paralysis  of  the  bladder  and  rectum, 
club-foot,  and  sensory  and  trophic  disorders  in  the  regions  below  the  level  of 
the  lesion. 

3.  Hydromyelocele.  Occasionally,  as  seen  in  a  few  cases,  the  spinal  cord  not 
only  adheres  to  the  original  epiblastic  layer,  as  described  in  the  last  group, 
but  as  the  resulting  sac  develops  and  expands,  it,  too,  dilates  in  its  central 
canal.  Hence  its  tissue  becomes  a  lining  layer  to  the  sac,  the  cavity  of 
which  is  not  continuous  with  the  subarachnoid  space,  but  with  the  central 
canal  of  the  cord.^  In  this  variety  the  nerves  consequently  do  not  run 
through  the  sac,  but  along  its  sides  or  imbedded  in  them.  This  form  can 
readily  be  mistaken  for  a  simple  meningocele,  in  which  no  neural  tissue  is  in 
the  sac.  This  is  because  of  the  fact  just  stated,  that  the  nerves  do  not  run 
conspicuously  through  the  sac,  but  are  embedded  in  its  wall  between  its 
external  epithelial  layer  and  its  internal  neural  layer,  representing  the  spinal 
cord.  From  the  practical  standpoint  of  treatment  this  distinction  is  of  the 
utmost  importance.    Hydromyelocele  is  a  rare  form  of  spina  bifida. 

4.  Myelocele.  It  occasionally,  but  very  rarely,  happens  that  not  only  the 
vertebral  arches,  but  also  the  medullary  folds,  fail  to  coalesce.    This  is  even 

Fig.  161. 

Unclosed  spinal  cord. 


Spina]  canal 


Diagram  of  a  myelocele. 

a  more  sei'ious  defect  than  any  of  those  varieties  of  spina  bifida  already 
described.  In  those,  it  will  be  recalled,  the  neural  tube  was  always  properly 
closed  by  the  coalescence  of  the  medullary  folds ;  it  was  only  in  the  cases 
of  the  vertebral  arches  and  other  mesoblastic  tissues,  as  the  true  skin,  that 
coalescence  had  failed.  In  simple  myelocele,  however,  the  coalescence  of  the 
medullary  folds  has  failed,  usually  in  only  a  limited  portion  of  the  cord.  Of 
course  the  vertebral  arches  also  have  failed  to  unite,  so  there  is  seen  a  pro- 
tuberance, usually  small,  on  the  back,  usually  in  the  lumbar  region,  in  the 
centre  of  which  is  a  small  opening.  This  opening  leads  directly  into  the 
cerebro-spinal  canal,  and  the  small  protuberance  is  not  a  sac  but  a  mass, 
usually  red  and  pulpy,  of  neural  tissue.     From  this  opening  cerebro-spinal 

1  This  variety  is  called,  \>y  most  writers,  rather  unfortunately,  sf/j-mfiro-myelocele.  This  term  seems 
to  ally  it  with  syringomyelia,  which,  however,  is  now  known  to  be  not&  dilatation  of  the  central 
canal,  but  a  new  gliomatous  formation.  It  were  better,  therefore,  if  this  variety  of  spina  bifida  were 
called  /ii/dro-mj'elocele,  which  term  is  used  here. 


528  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

fluid  constantly  oozes.  This  protuberance  has  somewhat  the  appearance  of  a 
nsevus.  Myelocele  is  incompatible  with  prolonged  life ;  even  in  cases  in 
which  the  defect  is  limited  in  extent,  death  usually  occurs  in  a  few  days. 
According  to  Sutton^  myelocele  of  great  extent  has  been  seen  by  Lebedeff  in 

Fig.  162. 


Transverse  section  of  neural  tissue,  constituting  the  undeveloped  spinal  cord,  in  a  myelocele. 

(Sutton.) 

the  chick.  2  Sutton  believes,  probably  correctly,  that  this  form  of  spina 
bifida  is  not  so  rare  as  represented,  but  is  cast  aside  as  an  "atypical"  form. 

A  comparatively  harmless  form  of  spina  bifida,  in  which  a  slight  cleft 
exists  without  protrusion  of  a  sac,  is  called  sjnna  bifida  occulta. 

In  a  very  few  cases  of  sj)ina  bifida  the  sac  is  divided  by  membranous 
partitions,  so  that  it  forms  a  multilocular  cyst. 

Congenital  tumors  of  the  sacro-coccygeal  region  occasionally  occur,  the 
nature  of  which  may  be  obscure.  They  have  given  rise  to  much  confosion 
in  the  past,  and  a  voluminous  literature,  especially  in  France  and  Germany, 
has  sprung  up  about  them.^  It  is  evident  that  there  are  several  varieties  of 
these  congenital  sacral  and  coccygeal  tumors,  one  of  which  is  a  spina  bifida 
depending  upon  defective  development  of  the  laminje  of  one  or  more  bones 
of  the  sacrum.  In  some  of  these  cases  the  coccyx  is  wanting.  A  peculiarity 
of  some  cases  of  this  sacral  type  of  spina  bifida  is  the  protrusion  of  the  sac 
anteriorly  into  the  pelvis.  The  causes  for  this  probably  lie  in  the  fact  that 
for  some  reason  this  is  the  direction  of  least  resistance.  The  tumor  some- 
times forms,  as  pointed  out  by  Giraldes,  in  the  sacro-perineal  region.  It 
usually  pushes  the  rectum  and  anus  before  it.  Thus  Giraldes,  quoted  by 
Molk,  refers  to  a  case  in  an  adult  female,  in  Avhom  a  perineal  cystic  tumor 
was  punctured  by  a  surgeon,  and  who  died  very  soon,  as  a  consequence, 
with  the  tetanoid  symptoms  of  meningitis.  An  autopsy  demonstrated  that 
the  cyst  was  attached  to  the  sacrum  and  communicated  with  the  vertebral 
canal.  Emmet*  and  Thomas^  each  have  punctured  such  a  pelvic  cyst  by 
mistake,  and  both  have  lost  their  patients  in  consequence. 

Spina  bifida  is  occasionally  associated  Avith  other  developmental  defects,  as 
encephalocele,    hydrocephalus,   harelip,  cleft  palate,  ectopia  of  the  viscera, 

1  Op.  clt. 

2  Embryologists  know  that  deformities  in  the  chick  are  not  uncommon,  especially  if  the  eggs  are 
handled  much  in  the  course  of  artificial  hatching.  Such  specimens,  however,  are  usually  cast  aside. 

3  See  especially  Des  Tumeurs  Congenitales  de  I'extremite  inferieure  du  tronc,  by  Molk,  Stras- 
bourg, 186S  ;  and  Resherches  sur  les  Tumeurs  Congenitales  de  la  Region  Sacro-coccygienne,  by  La- 
chaud,  Paris,  1883. 

■*  Am.  Journ.  Obstetrics,  1871. 

5  Gaillard's-Med.  Journ.,  March,  1885,  p.  237.  See  also,  for  report  of  a  similar  case  in  which  death 
followed  labor,  Gaz.  Med.  de  Paris,  1838,  p.  10. 


DISEASES  OF  THE  SPINAL  CORD.  529 

and  imperforate  anus.  These  defects  are  of  the  kind  that  are  caused  by 
faihire  of  coalescence  in  various  regions  of  the  embryo-body.  Hydroceph- 
akis  is  reported  as  a  not  infrequent  complication  (Fig.  163).  Encephalocele 
is  seen  especially  at  the  posterior  base  of  the  skull,  involving  the  cerebellum. 

Causes.  The  causes  of  spina  bifida  are  altogether  obscure.  As  stated 
already,  the  deformity  has  been  seen  in  the  chick,  in  which  it  extends  sometimes 
throughout  almost  the  whole  extent  of  the  siDine.  Monstrosities  of  various 
kinds  are  produced  rather  easily  in  the  embryo-chick  in  the  course  of  arti- 
ficial hatching.  This  suggests  the  probability  that  trauma  or  shock  may 
interfere  with  proper  development,  and  may  be  capable  of  producing  spina 
bifida.  This,  of  course,  is  a  mere  hypothesis.  Heredity  has  seemed  to  have 
an  influence  in  a  very  few  cases.  In  one  instance,  in  the  list  prepared  by 
the  London  Clinical  Society's  Committee,  three  successive  cases  of  spina 
bifida  occurred  in  one  family ;  while  Demme^  refers  to  two  instances  in 
which  there  had  been  three  cases,  and  three  in  which  there  had  been  two 
cases  of  spina  bifida  in  one  family.  Camper,  quoted  by  Ashhurst,'  noted 
spina  bifida  in  twins.  In  a  few  instances  congenital  club-foot  and  harelip 
have  been  reported  in  one  or  other  parent  of  children  with  spina  bifida. 

Clinical  History.  Spina  bifida  occurs  rather  more  frequently  in  females 
than  in  males.  According  to  the  tables  compiled  by  the  London  Clinical 
Society's  Committee,  from  returns  of  the  Registrar  General  of  England,  of 
1768  cases,  779  were  in  males  and  989  in  females. 

According  to  Chaussier,  one  case  of  spina  bifida  occurred  in  the  Paris 
Maternite  in  about  one  thousand  births. 

The  position  of  the  tumor  is  most  commonly  in  the  lumbar,  lumbo-sacral, 
or  sacral  region.  It  is  comparatively  infrequent  in  the  cervical  and  upper 
dorsal  region.  The  reason  for  this  preponderance  of  the  lesion  in  the  lower 
region  of  the  spine  lies  in  the  fact  that  the  medullary  folds  in  the  embryo 
close  over  last  at  the  caudal  end.  Occasionally  two  tumors  are  seen,  but  this 
is  extremely  rare. 

The  malformation  is  usually  discovered  at  the  birth  of  the  child.  It  varies 
in  size  at  birth  in  different  cases,  and,  of  course,  is  more  likely  to  be  over- 
looked when  it  is  very  small.  In  the  occult  form,  which  may  persist  through 
a  comparatively  long  life,  and  which  is  not  marked  by  a  tumor,  the  deformity 
may  be  readily  overlooked.^  Schon*  reports  a  case  of  sjiina  bifida  occulta  in 
a  girl  aged  thirteen  years.  The  defect  was  in  the  fifth  lumbar  and  upper 
sacral  vertebrae.  The  first  symptom  noted  was  scoliosis,  which  was  first  seen 
in  the  patient's  seventh  year.  The  lumbar  region  was  covered  with  a  dense 
growth  of  hair  (hypertrichosis),  and  the  skin  was  pigmented  from  the  twelfth 
dorsal  vertebra  to  the  coccyx.  The  size  of  the  sac  at  birth  is  not  always  a 
criterion  of  its  dangerous  character.  It  may  be  no  larger  than  the  end  of  a 
large  thumb,  and  yet  it  may  increase  in  size  rapidly.  Moreover,  it  cannot  be 
judged  by  its  size  to  which  type  it  belongs,  and  upon  its  type  depends,  to  a 
large  extent,  the  prognosis.  Thus,  if  it  is  a  simple  small  meningocele,  it 
may  enlarge,  even  quite  rapidly,  and  yet  the  possibility  of  a  cure  is  greater 
in  this  than  in  any  other  variety.  If  it  is  a  meningomyelocele  or  an  hydro- 
myelocele,  it  may  be  accompanied  with  club-foot.  If  it  is  a  pure  myelocele, 
it  will  present  only  a  small  fleshy  excrescence,  in  the  centre  of  which  careful 
inspection  would  probably  reveal  a  leaking  fistula  communicating  with  the 
cerebro-spinal  canal.    In  every  form  the  tumor  almost  invariably  occupies  the 

1  Quoted  by  Lond.  Clin.  Soc.'s  Committee.  -  Am.  Syst.  of  Med.,  vol.  v.  p.  757. 

3  Lancisi  saw  a  case  in  which  the  tumor  did  not  declare  itself  until  the  fifteenth  year,  and  Akin 
refers  to  a  case  in  which  the  lesion  did  not  show  until  the  twentieth.  Diet,  des  Sciences  Med.,  1818, 
art.  "  Hydrorachis."  tome  22. 

*  Berl.  klin.  Wochenschrift,  1894. 

34 


530  NEBVOUS  DISEASES  AXD  THEIR  TREATMENT. 

region  of  the  sj)iuous  processes ;  exceptions  are  very  rare,  as  in  those  cases 
that  are  reported  as  protruding  anteriorly.  In  some  cases  only  one  or  two 
vertebrae  are  involyed,  in  others  a  larger  number.  The  lesion,  as  said  already, 
is  far  more  common  in  the  lower  dorsal,  lumbar,  and  sacral  regions  than  in 
the  upper  part  of  the  spine. 

The  child  at  birth  may  appear  otherwise  in  normal  health.  Many  observers 
report,  however,  that  the  children  with  spina  bifidfe  are  not  well  nourished, 
and  that  they  soon  begin  to  pine  and  fail.  The  growth  of  the  tumor  varies. 
The  great  majority  of  patients  born  with  spinse  bifidse  die  within  the  first 
year,  and  the  majority  of  these  within  the  first  three  months,  and  many  of 
these  deaths  are  caused  by  a  rapid  distention  and  ruj)ture  of  the  sac.  In 
some  cases,  however,  the  growth  is  very  slow  at  first,  or  even  not  perceptible, 
so  that  the  child,  in  a  small  proportion  of  cases,  survives  for  some  years,  or 
may  even  attain  adult  life. 

The  appearance  and  constituents  of  the  sac  vary  according  to  its  type,  to 
understand  which  it  is  essential  to  refer  constantly  to  the  facts  as  illustrated  by 
embryology.  In  some  cases  the  sac  is  covered  with  good  healthy  skin  ;  in 
these  the  probability  is  that  the  t}"pe  is  not  the  worst.  Even  though  not 
a  simple  meningocele,  the  covering  of  healthy  skin  is  a  support  and  pro- 
tection. In  other  cases  the  healthy,  fully  developed  skin  ceases  at  the 
base  of  or  near  the  summit  of  the  sac,  the  remainder  of  the  sac  being 
covered  with  a  thin,  delicate  membrane.  This  membrane  is  not  the  dura 
mater,  but  the  epithelial  layer  of  the  skin  formed  by  the  epiblast.  This  form 
should  suggest  to  the  observer  the  probability  that  the  tissue  of  the  spinal 
cord  is  included  in  the  sac  either  as  a  meningomyelocele  or  an  hydromyelo- 
cele.  An  umbilicus,  marking  the  attachment  of  the  cord,  may  possibly  be 
seen.  In  such  a  case  the  dura  mater  does  not  intervene  between  the  cord- 
tLssue  and  the  ei^ithelial  layer,  as  is  commonly  said ;  but  the  cord,  usually 
spread  out  as  a  layer  of  neural  tissue  in  direct  contact  with  the  sac,  which 
is  formed  only  of  this  delicate  epithelial  membrane,  is  an  important  constitu- 
ent of  the  sac,  and  sends  nerves  forward,  through,  and  out  of  the  sac  to  their 
resjDective  foramina.^  The  opening  in  the  bones  may  sometimes  be  felt  with 
the  fingers,  but  it  is  doubtful  if  the  nerve-cords  passing  out  of  the  sac  into 
the  vertebral  canal  could  be  distinguished  by  palpation.  In  some  of  these  cases 
the  walls  of  the  sac  at,  or  soon  after,  birth  are  much  distended,  and  they 
may  even  be  inflamed  or  ulcerated.  Occasionally  the  sac  soon  begins  to 
leak,  the  fluid  either  escaping  by  a  small  opening  or  oozing  out  through 
many  pores.  On  the  other  hand,  the  surface  of  the  sac  may  be  rugous  or 
coreaceous.  The  tumor  itself  is  usually  tense  and  elastic,  and  its  contents 
fluctuate.  Pressure  on  it  causes  often  some  significant  symptoms ;  thus  its 
volume  may  be  reduced  somewhat  by  pressure,  but  brain-symptoms  result. 
These  are  uneasiness,  then  stupor  or  even  coma,  and  convulsions.  Holmes^ 
says  that  convulsions  are  common  during  all  stages  of  the  disease,  but  espe- 
cially after  the  sac  has  burst,  when  they  are  often  the  immediate  cause  of  death. 
When  associated  with  encephalocele,  according  to  Treves,^  the  fontanelles 
bulge  when  pressure  is  made  on  the  sac.     When  the  child  cries  the  sac  distends. 

The  fiuid  in  the  sac  of  a  spina  bifida  has  been  proved  frequently  to  be  iden- 
tical with  the  cerebro-spinal  fluid.  It  is  watery,  with  a  few  salts,  and  with 
only  a  slight  trace  of  albumin.  Of  course,  in  case  inflammation  and  sup- 
puration have  occurred,  the  fluid  is  altered  accordingly. 

In  some  cases  the  tumor  is  pedunculated  and  the  opening  into  the  vertebral 
canal  is  small ;  in  such  cases  the  j^robability  is  that  the  sac  does  not  contain 

1  This  is  constantly  misunderstood  by  surgeons,  who  speak  of  the  nerves  running  hiio  the  sac, 
and  who  overlook  this  thin  layer  of  tissue  representing  the  spinal  cord. 
-  Surg.  Treat,  of  the  Dis.  of  Infancy  and  Childhood.  ^  int.  Encyc.  of  Surgery,  vol.  iv. 


DISEASES  OF  THE  SPINAL  COBD.  531 

nerve-tissue,  i.  e.,  that  it  is  a  meningocele.     If  so,  it  would  not  be  attended 
with  paralysis. 

In  grave  forms  of  spina  bifida  involving  the  spinal  cord  and  nerves  symp- 
toms of  paralysis  in  some  form  are  usually  observed.  Thus  there  may  be  an 
almost  complete  paraplegia  with  ansesthesia,  and  involvement  of  the  bladder 
and  rectum.  It  is  rather  more  common,  however,  to  observe  modifications 
of  this  extreme  type.  Amyotrophic  paralysis  of  some  muscle-groups  is  not 
uncommon,  due  to  involvement  of  the  nerves  and  anterior  horns.  This  form 
presents  the  usual  symptoms  of  wasted  muscles,  coldness,  and  mottling,  with 
alterations  in  the  electro-tonus.  Club-foot,  especially  talipes  equino-varus,  is  a 
common  result.  Paralysis  of  the  bladder  and  rectum  is  a  common  complica- 
tion. Ansesthesia  in  various  areas  is  often  present.  In  one  case  under  the 
author's  care  trophic  lesions  were  seen. 

The  following  case  occurred  in  a  girl  who  was  admitted  into  the  Home  for 
Crippled  Children  under  the  writer's  care.  She  presented  some  typical  symp- 
toms : 

C.  E.,  female,  aged  nine  years,  had  a  spina  bifida  of  the  lumbar  region, 
involving  the  first  three  vertebral  arches.  She  was  paralyzed  in  her  limbs 
and  had  badly  impaired  feet,  walking  on  the  backs  of  her  feet,  i.  e.,  present- 
ing an  extreme  varus.  There  was  some  wasting  of  the  muscles  below  the 
knees.  There  was  slight  foot-clonus  on  the  right,  none  on  the  left.  The 
patellar  reflexes  were  abolished.  The  patient  had  no  control  over  the  blad- 
der, and  diminished  control  over  the  rectum.  The  tactile  sense  was  very 
blunt  below  the  knees,  if  not  abolished.  Above  the  knees  a  line  of  demarca- 
tion of  the  ansesthesia  was  quite  well  marked.  Slight  sensation  was  preserved 
on  the  inner  side  of  the  leg.  The  thighs  were  sensitive.  To  heat  and  cold 
sensation  below  the  knees  was  abolished,  above  the  knees  it  was  normal.  All 
the  muscles  of  the  legs  and  thighs  responded  normally  to  the  faradic  current, 
except  the  peroneal  group.  In  this  there  was  no  response  to  the  strongest 
currents.  To  galvanism  in  strong  currents  there  was  complete  abolition  of 
response  in  the  peroneal  group.  Slight  modal  change  was  noted  in  the  flexors 
of  the  big  toe.  There  was  no  serial  change.  The  mother  reported  that  the 
child  was  liable  to  the  formation  on  the  legs  of  "  bladders,"  i.  e.,  bullae,  lead- 
ing to  trophic  sores.  These  sores  left  a  scar  after  healing.  In  the  bullous 
stage  they  resembled  pemphigus.  On  admission  one  of  these  trophic  sup- 
purating sores  was  seen  on  the  left  great  toe,  looking  almost  like  a  perforat- 
ing ulcer.     The  fronts  of  the  tibise  were  marked  by  the  scars  of  these  sores. 

It  was  evident  in  this  case  that  the  trophic  and  reflex  centres  in  the  lum- 
bar enlargement  were  impaired ;  probably  also  some  of  the  nerve-trunks. 
The  mother  said  that  at  birth  the  tumor  was  the  size  of  an  end  of  a  thumb. 
It  had  not  increased  much  if  any  at  first,  and  the  child  had  learned  to  Avalk 
and  its  legs  seemed  all  right  until  it  was  three  years  old.  The  tumor  had 
been  growing  rapidly  during  the  last  two  years.  The  sac  was  very  firm, 
covered  with  apparently  healthy  skin,  and  was  not  as  yet  overstretched. 

Another  interesting  case  occurred  in  a  boy,  a  picture  of  whom  is  presented 
here  (Fig.  163).  He  was  seen  by  me  in  the  Methodist  Hospital.  H.  C, 
aged  about  seven  years,  had  a  spina  bifida  in  the  lumbo-sacral  region,  and  had 
also  hydrocephalus,  with  convergent  strabismus.  He  had  paralysis  of  the 
bladder,  rectum,  and  legs,  and  presented  double  club-foot  in  minor  degree. 
The  case  was  apparently  one  of  meningomyelocele.  I  advised  against  opera- 
tion in  his  case,  as  I  had  no  doubt  that  the  sac  contained  tissue  of  undeveloped 
spinal  cord. 

In  pelvic  spina  bifida,  instances  of  which  have  been  reported  by  Emmets 
and  by  Thomas,^  the  cyst  is  firmly  attached  to  the  saci'um.     It  pushes  the 

1  Op.  cit.  "  Op.  cit. 


532 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


rectum  forward,  and  in  some  cases  causes  obstruction  of  the  rectum,  and  con- 
sequent distention  of  the  bowel.  In  some  of  these  reported  cases  the  patients 
had  reached  adult  life.  Emmet's  patient  was  apparently  about  forty-five 
years  of  age,  and  Thomas'  was  nineteen.  In  the  latter  case  the  lady  had 
noticed  that  she  was  not  in  a  normal  condition,  and  sought  relief  because 
she  intended  to  marry.  The  inconvenience,  however,  had  been  slight,  and 
there  were  no  paralytic  symptoms.  In  a  few  hours  after  the  cyst  had  been 
tapped  grave  symptoms  of  involvement  of  the  brain  and  cord  appeared.  The 
patient  had  intense  headache,  maniacal  delirium  and  rigidity  of  muscles, 
and  she  failed  rapidly  and  died. 


Fig.  W3. 


Spiua  bifida  with  hydrocepbalus.     (Methodist  Hospital.) 


Diagnosis.  The  diagnosis  of  spina  bifida  can  be  established  sometimes  in 
early  cases  by  the  detection  of  the  orifice  into  the  spinal  canal.  This  can  be 
felt,  with  its  bony  outline,  at  the  base  of  the  tumor.  The  distention  of  the 
sac  when  the  child  cries,  the  umbilicoid  ]3it  in  the  walls  of  the  sac,  the 
absence  of  true  skin  over  the  summit  of  the  tumor,  are  all  characteristic  signs 
upon  which  reliance  can  be  placed.  It  is  not  probable  that  confusion  could 
occur  to  any  ordinarily  intelligent  observer  between  either  a  lipoma  of  the 
back  or  a  spinal  caries  and  a  spina  bifida. 

Congenital  tumors  of  the  sacro- coccygeal  region  have  given  rise,  as  already 
said,  to  considerable  confusion  in  diagnosis.     There  are  several  varieties  of 


DISEASES  OF  THE  SPINAL  COED.  533 

these  congenital  tumors,  which,  as  Sutton  has  pointed  out,i  may  he  divided 
into  four  groups  :  dermoid  cysts,  tumors  arising  from  tlie  post-anal  gut,  forms 
of  spina  bifida,  and  teratomata,  with  remains  of  suppressed  embryos.  The 
differential  diagnosis  between  these  various  forms  in  very  young  children  is 
no  doubt  difficult,  and  reliance  must  be  placed  in  cases  of  supposed  spina 
bifida  ujjon  the  symptoms  just  described.  Especial  difficulty  has  been  en- 
countered in  cases  of  pelvic  spina  bifida,  which  has  been  graphically  described 
by  Thomas.^  In  these  cases  the  tumor  is  firmly  adherent  to  the  sacrum,  and 
is  behind  the  rectum,  which  is  pushed  forward — a  most  important  distinction. 
In  doubtful  cases  a  small  quantity  of  fluid  should  be  withdrawn  and  tested. 
If  it  prove  identical  with  cerebro-spinal  fluid  the  diagnosis  of  spina  bifida 
may  be  considered  established. 

Prognosis.  Spina  bifida  is  an  exceedingly  grave  affection,  and  the  prog- 
nosis in  the  case  of  the  newborn  child  is  always  doubtful.  As  said  already, 
more  than  one-half  of  the  cases  of  spina  bifida  die  in  their  first  year,  and  the 
majority  of  these  in  the  first  three  months.  In  all  forms,  except  simple 
meningocele,  the  probability  is  that  if  the  child  survives  it  will  have  club- 
foot and  either  partial  or  complete  paraplegia,  with  incontinence  of  urine. 
The  pelvic  or  anterior  form  appears  to  be  attended  with  less  immediate  risk 
to  life  and  limb.  This  is  shown  by  the  fact  that  all  four  cases  of  this  very 
rare  type,  referred  to  in  this  paper,  were  in  adult  females ;  but  they  all  event- 
ually proved  fatal,  three  from  surgical  interference,  and  one  from  the  effects 
of  childbirth.  On  the  other  hand,  according  to  Treves,  patients  with  spinas 
bifidee  have  lived  to  thirty-seven,  forty-three,  and  fifty  years  of  age. 

Treatment.  The  treatment  for  spina  bifida  is  almost  entirely  surgical. 
Some  of  this  surgical  treatment  seems  to  be  conducted  with  too  much  disre- 
gard for  the  pathology  of  the  affection,  and  hence. meets  with  mortif^dng 
results.  Thus  Holmes^  relates  how  he  excised  a  spina  bifida  from  a  girl  aged 
eight  years,  who  had  paralysis  of  the  sphincters.  The  child  succumbed 
promptly  to  meningitis,  opisthotonus,  etc.,  and  died.  The  surgeon  looked 
for  nerve-trunks  to  warn  him  away  from  dangerous  ground,  but,  apparently, 
he  ignored  the  fact  that  in  the  type  of  spina  bifida  to  which  his  case  evidently 
belonged  the  sac  itself  is  composed  partially  of  undeveloped  spinal  cord, 
and,  therefore,  that  he  was  excising  part  of  the  cord.  It  is  obviously  impos- 
sible for  any  surgical  procedure  to  restore  perfect  health  to  body  and  liml)  in 
cases  of  meningomyelocele  and  hydromyelocele.  The  protruding  sac  being 
composed  partially  of  neural  tissue,  representing  the  undeveloped  spinal 
cord,  to  either  excise  it  or  to  extirpate  it  Avith  irritating  injections  will  not 
cure  the  patient.  At  best,  if  occlusion  is  obtained,  the  child  can  continue 
as  hopelessly  a  more  or  less  complete  paraplegic.  In  simple  meningocele,  in 
which  type  no  nerve-tissue  is  included  in  the  sac,  the  prognosis  is  more  hope- 
ful and  the  prospect  for  cure  by  surgical  means  is  much  brighter.  In  the 
pelvic  form,  experience  so  far  seems  to  prove  that  surgical  interference  is 
invariably  fatal.  For  details  and  results  of  surgical  treatment  reference  is 
made  to  Chapter  XXXIII.  and  to  the  report  of  the  Committee  on  Spina 
Bifida  to  the  London  Clinical  Society. 

PACHYMENINGITIS  AND  LEPTOMENINGITIS. 

Inflammation  of  the  membranes  of  the  spinal  cord  is  usually  secondary  to 
some  other  pathological  state,  and  in  the  great  majority  of  cases  is  probably 

1  See  discussion  of  Bowiby's  report  of  "  Three  cases  of  Coccygeal  Tumor,"  Brit.  Med.  Journ.,  1890, 
i.  p.  663. 

2  Op.  cit.  3  Op.  cit. 


534  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  result  of  infection.  An  instance  of  the  former  is  the  combined  pachy- 
meningitis and  leptomeningitis  that  occurs  in  caries  of  the  spine :  of  the 
latter  the  inflammation  and  thickening  of  the  membranes  that  are  chie  occa- 
sionally to  syphilis.  The  membranes  are  also  inyolyecl  secondarily  in  gross 
lesions,  such  as  tumor ;  and  acutely  in  some  forms  of  infection,  such  as 
cerebro-spinal  feyer.  They  are  also  inyolyed  usually  in  more  diffused  lesions, 
such  as  the  yarious  forms  of  myelitis ;  in  fact,  the  worse  symptoms  of  menin- 
gitis are  those  that  are  due  to  inyolyement  of,  or  j)ressure  upon,  the  tissue  of 
the  spinal  cord.  I  shall  describe  here  only  the  more  distinct  and  character- 
istic types  of  meningitis  of  the  cord. 

Causes.  Caries  of  the  yeitebral  bodies  is  a  common  cause  of  meningitis. 
The  symptoms  usually  ascribed  to  bone-pressure  in  Pott's  disease  are  in  fact 
due,  as  a  rule,  to  secondary  inyolyement  of  the  membranes,  and  eyen  of  the 
cord  itself,  by  the  infectious  process.  This  will  be  referred  to  later,  and  illus- 
trated with  original  cases.  Syphilis  doubtless  causes  inflammation  of  the 
membranes  of  the  cord,  and  in  this  way  is  possibly  the  cause  of  some  of  the 
so-called  system  lesions.  A  type  of  spinal  syphilis  has  been  described  by  Erb, 
which  is  probably  due  to  a  syphilitic  meningitis,  the  inflammation  inyolying 
eyentually  some  areas  of  the  cord  itself.  Trauma  is  regarded  almost  uni- 
yersally  as  a  cause  of  pachymeningitis,  and  cases  occur  not  infrequently 
which  confirm  this  yiew.  The  type  described  by  Charcot  as  pachymeningitis 
cervicalis  hypeiirojjhica  is  caused  sometimes  by  trauma.  Exposure  to  cold 
and  wet,  especially  in  alcoholic  subjects  and  in  persons  poorly  nourished,  is 
apparently  a  cause  of  meningitis,  just  as  it  may  be  of  neuritis.  Pysemia, 
or  infection  with  the  streptococcus  pyogenes,  secondary  sometimes  to  suj)- 
puratiye  lung  and  j^leural  disease  or  to  puerperal  infection,  is  a  most  im- 
portant cause,  especially  of  leptomeningitis.  The  infections  of  acute  dis- 
eases, such  as  typhoid  feyer  and  smallpox,  haye  the  power  possibly  of  causing 
inflammation  of  the  spinal  membranes.  Finally,  cases  occur  in  which  the 
etiology  is  obscure,  probably  because  accurate  histories  of  the  j^atients  are 
not  attainable. 

Pathology.  In  cases  of  infection  by  contact,  as  in  spinal  caries,  the  mode 
of  the  disease-progress  is  easily  understood.  In  some  rare  cases,  howeyer,  a 
tubercular  infection  of  the  spinal  meninges  may  occur  quite  independently 
of  a  bone  lesion,  just  as  it  occure  in  cases  of  tubercular  meningitis  at  the 
base  of  the  brain.  In  these  cases,  of  course,  the  bacilli  of  tubercle  are  con- 
yeyed  du-ectly  to  the  membranes  by  the  blood,  the  seat  of  primary  infection 
being  elsewhere,  and  perhaps  not  always  determinable.  In  pysemic  cases  the 
lymphatics  may  possibly  conyey  the  germs ;  but  it  is  most  probable  that  in 
tiie  cases  of  this  and  all  other  infectiye  germs  the  blood  is  the  means  of  con- 
yeyance.  The  exact  mode  of  operation  of  cold  and  of  trauma,  which  indubi- 
tably act  as  causes  of  meningitis,  is  not  so  readily  understood.  If  we  confine 
the  idea  of  an  inflammatory  process  to  the  action  merely  of  a  microbic 
organism,  then  there  is  some  difficulty  in  including  the  destructiye  actions  of 
trauma  and  cold  in  the  category  of  inflammation.  The  facts,  howeyer, 
speak  loudly  against  such  a  decision.  The  theory  has  been  adyanced  that 
cold  may  generate,  by  a  sort  of  vito-chemistry,  a  rheumatoid  humor,  which 
is  the  obnoxious  agent ;  but  this  is  a  mere  theory.  We  haye,  howeyer,  noth- 
ing better  to  offer,  unless  we  suppose  that  a  diminished  resistance  is  brought 
about  in  the  tissues  by  the  depressing  action  of  cold,  and  that  this  permits 
an  unopposed  or  feebly-opposed  actiyity  of  the  destructiye  organisms  which 
are  probably  present  in  the  system  at  all  times.  In  the  case  of  trauma  a 
somewhat  similar  explanation  may  hold ;  and  in  addition  it  may  be  recalled 
that  the  efforts  at  repair  may  constitute  in  themselyes  an  almost  inflammatory 
process ;  that  one  effect  of  shock  or  injury  may  be  a  cell-proliferation,  in  the 


DISEASES  OF  THE  SPINAL  COED.  535 

line  or  direction  of  a  healing  process,  which  may  overstep  the  mark  and  be- 
come in  its  turn  a  truly  destructive  process.  In  granulation  tissue  we  witness 
something  of  this  kind.  In  this  new  and  not  highly  vitalized  tissue  various 
desti'uctive  and  even  pyogenic  organisms  may  find  a  lodgment,  and  thus  a 
truly  inflammatory  and  even  suppurative  j^rocess  may  be  established. 

Morbid  Anatomy.  In  pachymeningitis  due  to  spinal  caries  the  bodies  of 
the  diseased  vertebrae,  usually  soft  and  carious,  form  a  mass  which  is  in  direct 
contact  with  the  dura.'  At  this  jDoint  the  thickened  membranes  and  fibrinous 
deposits  form  a  felted  mass,  which  impinges  more  or  less  upon  the  cord.  It 
usually  extends  to  either  side  of  the  cord,  but  only  exceptionally  reaches 
entirely  around  it.  The  dura  mater  is  often  greatly  thickened,  and  this 
tubercular  mass,  comj)osed  of  broken-down  tissue,  the  result  of  tubercular 
inflammation,  is  attached  to  it  at  the  anterior  aspect  of  the  cord.  This 
mass  represents  apparently  old  and  degenerated  tubercular  matter,  giant  cells, 
and  inflammatory  lymph.  The  inflammatory  process  in  these  cases  takes 
place  largely  upon  the  outside  of  the  dura  (the  pachymeningitis  externa  of 
some  authors),  but  not  entirely  so  ;  since  in  advanced  cases  there  is  usually 
also  a  leptomeningitis  and  even  a  myelitis  accompanying  it.  In  some  cases, 
in  fact,  as  in  one  of  the  writer's  cases,  the  dura  may  be  perforated,  the  ragged 
edges  of  the  membrane  adhering  to  the  carious  mass  in  front,  and  thus  com- 
municating with  and  draining  into  a  psoas  abscess.  The  cord  may  show 
considerable  evidence  of  myelitis,  as  softening,  and  some  deformity,  which 
may  be  due  to  pressure  of  the  tubercular  mass.  Thus,  in  a  recent  case  exam- 
ined post-mortem  by  the  writer,  a  large  tubercular  mass  made  pressure  at 
one  side  of  the  cord.  It  had  caused  some  unilateral  symptoms  during  life. 
This  pressure,  however,  does  not  usually  cause  a  total  transverse  lesion.    This 

Fig.  164, 


A. 


Section  of  the  spinal  cord  from  a  ease  of  Pott's  disease     (At  the  seat  of  caries.) 

is  made  evident  in  the  accompanying  figures  (see  Figs.  164, 165,  and  166),  in 
which,  as  can  be  seen  readily,  neither  the  white  nor  the  gray  matter  is  pressed 
much  out  of  shape  or  materially  destroyed.  There  is  seen,  however,  a  rim  of 
degenerated  tissue  around  the  border  of  the  cord,  evidently  due  to  contact 
with  the  inflamed  meninges.  This  may  be  visible  only  under  the  microscope. 
Secondary  upward  and  dowuAvard  degenerations  are  also  seen. 

The  secondary  degenerations  in  the  cord  in  these  cases  are  characteristic, 
and  are  seen  in  the  figures.     At  the  level  of  the  lesion  the  cord  is  misshapen, 

1  This  description  is  based  largely  upon  cases  described  elsewhere  by  the  writer.  See  "Pachy- 
meningitis and  Myelitis  from  Pott's'Dlsease,"  etc.,  with  illustrations.  University  Medical  Magazine, 
December,  1893. 


536 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


degenerated  about  its  peripliery,  and  presents  the  commencement  of  ascend- 
ing posterior  and  descending  lateral  degeneration.  At  a  point  well  above 
the  level  of  the  lesion  the  deep  degeneration  of  the  postero-internal  columns 
(columns  of  GoU)  is  most  conspicuous.  (Fig.  165.)  The  direct  cerebellar 
tracts  to  the  exterior  of  the  lateral  i^yramidal  tracts  are  notably  degenerate. 
These  also,  being  ascending  fibres,  follow  the  Wallerian  law.     Finally,  the 

Fig   16d 


IT  f-  >  »»'•? 


Section  of  the  spinal  cord  from  a  case  of  Pott's  disease.     (Dorsal  region.) 

region] "of  the  anterior  ground  bundles,  including  Gowers's  tract,  which 
degenerates  upward,  shows  quite  extensive  degeneration.  Below  the  level  of 
the  lesion  the  appearance  of  the  cord  is  quite  different.  (Fig.  166.)  There 
is  marked  degeneration  of  the  lateral  pyramidal  tracts,  which  as  they  pass 
downward  apjDroach  nearer  and  nearer  to  the  periphery.    The  thickened  dura 


Fig.  166. 


with  its  layer  of  fibrinous  deposits  extends  in  some  cases  far  above  and  below 
the  level  of  the  caries,  and  in  such  cases  may  be  attended  with  changes  on 
the  anterior  aspect  of  the  cord  coextensive  Avith  its  own  limits.  Pus  may 
infiltrate  through  the  loose  cellular  tissue  of  the  vertebral  canal. 

The  form  "of  meningitis  described  by  some  writers  as  pachymeningitis 
interna  is  of  different  origin  fi-oiu  that  of  the  form  just  described.     It  is 


DISEASES  OF  THE  SPINAL  CORD.  537 

supposed  to  begin  in  minute  hemorrhages,  the  blood  from  which  becomes 
organized,  and  thus  leads  to  a  hypertrophy  of  tissue.  The  process  is  some- 
what analogous  to  that  which  occurs  in  hemorrhagic  pachymeningitis  Avithin 
the  cranium.  It  was  first  described  accurately  by  Charcot ;  one  of  its  favor- 
ite seats  is  the  cervical  enlargement,  and  one  of  its  most  common  causes  is 
trauma.^  Compression  of  the  cord  occurs  sooner  or  later,  with  impairment 
of  the  anterior  horns,  and  with  degeneration  of  the  conducting  paths,  as  has 
just  been  described. 

Leptomeningitis  of  acute  pyemic  origin  is  marked  by  a  thickened  and 
opaque  pia-arachnoid,  under  which  pus  in  some  quantity  is  usually  seen. 
The  cord  is  hypersemic.  The  pus  is  usually  distributed  widely  in  vertical 
extent.  The  process,  however,  is  not  apt  to  be  confined  strictly  to  the  pia, 
but  to  invade  also  the  inner  surface  of  the  dura.  The  tissue  of  the  cord  is 
evidently  involved  in  the  acute  infective  process,  but,  as  pressure  is  not  usu- 
ally a  marked  condition,  and  as  the  course  of  the  case  is  often  rapid,  system- 
lesions  are  not  so  well  marked  as  in  the  more  chronic  forms  described  above. 

A  more  chronic  form  of  combined  lepto-  and  pachymeningitis  is  described 
sometimes  as  due  especially  to  syphilis.  It  consists  in  a  proliferation  of 
tissue  without  pus  formation,  and  it  encroaches  gradually  upon  the  cord. 
Erb''  has  described  a  form  of  syphilitic  infection,  which  appears  to  invade 
by  preference  the  lower  dorsal  and  lumbar  region,  and  to  be  limited  almost 
exclusively  to  the  lateral  aspects  of  the  cord.  It  becomes  in  time  a  partiall}^ 
transverse  lesion  symmetrically  situated,  affecting  the  posterior  halves  of  the 
lateral  columns,  extending  thence  to  the  posterior  horns  and  posterior  col- 
umns. (See  also  Chapter  XXIV.).  As  is  seen  it  is  not  a  pure  meningitis, 
but  rather  a  meningomyelitis.  A  somewhat  similar  slow  proliferative 
meningitis  may  possibly  be  caused  by  alcohol,  by  exposure,  and  by  trauma, 
or  by  all  combined. 

Symptoms.  The  symptoms  of  the  various  types  of  meningitis  differ  ac- 
cording to  the  cause,  the  stage  of  activity,  and  the  seat  of  the  lesion.  The 
chronic  form,  as  for  instance  the  pachymeningitis  of  spinal  caries,  may  ap- 
proach insidiously,  and  its  approach  may  be  masked  by  the  primary  disease. 
The  traumatic  form,  too,  is  often  slow  in  its  onset,  and  sometimes  appears 
unmistakably  only  after  the  primary  effects  of  the  injury  have  disappeared. 
The  acute  form,  however,  may  appear  brusquely,  even  explosively,  and  may 
destroy  life  in  a  comparatively  short  time.  This  grave  form  is  seen  occasion- 
ally after  puerperal  infection. 

In  the  pachymeningitis  of  spinal  caries  the  earliest  symptom  may  be  pain, 
due  to  irritation  of  one  or  more  of  the  sensory  nerve-roots.  This  pain,  re- 
flected along  one  or  more  of  the  nerve-trunks  of  the  thorax  or  abdomen, 
may  appear  even  before  the  hump  is  noticed,  and  its  cause  may  thus  he 
overlooked.  In  this  form  the  motor  symptoms,  however,  are,  as  a  rule, 
the  most  consjDicuous.  There  occurs  a  gradually  increasing  paresis  in  the 
legs,  with  contractures  in  the  muscles,  increased  knee-jerks,  and  ankle-clonus. 
The  loss  of  power  may  advance  to  complete  paraplegia.  In  advanced  cases, 
and  even  sometimes  in  early  stages,  the  bladder  may  become  involved  ;  con- 
trol over  the  rectum  also  is  occasionally  lost.  Sensory  symptoms,  excepting 
the  initial  neuralgic  pains,  are,  as  a  rule,  not  nearly  so  conspicuous  as  the 
motor  ;  in  fact,  a  child  may  be  almost  hopelessly  paralyzed,  and  yet  ^^reserve 
some  degree  of  tactile  sensibility.  This  is  explained  by  the  fact  that  the 
anterior  and  lateral  regions  of  the  cord  are  most  involved  in  the  inflamma- 
tory process.     In  a  fair  proportion  of  cases,  however,  and  especially  in  those 

1  For  a  report  of  cases  by  the  writer,  see  a  paper  on  '■  Traumatic  Affections  of  the  Cervical  Reerion 
of  the  Spinal  Cord  Simulating  Syringomyelia,"  Journal  of  Nervous  and  Mental  Diseases,  June,  1894. 

2  "  Ueber  Syphilitische  Spinal  Paralyse."    Neurolog.  Centralb.  xi.  161-168. 


538 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


far  advanced,  anaesthesia  to  touch  and  to  jDain  is  present.  This  analgesia  was 
strikingly  shown  in  a  little  boy  with  dorsal  caries  under  the  writer's  care  in 
the  Home  for  Crippled  Children  within  the  past  year.  It  became  necessary 
to  circumcise  the  child  because  of  a  long  and  constantly  inflamed  and  ulcer- 
ated prepuce.  The  operation  was  done  under  ether,  by  Dr.  Hamilton,  but 
during  the  subsequent  changes  of  dressings,  removal  of  stitches,  etc.,  the 
patient  was  quite  indifferent,  and  evidently  felt  no  pain.  Bed-sores  occur 
readily  in  these  advanced  paraplegic  cases.  The  seat  of  spinal  caries  is 
usually  in  the  dorsal  or  dorso-lumbar  region.  In  those  comparatively  rare 
cases  in  which  it  is  in  position  for  its  resulting  meningitis  to  involve  either 
the  cervical  or  lumbar  enlargement  of  the  cord  there  result  muscular  atrophy 
and  flaccid  paralysis  of  the  corresponding  limbs. 


Fig.  167. 


Trauma  of  the  cervical  region  of  the  spinal  cord. 


In   the  type  first  described  by  Charcot  as  pachymeningitis  hypertrophica 
cervicalis  the  symptom-complex  is  quite  characteristic  and  resembles  markedly 


DISEASES  OF  THE  SPINAL  CORD.  539 

syringomyelia.  In  this  form,  as  the  name  implies,  the  cervical  enlargement 
is  the  seat  of  disease.  Among  the  first  symptoms  is  pain,  of  a  neuralgic 
kind,  in  the  occiput,  neck,  shoulders,  and  arms.  Wasting  of  the  muscles  of 
the  hand  (the  thenar,  hypothenar,  and  inter-osseous  groups),  the  forearm,  and 
shoulder  next  attract  attention.  This  wasting  advances  to  an  extreme 
emaciation  of  the  muscles  (Fig.  167),  with  corresponding  loss  of  power.  It  is 
usually  of  the  Aran-Duchenne  type  of  progressive  muscular  atrophy,  i.  e., 
flaccid  and  with  diminished  myotonus,  but  this  is  not  an  invariable  rule,  as 
markedly  increased  tonus  is  seen  in  some  cases.  Fibrillation  of  the  wasting 
muscles  occurs.  Deformity  of  the  cervical  spine  and  scoliosis  appear.  As 
the  cervical  symptoms  increase  a  spastic  paraplegia,  with  increased  knee- 
jerks,  and  usually  without  involvement  of  the  bladder  and  rectum,  becomes 
established.  Sensory  symptoms  of  great  interest  may  appear  in  these  cases. 
There  may  be  thermo-ansesthesia  and  analgesia  without  abolition  of  tactile 
sensibility  (the  so-called  dissociation  symptom  of  syringomyelia)  in  some 
areas.  There  may  be  however,  some  areas  or  anjesthesia.  The  sensory 
changes  may  preserve  an  hemiplegic  type,^  Occasionally  changes  in  the 
pupils  occur,  due  to  involvement  of  the  sympathetic  nerve. 

Leptomeningitis  of  the  spinal  cord  usually  occurs  as  a  part  of  the  more 
generalized  cerebro-spinal  meningitis.  This  latter  may  be  due  to  the  specific 
contagion,  usually  epidemic,  to  which  the  term  "  cerebro-spinal  fever  "  is 
popularly  applied  ;  or  an  equally  diffused  cerebro-spinal  leptomeningitis  may 
be  due  occasionally  to  tubercle  (quite  independent  of  spinal  caries),  or 
finally  it  may  be  caused  by  pyaemia.  I  once  saw  a  patient  with  meningitis  of 
the  lower  third  of  the  vertebral  canal  caused  by  direct  infection  from  an  ex- 
tensive bed-sore  beneath  the  sacrum.  Similar  cases  due  to  puerperal  and  to 
pulmonary  infection  have  been  noted.  Primary  spinal  leptomeningitis, 
without  cranial  leptomeningitis,  is  an  extremely  rare  affection.  Macewen,^ 
speaking  of  purulent  leptomeningitis  of  the  cerebrum,  due  to  suppurative 
ear  diseases,  says  that  the  pus  may  extend  down  to  the  cauda  equina.  When 
the  affection  extends  thus  to  the  spinal  cord  spinal  symptoms  are  seen  ;  these 
are  especially  the  girdle-sense,  severe  shooting  pains,  and  rapid  and  complete 
prostration.  Other  symptoms  of  spinal  irritation  occur,  such  as  rigidity  and 
opisthotonus,  and  finally  the  rapid  onset  of  paralysis  indicates  that  the  gan- 
glionic centres  in  the  cord  and  the  conducting  nerves  have  been  invaded  by 
the  poison  of  the  infection.  Hemorrhagic  pachymeningitis  (pachymeningitis 
interna)  of  the  sj)inal  canal  occurs  usually  in  association  with  the  same  affec- 
tion within  the  cranium,  and  as  an  accompaniment  of  degenerative  processes, 
such  as  occur  in  general  paresis  and  in  chronic  alcoholism.  It  is  consequently 
difficult  to  recognize  it  during  life,  as  it  is  usually  masked  by  other  conditions. 

The  various  forms  of  syphilitic  infection  of  the  cord  doubtless  involve  the 
membranes,  in  some  cases  even  primarily  ;  but  they  are  best  described  under 
other  headings,  as  they  are  in  this  treatise.     (See  ChajDter  XXIV.) 

To  recapitulate,  it  may  be  said  that  meningitis  within  the  vertebral  canal 
has  usually  three  stages.  (1)  Irritation,  marked  by  neuralgic  pains,  girdle- 
sense,  and  slight  beginning  loss  of  power.  (2)  Paralysis,  both  of  sensation 
and  motion,  gradually  increasing.  (3)  System  degenerations,  upward  and 
downward,  trophic  disorders,  paralysis  of  the  bladder  and  rectum.  This 
order  of  symptoms,  however,  is  subject  to  variation. 

Diagnosis.  In  the  early  stages  of  spinal  caries,  before  the  appearance 
of  the  hump,  it  is  most  important  to  recognize  the  true  character  of  the 

1  See  author's  paper,  already  referred  to  (op.  cit.),  for  a  fall  discussion  of  tlie  symptomatology  of 
these  cervical  cases. 

2  See  Macewen's  recent  work,  "  Pyogenic  Infectious  Diseases  of  the  Brain  and  Spinal  Cord,"  for  a 
description  of  these  forms 


540  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

thoracic  and  abdominal  pains  tliat  are  caused  by  irritation  of  the  nerve- 
roots.  Stiffness  of  the  spine  and  a  focus  of  beginning  pain  and  deformity- 
can  usually  be  detected  early  if  the  observer  is  alert  to  the  significance  of 
the  first  symptoms.  In  later  stages  of  spinal  caries  the  diagnosis  of  pachy- 
meningitis can  scarcely  be  in  doubt. 

To  differentiate  a  pachymeningitis  from  myelitis  is  not  practicable  in 
many  cases,  because  the  two  states  are  likely  to  be  associated.  The  early 
appearance  and  the  predominance  of  pain,  "with  the  slow  onset  of  symptoms 
of  system-lesions,  such  as  spastic  paraplegia,  atrophic  paralysis,  and  various 
types  of  ansesthesia,  with  involvement  of  the  bladder  late  in  the  case,  or  even 
altogether  exempt,  would  suggest  a  meningitis  with  gradual  involvement  of 
the  cord. 

In  some  cases  of  the  hypertroj)hic  form  of  cer^'ical  pachymeningitis,  the 
resemblance  to  syringomyelia  is  so  great  that  the  history  of  severe  injury  can 
alone  determine  the  diagnosis.  It  is  well  to  recall,  however,  that  trauma  has 
figured  among  the  causes  of  syringomyelia.  Severe  and  persistent  pain  in 
the  occiput,  neck,  and  shoulders,  following  trauma  in  these  cases,  is  the  surest 
diagnostic  sign. 

Acute  leptomeningitis,  either  spinal  or  cerebro-spinal,  has  some  resem- 
blance to  tetanus.  The  exacerbations  of  opisthotonus,  the  trismus,  the  per- 
sistent course,  the  history  of  a  wound,  distinguish  tetanus  from  meningitis. 

Various  forms  of  spinal  meningitis  have  some  superficial  resemblance  to 
locomotor  ataxia,  but  the  pupillary  changes,  the  abolished  knee-jerks  (abol- 
ished also  in  meningitis  of  the  himbar  enlargement  and  cauda  equina)  and 
the  ataxia,  without  paralysis,  serve  usually  to  distinguish  the  latter  disease. 

Leptomeningitis  is  to  be  distinguished  from  hysteria  by  the  absence  of  the 
stigmata  of  this  disease. 

Prognosis.  In  spinal  caries  a  pachymeningitis  is  a  serious  complication. 
"When  pus  is  formed  in,  or  finds  its  way  into,  the  vertebral  canal,  or  when  in- 
flammatory lymph  is  organized  on  the  ventral  aspect  of  the  cord,  the  case 
usually  advances  to  a  septic  or  py^emic  stage,  and  the  paralysis,  resulting 
fi'om  involvement  of  the  cord,  is  usually  permanent.  In  mild  cases,  in  which 
presumably  pus  does  not  form,  a  partial  or  even  a  complete  recovery  may 
occur. 

In  acute  cerebro-spinal  leptomeningitis,  especially  of  pyasmic  origin,  as  in 
suppurative  ear-diseases,  death  invariably  results. 

In  cervical  pachymeningitis  of  traumatic  origin,  the  resulting  deformities 
are  permanent,  but  life  is  often  prolonged  for  years. 

In  some  cases  of  alleged  spinal  meningitis,  clue  to  various  causes,  good  re- 
coveries are  reported.  In  syphilitic  casas  recoveries  are  claimed  by  some 
from  specific  treatment.  On  the  whole,  however,  all  forms  of  the  affection 
are  grave  diseases,  and  a  guarded  prognosis  is  to  be  given. 

Treatment.  Surgery  alone  can  offer  any  hope  of  relief  in  cases  of  pachy- 
meningitis due  to  spinal  caries.  Patients  have  been  operated  on  successfully 
and  relieved  from  the  effects  of  pressure  by  tubercular  nodules  and  organized 
lymph,  and  have  been  benefited  also,  probably,  by  the  drainage  of  the  verte- 
bral canal.  In  one  case  observed  by  the  writer,  spontaneous  drainage  had 
occurred  through  a  psoas  abscess,  the  dura  being  perforated  and  the  perfora- 
tion communicating  directly  with  the  tract  of  the  abscass.  In  the  main, 
however,  the  worst  of  the  disease  process  is  on  the  ventral  aspect  of  the  cord 
and  so  not  easily  reached  by  the  surgeon.  Moreover,  not  pressure  so  much 
as  a  secondary  myelitis  is  the  cause  of  the  cord  symptoms,  and  this  latter 
cannot  be  relieved  by  surgery.  For  fuller  details,  Chapter  XXXIII.  may  be 
consulted.  Fx'om  the  pathologist's  standpoint,  after  many  opportunities  to 
study  these  cases  post-mortem,  the  opinion  has  been  reached  by  the  writer 


DISEASES  OF  THE  SPINAL  CORD.  54 1 

that  comparatively  few  of  them  are  likely  to  be  benefited  permanently  by 
operation. 

In  syphilitic  cases,  or  even  in  cases  in  which  syphilis  is  only  suspected,  in 
patients  presenting  evidence  of  the  early  stages  of  meningeal  irritation,  an 
active  specific  treatment  should  be  commenced  at  once. 

In  traumatic  cases,  and,  in  fact,  in  all  cases,  rest  and  counter-irritation 
must  be  employed.  Rest  is  of  first  importance  in  traumatic  cases,  and  after 
rest  comes  time.  One  patient,  at  present  under  observation,  went  back  to 
work  as  a  stonemason  after  several  years'  invalidism  due  to  a  cervical  pachy- 
meningitis. Counter-irritation  may  be  used  by  the  method  of  blisters  or  of 
the  hot-iron.  In  chronic  cases  iodide  of  potassium  may  be  employed,  but  it 
gives  doubtful  prospect  of  relief  Electricity  is  probably  useless  in  any  form 
of  spinal  meningitis.  Symptoms  must  be  treated  as  they  arise.  Pain  may 
demand  relief,  but  the  danger  of  a  patient  forming  the  opium  habit  must  not 
be  despised.  Bed-sores  should  be  guarded  against,  and  when  they  occur 
should  be  treated  with  strict  antiseptic  precautions,  because  there  is  always 
danger  that  they  may  infect  the  system. 


INTRA-SPINAL  HEMORRHAGE. 

Intra-spinal  hemorrhage  may  be  divided  into  two  classes ;  first,  menin- 
geal, and,  second,  medullary.  The  first  is  the  more  common  ;  it  may  be  sub- 
divided into  the  extra-dural  and  the  subdural.  The  second  or  medullary 
variety,  the  true  hematomyelia,  is  a  rare  affection,  but  not  so  uncommon, 
probably,  as  some  writers  contend.  Recent  medical  literature  contains  the 
records  of  some  striking  and  characteristic  instances,  confirmed  by  autopsy, 
of  true  hemorrhage  within  the  substance  of  the  cord,  so  that  it  is  no  longer 
reasonable  to  contend  on  d  priori  grounds  that  such  hemorrhages  cannot 
occur,  and  that  myelitis  has  been  mistaken  in  all  such  cases  for  hemorrhage. 
The  reverse  is  more  likely  to  be  true,  especially  in  traumatic  cases,  in  which 
the  so-called  myelitis  is  probably  a  necrotic  softening,  having  as  its  initial 
lesion  a  blood-clot  or  minute  capillary  hemorrhages.  It  has  been  assumed, 
almost  universally,  that  for  some  mysterious  reason  the  spinal  cord  is  ex- 
empt from  those  accidents  in  the  vascular  system,  such  as  embolism,  throm- 
bus, and  hemorrhage,  that  play  such  a  conspicuous  part  in  cerebral  path- 
ology. This  assumption  has  always  appeared  to  the  writer  to  be  entirely 
unwarranted.  The  explanation  for  it,  i.  e.,  that  the  long  course  of  the  spinal 
vessels  relieves  them  from  the  effects  of  undue  blood-pressure,  seems  to  be  not 
in  accord  with  sound  hydro-dynamics ;  and  the  claim  that  capillary  aneu- 
risms are  never  found  below  the  oblongata,^  at  least  needs  confirmation. 
The  fact,  probably,  is  that  cases  of  acute  transverse  softening  (usually  mis- 
called myelitis)  are  due  primarily  to  a  vascular  defect,  and  are  not  truly  in- 
flammatory, i.  e.,  the  result  of  infection.  Some  of  these  cases,  as  already 
said,  may  owe  their  start  to  capillary  hemorrhages  or  even  to  a  small  blood- 
clot  poured  out  into  the  substance  of  the  cord. 

The  great  authority  of  Charcot  has  been  sufficient,  apparently,  to  establish 
the  opinion  among  most  writers  that  hemorrhage  in  the  cord  is  always  the  re- 
sult of  some  primary  lesion,  usually  the  necrotic  process  miscalled  by  him  acute 
myelitis.  Hayem'''  elaborated  this  idea  in  an  exhaustive  treatise,  in  which  lie 
subjected  all  reported  cases,  up  to  1872,  to  a  critical  study.  His  conclusion 
was  {op.  cit,  p.  146)  that  there  was  no  unobjectionable  case  reported  of  primary 

1  Gowers  propounds  both  these  explanations  in  his  text-book  on  diseases  of  the  nervous  system. 
"  "Des  Hemorrhagies  Intra-Kachidiennes,"  These  de  Paris,  1872. 


542  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

lieniatomyelia.  This  conclusion  is  based,  evidently,  in  j^art  upon  the  erro- 
neous ideas  that  prevailed  formerly  on  the  subject  of  inflammation.  Many 
degenerative  and  some  necrotic  processes  in  the  cord  were  ascribed  univer- 
sally to  inflammation.  According  to  the  modern  microbic  pathology  the 
term  inflammation  has  a  much  more  restricted  meaning  and  is  applied 
almost  exclusively  to  the  results  of  infection.  It  cannot  be  proved  that 
hemorrhage  and  softening  of  the  cord  in  all  cases  are  due  to  infection.  They 
seem  rather  to  be  due  to  causes  which  sometimes  act  primarily  upon  the  vas- 
cular system,  as  trauma,  cold,  exposure,  and  overexertion.  That  they  may  even 
be  due  in  a  few  cases  to  vascular  degeneration,  similar  to  what  occurs  in  the 
brain,  is  not,  in  the  writer's  opinion,  conclusively  disproved.  From  a  practi- 
cal point  of  view  it  is  not  a  vital  question  whether  the  hemorrhage  precedes 
the  softening,  or  vice  versa ;  both,  in  fact,  may  be  due  to  the  same  cause,  and 
may  be  practically  coincident.  It  appears,  however,  from  reported  cases,  to 
be  an  undoubted  fact  that  hemorrhage  does  occasionally  occur  primarily, 
i.  e.,  independently  of  a  precedent  myelitis  or  softening ;  that  it  produces 
quite  characteristic  symptoms,  and  that  it  may  be  rapidly  fatal.^ 

A  most  interesting  and  instructive  case  of  non-traumatic  hemorrhage  into 
the  spinal  cord,  illustrating  this  whole  subject,  has  been  put  on  record  by 
Kindred.^  The  patient,  a  man  aged  fifty-nine  years,  in  previous  good 
health,  was  seized  suddenly  with  pain  in  the  cardiac  region  simulating 
angina  pectoris ;  there  were  also  dorsal  pain,  general  spinal  tenderness,  and 
the  "  cincture  feeling "  in  the  chest  and  abdomen.  The  patient  was  able, 
after  the  first  shock,  to  walk  some  distance,  but  then  paralysis  of  the  legs 
came  on  quickly.  There  was  also  quickly  beginning  and  rapidly  increasing 
numbness  in  the  lower  limbs  and  trunk  up  to  the  level  of  the  afiected  seg- 
ment. There  were  priapism,  paralysis  of  the  bladder  and  rectum,  dimin- 
ished reflexes,  embarrassed  respiration,  and  intestinal  flatus.  The  initial 
agonizing  pain  soon  disappeared.  Death  resulted  in  six  and  one-half  hours. 
Consciousness  was  not  afiected.  The  autopsy  revealed  a  bulging  of  the 
fourth  dorsal  segment.  At  this  point  a  dark-red  clot,  about  the  size  of  an 
almond,  lying  almost  wholly  in  the  gray  matter,  was  found.  Adjacent  parts 
were  somewhat  softened  and  congested.  There  was  nothing  else  abnormal. 
There  was  no  history  of  trauma,  fatigue,  excessive  venery,  vertebral  disease, 
or  toxaemia.  It  seems  to  me  impossible,  considering  the  history,  the  abrupt 
onset,  the  rapidly  fatal  issue,  and  the  authentic  auto|)sy  in  Kindred's  case, 
to  regard  the  hemorrhage  as  other  than  primary  and  the  slight  softening 
as  secondary.  The  case  suggests  some  vascular  defect  as  the  cause  of  the 
hemorrhage. 

Starkey^  also  records  a  case  of  hematomyelia,  traumatic  in  origin.  A 
boy,  aged  thirteen  years,  after  a  heavy  fall  on  the  ice,  walked  home.  After 
reaching  home  he  had  pain  in  the  left  shoulder,  abdomen,  and  legs ;  then  he 
began  to  be  paralyzed,  so  that  in  two  hours  he  could  not  walk.  The  pain 
and  paralysis  persisted  ;  then  later  there  Avere  retention  of  urine,  tachycardia, 
and  obstinate  constipation.  Sensation  failed  as  high  as  the  fourth  or  fifth 
dorsal  spine,  the  anaesthesia  being  slightly  higher  on  the  left.  A  small  mar- 
ginal zone  of  hyperesthesia  was  present,  and  there  was  slight  numbness  in 
the  left  hand.  The  right  knee-jerk  was  completely  abolished  ;  the  left  was 
diminished.  There  was  no  ankle-clonus.  The  abdominal  and  cremasteric  re- 
flexes were  absent ;  the  plantar  were  fairly  brisk.    The  pupils  were  contracted 

1  For  a  further  discussion  of  this  subject  the  reader  is  referred  to  a  paper  by  Dr.  Joseph  Collins  on 
"  Hsematomyelia  and  Acute  Myelitis."    N.  Y.  Med.  Kecord,  May  27,  1893. 

"  A  Case  of  Non-traumatic  Hemorrhage  into  the  Spinal  Cord,  by  J.  Joseph  Kindred,  M.D.  Med. 
News.  February,' 13, 1892. 

3  "  A  Case  of  Primary  Hemorrhage  into  the  Spinal  Cord,"    Lond.  Lancet,  May  23, 1891,  p.  1137. 


JDTSEASES  OF  THE  SPINAL  CORD.  543 

and  did  not  resj^ond  to  light.  The  temperature  was  j^ersistently  high.  The 
anaesthesia  diminished  slightly  toward  the  last.  The  boy  lived  eight  days, 
dying  of  pneumonia.  At  the  autopsy  no  bruising,  laceration,  or  hemorrhage 
of  the  spine  or  membranes  was  found.  The  pia  was  congested,  but  free  from 
lymph.  At  the  third  dorsal  segment  was  a  hard  localized  swelling,  and  at  this 
level  the  cord  bulged.  Above  and  below  this  bulging  the  cord  was  softened 
and  had  a  slight  yellow  tinge.  On  section  an  extravasation  of  blood  was  found 
occupying  nearly  the  whole  of  the  transverse  extent  of  the  cord.  Only  a 
little  white  and  gray  matter  on  the  right  side  could  be  made  out.  Above  the 
hemorrhage,  so  fer  as  the  upper  cervical  region  and  below  so  far  as  the  mid- 
dorsal  region,  the  anterior  and  posterior  cornua  of  gray  matter  of  the  left  side 
were  converted  into  a  long  cavity  containing  blood.  The  microscope  showed 
that  the  hemorrhage  was  the  only  lesion ;  there  was  no  inflammation. 

Etiology.  The  most  common  cause  of  intra-spinal  hemorrhage,  either 
meningeal  or  medullary,  is  trauma.  There  may  or  may  not  be  a  coinci- 
dent fractui'e  of  one  or  more  of  the  vertebrae.  In  most  traumatic  cases  there 
may  be,  and  probably  usually  is,  some  coincident  damage  to  the  cord-tissue. 
The  fracture,  or  the  damage  to  the  cord-tissue  by  crush  or  by  compression, 
or  both  of  these  lesions,  are  often  so  conspicuous  that  the  cases  are  more 
properly  classed  under  one  or  other  of  these  heads.  In  some  cases,  however, 
there  may  be  no  fracture,  and  the  direct  injury  to  the  cord  may  not  be  con- 
spicuous, but  most  or  all  of  the  symptoms  may  be  due  to  the  hemorrhage.  In 
some  cases  of  so-called  concussion  of  the  spinal  cord,  due  to  trauma,  it  is  not 
unreasonable  to  suppose  that  minute  capillary  hemorrhages  in  the  cord,  or 
small  extravasations  of  blood  in  the  membranes,  are  the  real  causes  of  the 
persistent  symptoms. 

Overexertion,  venereal  excess,  exposure  to  cold,  and  the  convulsions  of 
tetanus  and  strychnine-poisoning  have  been  claimed  as  causes  of  these  hemor- 
rhages. In  one  case  a  hard  labor  was  held  to  be  the  cause.  Some  of  these 
causes,  as  venereal  excess,  are  problematical.  Scurvy^  and  purpura  hemorrha- 
gica may  cause  meningeal  hemorrhage  in  exceptional  cases.  It  has  been 
conjectured  that  the  infectious  diseases,  as  smallpox  and  typhus  fever,  may 
do  likewise,  but  observations  are  lacking. 

Finally,  according  to  the  view  already  stated,  it  is  not  unreasonable  to  sup- 
pose that  vascular  defects  may  produce  hemorrhages  in  the  cord  or  its  mem- 
branes. Certainly  such  a  view  cannot  be  ignored  until  further  study  of 
the  2)0ssible  diseases  of  the  spinal  bloodvessels  shall  have  shown  it  to  be 
unfounded.     Such  disease  of  the  bloodvessels  may  be  caused  by  syphilis. 

Symptoms.  The  onset  of  sj)ontaneous  non-traumatic  hemorrhage,  especi- 
ally into  the  substance  of  the  cord,  is  always  sudden.  The  accident  causes 
a  shock,  as  in  Kindred's  case,  which  may  throw  the  patient  to  the  ground, 
or  even  temporarily,  according  to  some  writers,  obscure  consciousness.  From 
this  shock  the  jiatient  may  rally  and  be  able  to  walk  for  some  short  time 
and  distance,  but  paralysis  comes  on  soon,  and  rather  rapidly.  The  initial 
shock  is  usually  accompanied  with  pain,  often  of  an  agonizing  kind  ;  but  this 
pain,  as  in  Kindred's  case,  may  disappear  in  a  short  time.  This  pain  may 
simulate  angina  pectoris,  and  if  accompanied  with  tachycardia  and  eml)ar- 
rassed  respiration,  as  when  the  lesion  is  in  the  upper  dorsal  region,  the  simu- 
lation of  a  heart  or  lung-affection  may  be  still  more  marked. 

In  traumatic  cases  the  onset  of  symptoms  is  not  always  immediate  upon 
the  receipt  of  the  injury ;  this  depends  upon  the  extent  both  of  the  injury 
and  the  hemorrhage.     In  comparatively  slight  accidents,  where  the  hemor- 

1  See  an  instructive  paper  on  "  Htt-matoma  of  the  Dura  Mater  associated  witli  Scurvy  iu  Children," 
by  G.  H.  Sutherland,  M.D.  Brain,  Spring  No.  1894.  In  one  of  Dr.  Sutherhind's  cases  an  effusion  of 
hlood-stained  lymph  was  found  beneath  the  dura  in  the  dorsal  region  of  the  cord. 


544  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

rhage  is  evidently  slow,  the  symptoms  may  come  on  very  gradually.  This 
mode  of  onset  was  seen  in  Starkey's  case.  In  more  severe  accidents,  as  in 
falls  upon  the  feet  and  buttocks,  or  heavy  blows  upon  the  neck  or  back,  the 
effects  of  hemorrhage  are  seen  more  quickly.  Still  there  may  be  quite  ex- 
tensive extravasations  of  blood  outside  of  or  even  within  the  dura,  with  quite 
gradual  onset  of  symptoms  in  traumatic  cases. 

In  true  hematomyelia,  traumatic  or  otherwise,  the  symptoms  are  usually 
those  of  a  complete,  or  almost  complete,  transverse  lesion  of  the  cord.  The 
traumatic  cases  are  most  common  in  the  cervical  region.  In  these  cases, 
therefore,  there  is  usually  complete  paraplegia,  with  paralysis  of  the  bladder 
and  rectum,  abdominal  flatus,  priapism,  and  anaesthesia  so  high  as  the  distri- 
bution of  nerves  arising  from  the  highest  segment  involved.  It  is  a  notable 
fact  that  in  most  of  these  cases  the  patellar,  and  often  the  superficial,  reflexes 
are  abolished.  This  is  in  accord  with  observations  made  by  Bastian^  that 
a  total  transverse  section  of  the  spinal  cord  abolishes  all  reflexes  below  the 
hue  of  section,  and  that  contractures  of  the  limbs  with  increased  reflexes 
indicate  that  the  section  is  not  complete.  Both  Kindred's  and  Starkey's 
cases,  as  well  as  most  of  those  published  by  Parkin,'^  support  this  view. 

The  respiration  is  usually  involved  in  these  cervical  and  upper  dorsal 
hemorrhages.  In  some  cases  the  breathing  becomes  entirely  diaphragmatic. 
Tachycardia  is  often  present  because  apparently  of  irritation  of  the  accel- 
erator nerves  of  the  heart.  In  some  cases  the  pupils  are  affected  because  of 
involvement  of  the  sympathetic  centre  in  the  cervical  cord.  When  this  is 
irritated  the  pupils  may  be  dilated ;  toward  the  close,  paralysis  occurs  and 
the  pupils  are  contracted  to  a  pin-point. 

The  course  of  some  of  these  cases  is  extremely  rapid.  In  one  of  Parkin's 
cases  of  true  hematomyelia,  caused  by  a  fracture,  death  occurred  in  about 
thirty-six  hours.  In  Kindred's  case  of  spontaneous  hemorrhage  death  came 
in  six  hours. 

In  meningeal  hemorrhage  the  symptoms  usually  are  not  so  severe  as  in 
true  hematomyelia,  and  the  prognosis  is  better.  Pain,  due  to  irritation  of 
nerve-roots,  may  be  a  prominent  symjstom.  Meningeal  hemorrhage  of  the 
lumbar  enlargement  and  of  the  cauda  equina  is  caused  by  accidents,  such  as 
falls  upon  the  feet  or  buttocks.  In  these  cases  the  symptoms  vary  according 
to  the  extent  of  injury  and  amount  of  blood  extravasated.  The  distribution 
of  sensory  symptoms  may  follow  the  distribution  of  individual  nerve-trunks. 
The  bladder  often  is  involved,  and  the  paralysis  is  confined,  of  course,  to  the 
legs,  which  may  be  rather  flaccid  with  abolished  knee-jerks. 

Excessive  sweating  and  hyperpyrexia  are  seen  in  cases  of  intra-spinal 
hemorrhage,  especially  toward  the  end  in  fatal  cases. 

Diagnosis.  The  identification  of  a  lesion  of  the  cord  in  these  cases  is 
usually  easy  enough.  It  is  not  likely  that  such  an  affection  could  be  mis- 
taken for  a  disease  of  any  other  organ,  yet  it  is  well  to  recall  that  the  initial 
severe  pain,  with  embarrassed  respiration,  has  simulated  angina  pectoris. 
The  speedy  onset  of  paralysis,  with  priapism,  anaesthesia,  incontinence,  and 
abolished  reflexes,  would  distinguish  the  cord-lesion  unerringly. 

The  supreme  difficulty  in  these  cases  is  to  distinguish  intra-spinal  hemor- 
hage  from  transverse  myelitis,  acute  white  softening,  pachymeningitis,  and 
fracture.  The  sudden  onset  and  often  rapid  course  of  hematomyelia  distin- 
guish it  to  a  certain  extent  from  transverse  myelitis.  The  differentiation, 
however,  is  often  uncertain  and  sometimes  impossible,  as  can  be  readily  un- 
derstood from  what  has  already  been  said  about  myelitis.  Softening  and 
hemorrhage  may,  no  doubt,  be  due  to  the  same  causes,  and  some  cases  of  so- 

1  Medico-Chirurg.  Trans.,  vol.  Ixxiii.  • 

2  "  Seven  Cases  of  Intra-spinal  Hemorrhage  (HEematomyelia)."    Guy's  Hosp.  Rep.,  1891. 


DISEASES  OF  THE  SPINAL  COED.  545 

called  myelitis  are  uot  truly  iuflammatory  processes  at  all,  but  rather  necrotic 
ones.  The  practical  necessity  for  these  fine  distinctions  between  processes 
which  usually  are  all  equally  disabling  is  not  urgent. 

In  traumatic  cases,  however,  the  distinction  between  intra-spinal  hemor- 
rhage and  fracture  is  of  importance.  Unfortunately  the  two  conditions 
often  coexist.  Deformity  of  the  spine  is  the  surest  sign  of  fracture  ;  but 
even  in  cases  in  which  the  fracture  can  be  detected  and  relieved  the  cord 
may  be  so  injured  by  both  crush  and  hemorrhage  that  permanent  benefit  is 
not  gained.  It  must  be  borne  in  mind  in  these  cases  that  the  hemorrhage 
from  fracture  is  not  necessarily  merely  meningeal ;  it  may  be  within  the  cord, 
as  in  one  of  Parkin's  cases.  In  such  a  case  the  progress  is  usually  rapid 
toward  death. 

Morbid  Anatomy.  In  true  hematomyelia  the  cord  usually  bulges  at  the 
seat  of  hemorrhage.  The  blood  may  be  confined  entirely  to  the  interior  of 
the  cord.  In  Kindred's  case  the  clot  was  the  size  of  an  almond,  and  lay 
almost  wholly  in  the  gray  matter.  The  adjacent  parts  may  be  somewhat 
softened.  In  Starkey's  case  the  blood  occupied  almost  the  entire  transverse 
area  of  the  cord.  Above  and  below  the  seat  of  hemorrhage  cavities  extended 
through  the  gray  matter  to  the  extent  of  several  segments.  These  cavities 
wei'e  evidently  caused  by  a  process  of  necrosis  set  up  by  the  hemorrhage.  A 
similar  condition  was  noted  by  Parkin,  the  cavity  being  accurately  limited 
to  the  area  of  the  gray  matter.  Recently  Van  Gieson^  has  attempted  to 
explain  certain  long,  slender  columns  of  necrosis  in  the  cord,  associated  appar- 
ently with  myelitis.  They  traverse  long  distances  in  the  cord,  both  above 
and  below  an  apparently  circumscribed  myelitis,  and  cavities,  forming  long 
tubes,  may  result  from  them.  He  considers  these  exceedingly  rare,  and  has 
heard  of  but  two  of  these  cases.  These  "  columns  of  necrosis  "  are  formed. 
Van  Gieson  thinks,  by  hemorrhages  into  the  substance  of  the  cord,  especially 
in  traumatic  cases.  In  time  these  columns  break  down,  and  "perforating 
necrosis  "  occurs.  This  is  doubtless  the  correct  explanation  of  these  long, 
narrow  cavities,  which,  however,  are  not  so  rarely  reported  as  Van  Gieson 
claims,  one  of  Parkin's  cases  and  the  one  by  Starkey  both  showing  this  con- 
dition. The  hemorrhage  takes  these  courses  upward  and  downward  in  the 
cord  because  they  are  the  courses  of  least  resistance ;  i.  e.,  it  is  easier  for  the 
blood  to  force  its  way  up  and  down  through  the  substance  of  the  cord  than 
to  break  through  the  firm  and  resisting  enveloping  membrane.  In  true 
haematomyelia  there  is  no  inflammation  of  the  cord  or  its  membranes.  The 
pia,  however,  may  be  much  congested. 

In  simple  meningeal  hemorrhage  the  blood  may  be  outside  of  or  within 
the  dura.  It  often  extends  to  a  great  length,  even  to  the  cauda  equina.  The 
cerebro-spinal  fluid  is  blood-stained. 

Treatment.  No  treatment  avails  in  cases  of  true  hematomyelia.  The 
accident  is  almost  always  fatal,  and  usually  rapidly  so.  In  cases  which  sur- 
vive— and  such  may  occur  among  the  numerous  patients  who  are  said  to  be 
suffering  with  "  concussion  "  or  "  myelitis  " — the  future  is  likely  to  be  one  of 
chronic  invalidism  and  hopeless  paralysis.  Hemorrhages  into  the  mem- 
branes might  possibly  in  some  cases  be  relieved  by  surgery.  No  other  treat- 
ment could  be  of  much  benefit.  Ergot  or  one  of  its  preparations  should 
be  given  a  trial,  in  hope  that  it  would  tend  to  check  a  continuance  of  the 
bleeding.  Laminectomy,  in  case  a  clot  can  be  successfully  diagnosticated  and 
localized,  Avould  be  a  proj^er  operation. 

1  N.  Y.  Med.  Journ.,  June  2,  1894. 
35 


546  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

INJURIES  TO  THE   SPINAL  CORD  PROM  FRACTURES  AND 
DISLOCATIONS  OF  THE   SPINE. 

From  the  surgical  standpoint  much  can  be  written  about  fractures  and 
dislocations  of  the  spine  that  would  be  inappropriate  here.  I  shall  only 
describe  briefly  the  injuries  to  the  cord  that  are  caused  by  these  accidents. 
The  injuries  to  the  membranes  have  been  described  already  under  the  re- 
spective headings  of  meningitis  and  of  hemorrhage.  Reference  can  be  made 
to  those  descriptions.  The  injuries  to  the  cord  itself  are  usually  by  crushing, 
puncturing,  or  tearing.  In  patients  who  survive  the  accident  attempts  at 
repair  are  made,  and  a  consequent  thickening  of  the  membranes  and  in- 
creased density  of  the  cord  substance  (allied  to  scar-tissue)  may  result.  In 
other  cases  softening  results,  sometimes  miscalled  myelitis,  and  this  may  be 
associated  with  hemorrhage  into  the  tissue  of  the  cord,  which  has  been  de- 
scribed above. 

Deformities  of  various  kinds  in  the  spinal  column  are  caused  by  fractures 
and  dislocations,  and  when  present  are  the  best  evidences  of  the  lesion.  It 
must  not  be  forgotten,  however,  that  in  exceptional  cases  little,  if  any,  de- 
formity may  result  from  fracture,  and  yet  the  cord  may  be  seriously  injured. 
It  has  been  claimed  even  that  a  fracture  of  the  body  of  a  vertebra  may  quite 
readily  escape  observation ;  this  seems  to  have  been  so  in  a  case  of  fracture 
with  displacement  of  the  body  of  one  of  the  dorsal  vertebrae  which  I  saw  once 
with  Dr.  Willard  in  the  Presbyterian  Hospital.  Extensive  crush  of  the 
cord  had  resulted,  as  found  post  mortem,  although  but  little,  if  any,  deform- 
ity of  the  spine  had  been  visible  during  life.  It  has  been  supposed  that  in 
some  of  these  cases  the  displaced  fragment,  or  even  the  whole  vertebra  itself, 
having  been  displaced,  springs  back  into  place.  In  the  cervical  region  a 
fracture  may  cause  a  twist  in  the  neck  and  displacement  of  the  head,  so  as 
to  suggest  a  dislocation  ;  in  fact,  these  two  lesions  may  coexist.  Thus  in  a 
young  colored  man  under  my  care  in  the  Philadelphia  Hospital  this  de- 
formity with  twist  was  seen.  He  was  struck  between  the  shoulders  by  some 
bricks  Avhich  fell  from  a  fourth  story,  and  probably  sustained  a  fracture  of 
one  of  the  laminae  and  of  the  transverse  process,  with  resulting  hemorrhage 
and  damage  to  the  cord. 

Symptoms.  Pain  and  deformity  are  common  symptoms,  but  the  latter,  as 
just  said,  is  exceptionally  absent.  The  symptoms  depend  upon  the  extent  of 
injury  to  the  cord  and  upon  the  level  of  the  lesion.  In  severe  injuries  the 
symptoms  are  those  of  a  complete  or  almost  complete  transverse  lesion  of  the 
cord.  There  is  complete  paralysis  of  motion  and  sensation  below  the  point 
of  lesion,  with  involvement  of  the  bladder  and  bowels.  In  cervical  injuries 
there  are  atrophic  paralysis  of  the  arms,  spastic  paraplegia,  anaesthesia  of 
various  grades  and  areas,  diaphragmatic  breathing,  tachycardia,  involve- 
ment of  the  irides,  pyrexia,  and  sweating.  All  reflexes  may  be  lost,  as  ex- 
plained elsewhere,  below  the  seat  of  injury  if  this  is  totally  transverse.  This 
clinical  picture  varies  according  to  the  cases.'  In  cases  of  fracture  of  the 
first  and  second  cervical  vertebrae  death  is  usually  instantaneous.  In  cases 
of  fracture  of  the  third,  fourth,  and  fifth  cervical  vertebrae  the  phrenic  nerve 
may  be  involved,  and  hence  breathing  may  soon  become  fatally  embarrassed. 
In  cases  of  fracture  of  the  lower  dorsal  and  lumbar  region,  which  are  rare, 
atrophic  paralysis  of  the  legs,  instead  of  spastic  paraplegia,  is  found  as  a  rule. 

In  the  young  colored  man  above  referred  to  the  injury  was  to  the  mid  and 
lower  cervical  cord.     He  had  j)araplegia  with  paralysis  of  the  bladder,  but 

1  See  a  paper  by  the  author  on  "Traumatic  Affections  of  the  Cervical  Region  of  the  Spinal  Cord, 
Simulating  Syringomyelia."    Journ.  of  Nerv.  and  Ment.  Dis.,  June,  1894. 


DISEASES  OF  THE  SPINAL  COED.  547 

with  increased  knee-jerks.  He  had  also  paralysis  with  rapidly  advancing 
muscnlar  atrophy  of  the  arms  and  hands,  with  fibrillation.  There  was  but 
little  ansesthesia,  but  there  were  tachycardia,  diaphragmatic  breathing,  sweat- 
ing, and  some  pyrexia.  There  had  been  at  times  hiccough.  The  patient 
had  great  pain  on  passive  movement  of  the  hands.  The  case  ended  in  death, 
but  an  autopsy  was  not  obtained. 

The  following  case  of  fracture  of  the  cervical  spine  was  seen  recently  by 
me  in  the  Philadelphia  Hospital.  The  report  and  drawings  are  by  Dr.  John 
A.  Lichty,  resident  physician  : 

W.  M.,  white,  male,  aged  forty-seven  years,  was  thrown  from  a  cart  and 
fell  striking  his  right  scapula  and  the  right  side  of  his  neck.  He  was  un- 
conscious for  one-half  hour.  When  he  came  to  himself  he  was  lifted  to  his 
feet,  but  was  unable  to  stand.  In  spite  of  this,  when  he  was  taken  to  a  neigh- 
boring hospital  he  was  refused  admission  because  he  did  not  seem  to  the 
examining  surgeon  to  be  severely  injured,  and  he  was  rejected  as  a  malingerer. 
The  same  day  he  was  admitted  to  the  Philadelphia  Hospital.  He  was  a  large 
man,  weighing  about  200  pounds.  He  said  that  he  felt  well,  except  for  the 
pain  in  his  neck.  His  symptoms  on  admission  were  as  follows  :  He  had  pain 
in  the  right  side  of  his  neck  and  in  his  right  shoulder.  He  had  also  a  pecu- 
liar tingling  sensation  in  his  right  arm,  as  though  it  were  "  asleep."  He  said 
that  his  body  from  his  shoulders  down  seemed  dead  or  absent,  and  that  he 
could  not  raise  his  feet.  Examination  revealed  a  swelling  or  prominence  in 
the  region  of  the  right  trapezius  muscle,  without  injury  to  the  skin  and  with- 
out subcutaneous  ecchymosis.  At  the  fifth  cervical  spine  there  was  tender- 
ness on  ]Dressure,  and  upon  rotating  the  head  there  was  diffused  pain  in  the 
neck.  No  deformity  could  be  found  in  the  cervical  spine,  nor  could  crepitus 
be  elicited.  The  pupils  were  equal  and  responded  to  light  and  distance.  The 
throat  was  filled  with  mucus,  causing  a  gurgling  sound  on  breathing.  The 
forearms  were  partially  flexed,  and  the  hands  Avere  flexed  on  the  forearms. 
Motion  in  all  the  muscles  of  the  upper  extremities  was  free,  except  in  the 
interossei ;  the  patient  was  unable  fully  to  open  or  close  his  hands,  or  to 
abduct  and  adduct  his  fingers.  Sensation  in  the  arms  and  hands  was  not 
impaired.  Sensation  was  entirely  absent  from  about  the  region  of  the  third 
rib  downward.  Breathing  was  entirely  by  the  diaphragm.  There  was 
marked  increase  of  abdominal  flatus,  the  abdomen  being  tympanitic.  The 
bladder  was  paralyzed  and  distended  with  urine,  and  priapism  was  caused  by 
the  catheterization.  The  bowels  were  at  first  confined  ;  later,  evacuations  oc- 
curred involuntarily.  At  the  sacral  region  there  was  developed  in  a  few  hours 
a  commencing  bed-sore.  There  was  a  slight  fibrillary  tremor  of  the  muscles  of 
the  legs  below  the  knees.  A  similar  tremor  was  noted  in  the  arms,  especially 
in  the  biceps,  three  days  later.  The  patient  could  distinguish  which  sole  was 
tickled  or  stroked,  but  could  not  distinguish  the  point  of  a  pin.  The  patellar 
reflexes  were  absent,  and  there  was  no  ankle-clonus.  In  the  biceps  the  reflex 
Avas  marked.  There  were  both  mucous  and  sonorous  rales  in  the  chest.  The 
heart  was  slow  and  gradually  became  slower.  The  clinical  history  was  briefly 
as  follows  :  During  the  first  two  days  the  patient  was  very  di'owsy  and  slept 
most  of  the  time.  On  the  third  day  he  became  uneasy.  At  the  end  of 
forty-eight  hours  incontinence  of  urine  set  in,  and  twelve  hours  later  incon- 
tinence of  feces.  Eighty-four  hours  after  the  injury  anaesthesia  was  found  on 
the  ulnar  sides  of  the  forearms  below  the  elbow,  and  in  another  day  extended 
almost  to  the  axilla.  The  strength  of  the  biceps  and  brachialis  muscles  was 
not  impaired.  At  this  time  the  heels  and  tips  of  the  toes  became  discolored 
as  in  trophic  lesions.  Ansesthesia  gradually  made  its  appearance  first  on  the 
ulnar  aspect  of  each  forearm,  and  thence  extended  upward  almost  to  the  axilla 
(see  Fig.  168).     On  the  morning  of  the  sixth  day  the  patient  was  cheerful 


548 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


and  hopeful ;  at  4  p.  m.  of  the  same  clay  he  complained  of  a  peculiar  feel- 
ing in  the  abdomen.     His  respirations  were  normal,  but  his  lips  were  blue. 


Fig.  168. 


Anaesthesia  in  a  case  of  fracture  of  the  sixth  cervical  vertebra.    (Philadelphia  Hospital.) 

At  4.30  o'clock  he  began  suddenly  to  gasp  for  breath ;  the  heart  was  slow 
but  strong.  Artificial  respiration  was  begun,  but  in  fifteen  minutes  he  died. 
The  autopsy  showed  a  fracture  of  the  sternum,  between  the  first  and  second 

Fig.  169. 


."".X  Lines  of 
^^  Fracture. 


Fractures  of  the  sixth  cervical  vertebra. 


ribs.  The  sixth  cervical  vertebra  was  comminuted.  There  were  two  frac- 
tures of  the  left  lamina,  a  fracture  of  the  spinous  process  and  of  the  right 
transverse  process.     (Fig.  169.)     The  body  of  the  vertebra  was  dislocated 


DISEASES  OF  THE  SPINAL  CORD. 


549 


forward  about  one-lialf  inch,  and  between  the  lannnse  of  the  sixth  cervical 
and  the  body  of  the  seventh  cervical  vertebra  the  cord  was  compressed.  At 
the  point  of  compression  there  was  a  distinct  blue  line  transversely  across  the 
anterior  surface  of  the  cord.  Above  and  below  this  line  the  cord  was 
softened.  When  removed  it  seemed  to  be  held  together  only  by  the  mem- 
branes. There  was  a  slight  extra-dural  hemorrhage  posteriorly.  The  liga- 
mentum  subflavum  on  the  right  side  between  the  sixth  and  seventh  cervical 
vertebrae  was  ruj^tured. 

An  analysis  of  special  symptoms  in  this  case  leads  to  some  interesting  re- 
sults. It  is  to  be  noted  that  there  was  not  tachycardia,  but  slowing  of  the 
heart.  This  was  the  opposite  of  what  is  seen  in  some  cases  of  cervical 
injury,  and  probably  indicated  that  the  accelerator  nerves  of  the  heart  were 
jDaralyzed.  This  may  be  a  theoretical  explanation  ;  the  fact  remains  that  in 
my  observation  it  is  rather  an  uncommon  symptom. 

Fig.  170. 


/RHOMBOID 

iSUB-CLAVIAM 


SUPRA-SCAPULAR 


C.   WITH    FHR 


ERS  TO   LOM 
US   COLLI   8^ 
SCALEMl     \ 


SUB-SCAPULAR 

B-SCAPULAR 
CIRCUMFLEX 


1ST   DORSAL 


Scheme  showing  the  relation  of  the  internal  cutaneous  nerve  to  the  eighth  cervical  and 
first  dorsal  segments  of  the  spinal  cord.    (Gray.) 


The  temperature  in  this  case,  instead  of  pursuing  a  febrile  course,  fell  on 
the  first  day  from  a  febrile  point  (102°  F.,  almost)  to  a  subnormal  point, 
and  pursued  a  markedly  subnormal  course  to  the  end. 


550  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  distribution  of  anaesthesia  in  this  case  had  significance  as  a  localizing 
lesion.  It  may  be  noted  that  the  inner  aspects  of  the  arms  became  involved 
gradually,  whereas  all  the  body,  below  a  line  drawn  across  the  upper  thorax, 
was  aneesthetic.  This  is  explained  by  reference  to  the  figures.  The  seat  of 
fracture  was  in  the  sixth  cervical  vertebra,  which  is  opposite  the  seventh 
and  eighth  segments  of  the  cord.  The  internal  cutaneous  nerve,  which 
is  distributed  largely  to  the  anaesthetic  area  on  the  inner  aspect  of  the 
arm,  arises  from  the  lower  limb  of  the  cervical  plexus,  which  in  turn  arises 
from  the  eighth  cervical  and  first  dorsal  segments.  (Fig.  170.)  These  two 
segments  were  involved  in  the  crush  and  subsequent  softening.  Hence  it  is 
apparent  why  all  the  skin  of  the  arm,  except  on  the  inner  aspect,  escaped. 
Again,  the  ulnar  nerve  arises  in  close  proximity  to  the  internal  cutaneous, 
and  it,  too,  was  slightly  involved,  as  shown  by  the  paralysis  of  the  interossei. 
The  complete  abolition  of  the  knee-jerks,  which  was  noted  in  this  patient,  is 
common,  as  already  explained  with  reference  to  hemorrhage  in  the  cord,  in 
all  cases  in  which  the  lesion  is  totally  transverse.  It  is,  therefore,  an  ominous 
sign. 

Finally  the  mode  of  death  in  this  case  was  characteristic  of  cases  of  grave 
injury  to  the  cervical  spine.  It  came  suddenly  by  failure  of  resj^iration. 
Involvement  of  the  centre  for  the  phrenic  nerve  by  the  process  of  softening 
probably  accounts  for  this.  In  injuries  so  high  as  the  fifth  cervical  vertebra 
the  phrenic  may  escape  at  first,  because  its  first  and  second  branches  of 
origin  come  from  the  fifth  and  sixth  cervical  segments,  which  are  slightly 
above  this  level,  and  in  such  a  case  the  breathing  will  be  purely  dia- 
phragmatic, the  thoracic  nerves  arising  below  the  lesion,  and  hence  being- 
paralyzed.  But  as  the  process  of  necrosis  spreads,  as  it  usually  tends  to  do, 
the  phrenic  centre  is  invaded  and  death  comes  quickly,  even  suddenly.  I 
have  seen  this  mode  of  death  in  a  number  of  these  cases. 

Treatment.  The  treatment  for  these  cases  is  primarily  surgical,  and  yet 
surgery  cannot  always  bring  these  patients  relief.  It  is  not  my  province  to 
discuss  here,  except  briefly,  the  indications  for  laminectomy.  The  chance  in 
all  cases  of  fracture  and  dislocation  is  that  the  worse  injury  has  been  done 
to  the  cord  at  the  time  of  the  accident.  Surgery  obviously  cannot  repair  a 
cord  which  is  crushed,  or  which  is  disintegrated  by  a  medullary  hemorrhage, 
or  which  is  bound  down  by  a  pachymeningitis.  In  saying  this,  I  do  not 
intend  to  discourage  any  rational  operation  ;  but  I  think  the  tendency  has 
been  too  great  to  regard  simply  the  injury  to  the  spine  and  to  forget,  until  too 
late,  the  worse  injury  to  its  more  vital  contents,  the  spinal  cord.  In  cases 
with  total  anaesthesia,  abolished  knee-jerks,  rapidly  forming  bed-sores,  and 
diaphragmatic  breathing,  the  operation  of  laminectomy  is  contraindicated, 
because  these  are  the  signs  of  a  totally  transverse  lesion,  such  as  a  crush,  a 
hemorrhage,  or  an  area  of  softening,  or  a  combination  of  all  three  of  these 
lesions. 

SPINAL  CARIES. 

After  what  has  been  written  on  the  subjects  of  pachymeningitis  and 
leptomeningitis,  but  little  remains  to  be  said  from  the  standj^oint  of  neuro- 
l^athology  on  the  subject  of  spinal  caries.  This  disease  affects  the  membranes 
and  the  cord  secondarily,  so  that  there  result  by  infection  a  meningitis  and 
myelitis,  which  have  been  described  sufficiently  under  their  appropriate 
headings.  It  ought  always  to  be  remembered  that  bone-i^ressure  is  of  secon- 
dary importaiice  in  the  vast  majority  of  cases  in  causing  the  cord-symptoms. 

Spinal  caries  is  usually  a  disease  of  early  life,  but  cases  occur  sometimes 


DISEASES  OF  THE  SPINAL  CORD.  551 

even  in  middle  life,  I  have  seen  it  occur  in  a  man  about  forty  years  of  age. 
According  to  Gibney/  87  per  cent,  of  cases  begin  before  the  fourteenth  year. 
Sex  is  an  unimportant  factor :  the  disease  occurs  about  equally  in  boys  and 
girls.  Statistics  differ  as  to  the  seat  of  the  disease.  Taylor,  quoted  by  Brad- 
ford and  Lovett,  found  the  favorite  seats  of  the  disease  to  be  in  the  folloAving 
order :  Sixth  and  seventh  cervical,  eighth  dorsal,  second  and  third  lumbar 
vertebrae.  The  least  liable  are  from  the  first  to  the  fourth  dorsal,  the  eleventh 
and  twelve  dorsal,  and  the  two  extremities  of  the  spinal  column.  Other  ob- 
serv^ers  have  reached  rather  different  conclusions.  In  my  own  observation 
among  crippled  children  the  dorsal  and  the  dorso-lumbar  vertebrse  have  been 
seen  to  be  affected  much  more  commonly  than  the  cervical. 

The  surgical  conditions  accompanying  spinal  caries,  such  as  the  deformity 
and  the  abscesses,  and  the  various  internal  pathological  states,  such  as  secon- 
dary tubercular  infection  of  the  lungs,  spleen,  kidneys,  and  mesenteric  glands, 
are  not  to  be  described  here. 

Symptoms.  The  nerve-symptoms  of  spinal  caries  are  those  of  a  gradual 
involvement  of  the  membranes  and  the  cord.  An  early  symptom  sometimes 
is  pain  along  one  nerve-trunk,  or  in  a  limited  area,  simulating  neuralgia. 
This  is  caused  by  irritation  of  the  nerve-root.  The  symptoms  of  inflamma- 
tion and  compression  (by  inflammatory  products)  of  the  cord  are  similar  to 
those  that  occur  from  other  slowly  advancing  lesions  of  that  organ.  They 
consist  of  paralysis  of  motion  below  the  lesion  in  most  cases.  If  the  lesion 
is  cervical,  the  arms  are  the  seat  of  muscular  atrophy  and  paralysis  due  to 
involvement  of  the  cervical  enlargement,  and  there  is  spastic  paraplegia.  If 
the  lesion  is  dorsal,  a  spastic  paraplegia,  w^ithout  muscular  atrophy,  results. 
In  severe  cases  the  bladder  and  rectum  are  paralyzed.  If  the  lesion  is  lum- 
bar, a  muscular  atrophy  or  the  symptoms  of  a  multiple  neuritis  in  the  legs, 
with  or  without  knee-jerks  (according  as  the  lumbar  enlargement  is  or  is  not 
invaded),  results.  Sensory  symptoms  are  usually  much  less  conspicuous  in 
spinal  caries  than  motor.  The  reason  for  this  is  in  the  fact  that  the  mem- 
branes are  usually  invaded  from  the  body  of  the  vertebra,  hence  the  anterior 
and  lateral  aspects  of  the  cord  are  usually  most  affected  by  the  pachymenin- 
gitis and  the  compression  from  resulting  inflammatory  deposits.  When  these 
deposits,  however,  become  great  enough  to  cause  total  transverse  compression, 
or  in  the  rare  instances  in  which  such  compression  is  caused  by  the  diseased 
bone,  the  sensory  j)aths  are  involved,  and  anaesthesia  results. 

In  cervical  cases  the  sympathetic  is  involved  sometimes,  causing  alterations 
in  the  pupils  either  by  irritation  or  paralysis,  and  causing  also  sweating.  Res- 
piration also  may  be  affected  in  grave  cervical  cases.  All  the  symptoms 
sometimes  are  suddenly  aggravated  by  changes  or  progress  in  the  lesion. 
The  disease  in  many  cases  is  extremely  chronic,  and  some  patients  Avith  spinal 
caries  go  for  many  years  with  marked  angular  deformity  without  involvement 
of  the  spinal  cord.  In  fact,  there  is  no  necessary  connection  between  the 
degree  of  deformity  and  the  nerve-symptoms  ;  these  latter,  in  the  vast  majority 
of  cases,  depend,  as  already  said,  not  upon  compression  by  bone,  but  upon  the 
invasion  of  the  membranes  by  the  infectious  disease. 

The  following  case  occurred  in  the  services  of  Dr.  De  Forest  Willard  and 
the  writer  at  the  Home  for  Crippled  Children.  It  illustrates  several  patho- 
logical and  surgical  points  of  great  interest. 

H.  R.,  aged  four  years,  had  caries  of  the  fourth  dorsal  vertebra,  the  hump 
involving  the  fourth  to  the  eighth  dorsal  vertebra.  He  developed  gradually 
the  symptoms  of  spinal  pachymeningitis.  He  had  spastic  paraplegia,  in 
which  the  symptoms  were  much  more  marked  in  the  left  leg.     This  leg  Avas 

1  Quoted  from  Bradford  and  Lovett :  A  Treatise  on  Orthopedic  Surgery,  New  York,  1890. 


552 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Fig.  171. 


the  more  paralyzed,  and  the  knee-jerk  and  ankle-clonus  were  much  more 
marked  in  it.  He  lost  control  of  his  bladder  and  rectum,  so  that  he  lay 
constantly  bathed  in  his  urine  and  soiled  with  occasional  discharges  of 
feces.  This  condition  aggrayated  a  bed-sore,  which  formed  in  spite  of  eyery 
precaution.  The  elongated  prepuce  became  inflamed,  and  in  one  place  ulcer- 
ated quite  through,  so  that  it  was  necessary  to 
circumcise  the  child.  Sensation  was  inyolyed, 
although  not  completely.  It  was  discoyered  that 
the  patient  had  analgesia,  by  the  fact  that  he 
made  no  complaint  and  eyidently  felt  no  pain 
when  the  stitches  were  remoyed  from  the  fore- 
skin. There  was  ansesthesia  of  the  legs,  but  accu- 
rate tests  were  difficult  because  of  the  patient's 
age.  A  psoas  abscess  was  feared ;  an  abscess 
formed  oyer  the  left  hip,  and  tubercular  thick- 
ening of  this  joint  was  obsei'yed.  In  order  to  try 
to  giye  some  relief  to  this  suffering  a  laminectomy 
was  decided  upon,  and  the  operation  was  per- 
formed by  Dr.  AVillard.  When  the  laminje  and 
spine  of  the  fifth  dorsal  yertebra  had  been  re- 
moyed a  large  tubercular  nodule,  pressing  on  the 
posterior  and  left-  side  of  the  cord,  was  found. 
(See  Fig.  171.)  This  was  connected  in  front 
with  a  large  tubercular  cheesy  mass,  which  was 
the  debris  of  one  or  more  bodi&s  of  the  yertebree. 
Such  destruction  had  occurred  that  a  finger  could 
be  passed  down  into  the  cayity  past  the  cord. 
The  mass  pressing  on  the  cord  was  dissected  off" 
from  the  dura,  and  the  carious  bone  scraped  out 
from  its  position  in  front  of,  or  yentrad  to,  the 
cord.  During  this  procedure  one  or  two  of  the 
posterior  nen'e-roots,  apparently  diseased,  were  severed.  The  inflammation 
had  been  confined  almost  to  the  exterior  of  the  dura  (a  pachymeningitis 
exierna).  When  the  parts  had  been  cleaned  of  exudate  the  dura  was  found 
not  perforated  and,  to  a  certain  extent,  healthy.  After  the  cayity  had  been 
cleared  out  a  drainage-tube  was  passed  directly  around  the  cord  in  order  to 
drain  the  cayity  in  front  of,  or  yentrad  to,  the  cord.  The  appearance  now 
was  remarkable,  as  the  spinal  cord,  encased  in  its  dura  mater,  extended  across 
this  cayity  like  a  great  cable.  The  ends  of  the  drainage-tube  were  brought 
out  through  openings  in  the  muscles  and  integuments  of  the  back,  and  the 
wound  was  closed.  The  child  did  not  endure  the  operation  well,  and  died 
subsequently  from  shock  and  exhaustion. 

This  case  illustrates  the  extensiye  destruction  of  bone  and  the  graye 
inyolyement  of  cord  and  membranes  that  occur  in  some  of  these  cases.  The 
tubercular  nodule  was  similar  to  the  solitary  tubercle  sometimes  found  in  the 
spinal  cord,  independent  of  caries,  which  acts,  as  this  did,  practically  as  a 
cord  tumor.  The  inflammation  of  the  dura  was  not  so  extensiye  as  was 
anticipated,  and  many  of  the  symptoms,  especially  the  unilateral  features, 
were,  no  doubt,  due  to  this  nodule.  The  microscope,  howeyer,  has  revealed 
extensiye  myelitis  with  ascending  and  descending  degenerations.  The  clear- 
ing out  of  the  cayity  of  the  diseased  bodies  of  the  yertebree  and  the  passage 
of  a  drainage-tube  all  the  way  aiound  the  cord  were  procedures,  I  belieye, 
original  with  .Dr.  Willard.  They  furnish  precedents  which,  I  believe,  must 
be  followed  in  ftiture  cases,  if  the  real  focus  of  the  disease  is  to  be  attacked 
and  the  cord  relieved  entirely  from  the  noxious  processes  that  environ  it. 


Tubercular  nodule  in  a  case  of 
spinal  caries.  The  shaded  space 
indicates  the  area  exposed  by  the 
operation.  (Home  for  Cripipled 
Children.) 


DISEASES  OF  THE  SPINAL  COED.  553 

Diagnosis.  Spinal  caries  may  be  mistaken  for  rheumatism,  intercostal 
neuralgia,  gastralgia,  tumor  of  the  spinal  cord,  thoracic  and  abdominal  aneu- 
rism, the  various  forms  of  myelitis  and  meningomyelitis,  and  hysteria. 

The  disease  could  be  miscalled  rheumatism  by  only  a  careless  observer,  who 
was  in  the  habit  of  attributing  all  obscure  pains  about  the  back  and  joints 
to  "  rheumatism."  Intercostal  neuralgia  is  sometimes  closely  simulated  in 
the  first  stage  of  spinal  caries ;  this  is  due  to  the  fact  that  irritation  of  a  sen- 
sory nerve-root  causes  a  localized  pain.  Gastralgic  and  obscure  abdominal 
pains  also  may  be  caused  in  the  same  way  by  beginning  caries  of  the  body  of 
a  vertebra.  In  all  such  cases  a  careful  inspection  of  the  sjDine,  the  detection 
of  slight  beginning  deformity,  of  localized  tenderness,  of  stiffness  and  resist- 
ance on  movement  of  the  back,  and,  perchance,  if  the  case  had  advanced  to 
involvement  of  the  membranes,  of  paraplegia,  or  paraparesis,  would  suffice 
to  distinguish  the  true  character  of  the  affection. 

Tumor  of  the  spinal  cord,  especially  a  tubercular  nodule  similar  to  the  one 
reported  above,  might  simulate  the  nerve-symptoms  of  spinal  caries.  The 
deformity  of  the  spine  would  be  the  best  distinguishing  mark  of  caries. 
Carcinomatous  and  sarcomatous  growths  of  the  cord  or  spine  are  very  rare, 
and  not  likely  to  appear  in  early  life,  when  spinal  caries  is  most  common. 
There  might  be  much  difficulty  in  distinguishing  a  case  of  malignant  growth, 
in  which  the  vertebrse  were  involved,  softened,  and  deformed,  from  a  case  of 
spinal  caries  in  an  adult.  In  malignant  growth  more  severe  pain  would 
probably  be  present ;  the  progress  of  the  disease  would  be  more  rapid ;  secon- 
dary deposits  might  occur,  and  the  familiar  cachexia  would  be  seen. 

Erosion  and  pressure  by  an  aneurism  are  to  be  distinguished  by  physical 
exploration  of  the  chest  or  abdomen  and  the  detection  of  the  characteristic 
signs  of  aneurism. 

From  all  other  forms  of  myelitis  and  meningomyelitis  the  deformity  alone 
could  distinguish  spinal  caries. 

The  diagnosis  of  spinal  caries  in  its  early  stages  from  hysteria  is  not  always 
easy,  especially  in  children.  The  disease  itself  may  induce  hysterical  symptoms 
in  neurotic  children,  and  these  may  mask  the  true  nature  of  the  affection. 
Again,  a  slight  trauma  may  induce  an  hyj)er8esthetic  spine  in  an  hysterical 
child  and  thus  simulate  spinal  caries.  It  is  important  to  distinguish  correctly 
in  either  case.  This  can  only  be  done  by  careflil  inspection  of  the  back  for 
the  detection  of  the  objective  signs  of  caries,  and  by  an  examination  for 
hysterical  stigmata.  When  in  doubt  it  is  better  to  treat  for  incipient 
caries,  and  thus  gain  time,  than  to  announce  hastily  what  may  be  a  prema- 
ture judgment.  In  one  such  case  in  a  child,  in  whom  localized  spinal  tender- 
ness followed  a  fall,  I  once  applied  a  plaster-jacket  in  order  to  await  devel- 
opments.    The  patient  made  a  prompt  recovery. 

Treatment.  The  treatment  for  spinal  caries  is,  of  course,  largely  surgical. 
To  the  neuro-pathologist,  who  is  familiar  with  the  morbid  anatomy  of  the  dis- 
ease, and  knows  how  imminent  in  every  case  is  danger  from  infection  to  the 
cord  and  its  membranes,  as  well  as  to  other  organs  of  the  body,  the  usual 
treatment  by  braces  and  expectancy  seems  often  inadequate  and  unsatisfac- 
tory. The  difficulties  and  dangers,  however,  of  the  operation  of  laminectomy 
are  not  to  be  ignored,  and  they  have  been  indicated  already  in  the  rej)Oi"t 
of  the  above  case.  The  greatest  of  these  difficulties  is  in  the  fact  that  the 
carious  process  is  in  the  vertebral  body  and  consequently  ventrad  to  the  cord. 
Hence,  it  is  almost  inaccessible  to  the  surgeon.  Without  reaching  and  eradi- 
cating this  focus  of  infection  it  is  not  apparent  how  an  operation,  in  many  cases 
at  least,  can  do  permanent  good.  The  procedure  of  Dr.  Willard  in  the  above 
case  ma}^  supply  a  precedent  for  draining  this  cavity  in  more  favorable  cases. 
Another  difficulty  lies  in  the  fact  that  in  some  cases  the  inflammatory  exudate 


554  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

reaches  far  up  and  clown  the  anterior  asjDect  of  the  cord,  often  intimately 
adherent  to  the  dura.  To  remove  this,  in  some  cases  that  I  have  examined 
post  mortem,  would  seem  to  have  been  practically  impossible.  Still,  with  all 
the  difficulties  fairly  stated,  there  is  much  opportunity  for  this  most  useful  and 
rational  operation.  It  should  not  be  postponed  too  late.  It  is  far  better 
to  do  it  before  abscesses  have  formed  in  the  jDsoas  and  iliacus  sheaths,  and 
dense  inflammatory  exudates  have  bound  down  the  cord.  Consi^icuous  symp- 
toms of  commencing  involvement  of  the  cord  should  be  sufiicient  to  indicate 
and  to  justify  this  conservative  operation. 


SOFTENING  OF  THE  SPINAL  CORD. 

Acute  softening  of  the  spinal  cord  is  discussed  in  most  text-books  as  iden- 
tical with,  or  as  one  of  the  terminal  stages  of,  inflammation.  Varieties  of  it 
even  are  described  as  the  red,  yellow,  and  white.  There  can  be  no  doubt 
that  many  of  the  cases  thus  described  are  true  examples  of  myelitis,  and 
that  the  various  colors  or  tints  upon  which  such  stress  has  been  laid  are  sim- 
ply the  effects  of  various  degrees  and  stages  of  extravasation  of  blood  into 
the  tissue.  The  question  whether  an  acute,  non-inflammatory  softening, 
analogous  to  what  occurs  in  the  brain,  ever  takes  place  in  the  cord  is  still, 
perhaps,  an  open  one.  Most  authorities,  on  what  seems  to  me  to  be  insuffi- 
cient evidence,  claim  that  there  is  no  such  softening.  Striimpell  says  that  it 
is  still  undecided  whether  there  is  such  a  softening,  as  a  result  of  an  obstruc- 
tion of  the  vessels  by  a  thrombus  or  an  embolus.  He  states,  however,  rather 
contradicting  himself,  that  he  has  seen  one — but  only  one — spinal  cord  from 
such  a  case,  in  which  the  substance  was  changed  into  a  soft  pulp,  which  con- 
tained nothing  but  the  remains  of  the  nerve-tissue  and  fatty  granular  cells. 
I  can  add  to  Striimpell's  th^  record  of  a  case  of  my  own,  in  which,  as  in  his,  a 
small  but  totally  transverse  softening  was  found  in  the  dorsal  region,  without 
thickening  of  membranes,  extravasation  of  blood,  or  any  other  sign  of  in- 
flammation.   Unfortunately,  no  microscopic  study  was  made  of  this  tissue. 

It  is  not  possible,  of  course,  to  decide  such  a  purely  pathological  question 
on  a  priori  grounds,  but  these  seem  to  be  the  grounds  so  far  upon  which  most 
writers  base  their  arguments.  Upon  such  grounds  it  seems  that  an  equally 
valid  argument  can  be  maintained  in  favor  of  acute  softening.  In  the  first 
place,  it  is  known  that  the  spinal  bloodvessels  can  suflfer  from  infective  and 
degenerative  processes,  which  might  very  readily  impair  their  walls  and  con- 
duce to  thickening  of  the  coats,  and  hence  to  obstruction.  Syphilis  can  so 
act.  It  is  not  certain  that  atheroma  of  the  vessels  may  not  occur.  The  ar- 
gument of  Gowers,  based  upon  the  anatomical  arrangement  of  these  vessels, 
does  not  appear  adequate  to  disprove  this.  That  degeneration  of  vessels  in 
the  cord  does  occur  seems  to  be  proved  now  by  the  cases  of  undoubted  hemor- 
rhage into  its  substance  which  are  occasionally  reported.^  Finally,  we  must 
recast  to  some  extent  our  ideas  of  inflammation  in  the  spinal  cord.  It  has 
been  too  much  the  custom  to  call  most,  if  not  all,  disorganizing  processes  in 
the  cord  inflammatory.  Our  conception  of  the  idea  of  inflammation,  and  our 
use  of  the  term,  must  be  more  strictly  guarded  now  in  the  light  of  bacteriologi- 
cal science.  If  the  term  is  to  be  confined  to  the  processes,  such  as  congestion, 
migration  of  leucocytes,  pus-formation,  etc.,  that  arise  in  tissue  in  antagonism 
to  some  morbific  germ  or  germ-product,  then  it  is  certain  that  all  examples  of 
softening  of  the  spinal  cord  are  not  inflammatory.  The  softening  that  occurs 
after  trauma,  and  even  after  shock,  is  not  thus  always  inflammatory.    It  is  more 

1  See  section  on  "  Hemorrhage  into  the  Spinal  Cord,"  etc.,  in  the  present  treatise. 


DISEASES  OF  THE  SPINAL  CORD.  555 

truly  necrotic,  aud  probably  depends  primarily  upon  lesions  of  the  vessels  or 
capillaries,  causing  minute  hemorrhages  and  thrombi.  Even  the  thickening 
of  membranes  found  in  these  cases,  as  in  hypertrophic  pachymeningitis  cer- 
vicalis,  has  not  the  essential  characteristics  of  an  inflammatory  process.  It 
is  exceedingly  chronic  in  some  cases ;  there  is  no  pus-formation,  and  the 
results  to  the  cord  are  gradual  damage  by  degeneration  rather  than  by  in- 
flammation. In  such  cases  the  thickening  of  membranes  and  proliferation 
of  neuroglia  are  the  results  probably  of  the  attempts  of  the  tissue  at  repair. 
This  is  largely  as  yet  a  pathological  question.  Clinically  these  cases  will 
no  doubt  continue  for  a  long  while  to  be  grouped  with  the  cases  of  myelitis  ; 
and  as,  therefore,  to  describe  them  clinically  would  involve  a  mere  repetition 
of  the  section  on  myelitis,  this  will  not  be  done. 

HYPEREMIA  AND  ANEMIA  OP  THE  SPINAL  CORD. 

It  was  the  custom  formerly  of  some  writers  to  erect  an  elaborate  pathology 
and  symptomatology  upon  the  entirely  hypothetical  basis  of  hypereemia  and 
amemia  of  the  brain  and  spinal  cord.  It  is  almost  needless  to  say  that  this 
custom,  which  never  had  a  scientific  warrant,  is  now  falling  fast  into  disre- 
pute. I  do  not  believe  that  we  have  any  clinical  types  whatever  that  can  be 
attributed  exclusively,  or  even  in  a  minor  degree,  to  such  slight  variations 
in  the  circulation  as  would  be  indicated  by  these  terms.  It  requires  but  a 
glance  at  the  elaborate  descriptions  formerly  in  vogue  to  see  that  they  in- 
clude chiefly  the  symptoms  of  hysteria,  neurasthenia,  dyspepsia,  and  minor 
degrees  of  ill-health  which  were  often  poorly  described  and  are  now  quite 
unrecognizable.  There  is  no  proof  that  sexual  excess  induces  an  hypersemia 
of  the  spinal  cord  which  can  persist  long  enough  and  with  such  characteristic 
symptoms  as  to  constitute  it  a  distinct  clinical  entity.  There  is  no  reason  to 
believe  that  intense  brain-work  and  worry  can  cause  an  anaemia  of  the  cord. 
There  is  absolutely  no  justification  for  the  claim  that  special  regions  of  the 
cord,  as  the  anterior  horns  or  the  lateral  columns,  can  be  congested  or  de- 
pleted apart  from  the  rest  of  the  organ.  Congestion  of  the  cord  may  occur 
as  a  preliminary  stage  or  as  a  result  of  some  well-recognized  process,  as  in- 
flammation or  strychnine-j^oisoning ;  or  anaemia  may  result  from  excessive 
hemorrhage,  as  in  typhoid  fever  or  the  puerperium,  but  in  such  circum- 
stances the  hypera3mia  or  anaemia  is  but  a  concomitant  and  not  a  separate 
disease.  In  grave  forms  of  general  anaemia,  as  pernicious  anaemia,  the  spinal 
cord  and  the  tissue  of  the  nervous  system  in  general  suffer  doubtless  with  the 
rest  of  the  body.  Some  of  the  symptoms,  as  muscular  weakness,  hyperaes- 
thesia,  etc.,  may  be  due  in  part  to  the  impaired  functions  of  the  cord  and 
nerves.  It  is  impossible,  however,  to  regard  such  symptoms  apart  from  the 
general  symptoms  of  the  disease,  or  to  say  how  exclusively  they  are  caused 
by  involvement  of  the  cord.  It  must  be  remembered,  too,  that  organic 
changes  in  the  cord  have  been  found  in  pernicious  anaemia.  Posterior 
sclerosis  has  been  reported  by  a  number  of  observers.  Hence,  symptoms 
referable  to  the  cord  are  not  due  simply  to  anaemia  of  the  cord-tissue,  but  to 
actual  organic  changes.  Such  organic  changes  are  due  presumably  to  some 
irritant  in  the  blood  rather  than  to  a  mere  decrease  in  the  amount  of  any  of 
its  constituents.^ 

On  the  whole,  it  would  he  better  to  abolish  entirely  the  terms  hyperaemia 
and  anaemia  as  designations  for  special  forms  of  diseases  of  the  spinal  cord. 

1  Since  the  above  was  written  I  have  made  a  study  of  the  anatomical  changes  in  the  spinal  cord 
in  a  case  of  pernicious  anaemia  which  occurred  in  my  wards  at  the  Philadelphia  Hospital.  Exten- 
sive changes  were  found  in  the  posterior  columns  and  beginning  changes  in  the  lateral  tracts.  The 
case  will  be  reported  in  the  forthcoming  volume  of  the  Hospital  Reports. 


CHAPTEK  XIX. 

DISEASES  OF  THE  SPINAL  CORD. 

(Continued.) 
By  MORTON  PRINCE,  M.D. 

MYELITIS. 

Myelitis  is  an  inflammation  of  the  spinal  cord.  Besides  occurring  as  an 
acute,  subacute,  and  chronic  process,  several  varieties  of  myelitis  are  distin- 
guished according  to  the  distribution  of  the  inflammatory  process  in  the 
cord.  For  practical  purposes  it  is  only  necessary  to  recognize:  1.  Trans- 
verse (or  diffuse)  myelitis;  2.  Disseminated  myelitis;  3.  Central  myelitis; 
4.  Poliomyelitis.  The  last  is  commonly  known  in  its  acute  form  as  infan- 
tile paralysis,  and  is  described  as  a  distinct  affection. 

Acute  Transverse  Myelitis.  Acute  transverse  myelitis  involves  the 
whole  thickness  of  the  cord,  and  vertically  extends,  as  a  rule,  through  one 
or  two  segments.  It  thus  involves  both  white  and  gray  matter,  and  abolishes 
more  or  less  all  the  functions  of  the  cord  at  the  seat  of  the  lesions,  and  in- 
terrupts volitional  impulses  from  the  brain  to  segments  of  the  cord  below. 

Etiology.  The  most  common  cause  is  injuries  producing  a  laceration  or 
bruising  of  the  cord,  or  hemorrhage  within  its  substance.  Fractures  and 
dislocations  of  the  vertebrae,  gunshot-  and  stab-wounds,  produce  these  results, 
though,  more  logically  perhaps,  myelitis  from  these  causes  being  secondary, 
the  resulting  lesion  should  be  classed  as  lacerations  of  the  cord,  etc. ;  but 
hemorrhage  may  occur  independently  of  trauma,  and  even  when  minute  in 
amount  is  often  a  cause.  Hemorrhage  may  follow  injuries  even  when  no 
recognizable  injury  to  the  vertebrae  occurs.  Myelitis  has  been  known  to  fol- 
low violent  contraction  of  the  muscles  of  the  back,  and  in  these  cases  has 
been  ascribed  to  an  inflammation  spreading  from  the  connective  tissue  to 
the  membranes  and  cord  itself,  but  it  is  possible  that  in  such  cases  there  has 
been  a  temporary  dislocation  of  the  vertebrae,  with  spontaneous  reduction. 
The  cord  would  necessarily  be  bruised  by  the  dislocation.  I  have  known 
it  to  follow  falls  upon  the  back  without  demonstrable  lesion  of  the  bones. 
This  seemed  the  most  probable  explanation,  in  view  of  the  course  of  the 
symptoms.  The  statement  that  concussion  is  a  cause  of  myelitis  is  fre- 
quently made.  Such  statements  are  quoted  from  one  writer  by  another, 
and  seem  thereby  to  obtain  more  validity  than  should  properly  be  ascribed 
to  them.  That  concussion,  pure  and  simjDle,  can  be  a  cause  of  myelitis  may 
be  properly  questioned.  It  is  more  probable  that  when  such  seems  to  be  the 
case  there  has  been  a  direct  blow  upon  the  back  at  the  time  which  during 
the  excitement  of  the  accident  was  not  noticed  by  the  patient,  and  which 
may  have  caused  injury  to  the  vertebrae,  or  hemorrhages  within  the  cord 
itself 

Compression  of  the  cord,  as  from  tumors  or  caries  of  the  vertebrae,  is  a 


DISEASES  OF  THE  SPINAL  CORD.  557 

common  cause.  Many  cases  are  clearly  traceable  to  exposure  to  cold,  which 
is  particularly  regarded  as  an  exciting  cause.  Thus,  a  person  after  working 
in  the  water  and  becoming  thoroughly  chilled,  was  attacked  by  myelitis. 
Several  toxic  agents  may  give  rise  to  the  disease.  Thus,  it  sometimes  fol- 
lows or  occurs  in  the  course  of  various  infectious  diseases,  esi^ecially  measles, 
smallpox,  typhus  and  typhoid  fever.  Syphilis  is  so  frequently  present  that 
it  must  undoubtedly  be  regarded  as  an  exciting  cause,  though  it  more  com- 
monly gives  rise  to  the  subacute  or  chronic  form.  The  exact  nature  of  the 
connection  has  not  been  accurately  determined.  Myelitis  has  been  known  to 
follow  influenza,  and  two  well-marked  cases  followed  gonorrhoeal  infection. 
(Reynaud.)  Myelitis  has  been  found  experimentally  in  animals  poisoned 
by  arsenic,  and  probably  occurs  in  severe  cases  of  arsenical  poisoning  with 
general  neuritis  in  man. 

The  disease  also  is  sometimes  due  to  meningitis,  the  inflammation  spreading 
to  the  cord.  Various  other  causes  of  the  disease  have  been  described,  such 
as  gout,  alcohol,  overexertion,  mental  emotion,  etc.,  but  the  effect  of  such 
agents  in  directly  producing  the  disease  must  be  regarded  with  considerable 
suspicion.  Myelitis  sometimes  follows  the  caisson  disease,  and  is  then  due  to 
the  disturbances  of  the  circulation  induced  by  high  atmospheric  pressure. 
In  many  cases,  no  satisfactory  cause  whatsoever  can  be  obtained. 

Anatomical  Changes.  On  examining  the  cord  the  inflamed  area  may  be 
detected  by  the  cord  being  swollen  at  that  point  and  reddened  from  injec- 
tion of  the  membranes  if  death  has  taken  place  early  in  the  disease.  The 
cord  is  also  softer.  On  section  these  changes  are  still  more  apparent.  The 
distinction  between  white  and  gray  matter  is  lost.  The  softening  may  be 
so  great  that  the  cord  has  a  creamy  consistence.  If  there  have  been  much 
injection  and  extravasation  of  blood,  the  softened  substance  has  a  reddish 
color  (red  softening). 

In  other  instances  where  the  extravasation  has  been  small  in  amount,  the 
color  may  be  yellow  (yellow  softening).  This  may  also  be  the  case  when 
the  disease  has  existed  for  some  time,  owing  to  the  original  red  color  having 
faded  to  yellow. 

If  there  has  been  little  injection  of  the  vessels,  the  color  may  be  white 
(white  softening). 

The  axis-cylinders  of  the  white  fibres  at  first  are  swollen  and  the  myelin 
becomes  broken  up  and  later  disappears.  Nothing  remains  of  the  fibres  but 
the  axis-cylinders,  which  in  turn  become  degenerated,  and  finally  are  destroyed. 

The  cells  of  the  gray  matter  likewise  become  degenerated  ;  they  become 
swollen  and  their  contents  granular.  Within  them  may  be  seen  highly 
refracting  granules  which  have  all  the  appearance  of  fat  globules.  Their 
processes  also  are  shrivelled  or  lost.  Vacuoles  may  be  formed  in  them,  but 
there  is  some  difference  of  opinion  regarding  the  interpretation  of  these. 
The  intermediate  gray  matter  is  infiltrated  with  cells,  round  and  angular,  and 
the  substance  itself  has  a  granular  look. 

The  connective  tissue  of  the  white  substance  becomes  filled  with  amorphous 
material  and  numerous  cells  (nuclei).  Besides,  there  are  many  so-called 
Deiter's  or  spider  cells  to  be  seen  in  the  neuroglia,  which  is  thus  much  in- 
creased. 

In  old  cases  there  may  be  a  development  of  fibrous  tissue  in  the  form  of 
trabeculse. 

The  vessels  are  dilated,  filled  with  blood,  and  have  their  walls  studded 
with  an  increased  quantity  of  nuclei.  This  is  observed  in  both  capillaries 
and  arteries.  The  walls  of  the  arteries  are  thickened  in  consequence,  and 
their  sheaths  are  packed  with  cells  of  different  kinds.  In  some  places  ex- 
travasations of  blood  from  the  capillaries  are  conspicuous. 


558  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

In  severe  cases,  when  the  cord  is  much  softened,  nothing  of  the  normal 
structure  can  be  made  out ;  but  in  the  field  of  the  microscope  is  found  only  a 
mass  of  detritus,  consisting  of  swollen  axis-cylinders,  globules  of  myelin  and 
fat,  round  cells,  "spider  cells,"  amorphous  matter,  red  blood-cells,  and  pecu- 
liar bodies  called  "  corpora  amylacea."  These  are  probably  altered  myelin. 
In  such  cases  it  is  impossible  to  make  sections  of  the  diseased  segment,  which 
may  be  so  softened  as  to  flow  like  thick  cream.  When  the  destruction  is 
not  so  severe  as  this  the  pathological  changes  may  be  distributed  fairly  evenly 
through  a  transverse  section  of  the  cord,  or  they  may  be  more  intense  in  cer- 
tain spots  in  the  gray  or  white  matter,  or  in  the  lateral  columns,  etc.  It 
must  be  remembered,  however,  that  a  portion  escaping  at  a  given  level  may 
be  involved  in  a  section  just  above  or  below,  and  thus  a  complete  transverse 
myelitis  may  be  produced. 

The  proportion  in  which  the  various  elements — neuroglia  cells  and  fibres — 
sufier  varies  in  different  cases. 

In  the  later  stages  of  many  cases  which  survive  absorption  of  the  detritus 
takes  place,  the  bloodvessels  become  thickened,  and  a  great  development  of 
connective  tissue  takes  place,  so  that  the  cord  becomes  hardened  and  gray ; 
in  fact,  a  condition  of  sclerosis  develops.  Finally,  by  a  ftirther  extension  of 
this  process  into  the  adjoining  portions  of  the  cord,  an  acute  myelitis  becomes 
transformed  into  a  chronic  myelitis. 

An  important  fact,  also,  from  a  clinical  point  of  view,  is  that  the  inflam- 
mation may  extend  up  or  down  the  cord,  along  the  diflferent  special  tracts ; 
i.  e.,  up  or  down  the  pyramidal  tracts  or  anterior  horns.  This  extension  of 
the  inflammation  does  not  take  place  in  a  direction  corresponding  to  the 
physiological  conduction,  as  do  the  secondary  degenerations,  but  may  be  in 
either  direction,  up  or  down. 

In  disseminated  myelitis  reddish  foci  are  scattered  through  the  cord.  They 
may  be  widely  distributed.  Histologically  the  same  changes  are  found  as  in 
transverse  myelitis.  The  microscope  will  reveal  numerous  small  foci  which 
cannot  be  detected  by  the  naked  eye.  The  distribution  of  these  foci  may 
be  irregular,  aflfecting  a  piece  of  the  cord  here  and  another  there.  Clini- 
cally, this  is  of  importance.  In  central  myelitis  a  crowding  of  nuclei  will  be 
observed  round  about  the  central  canal,  in  addition  to  the  other  changes  in 
the  gray  matter. 

An  important  secondary  effect  which  takes  j)lace  in  severe  cases  is  the  de- 
generation which  occurs  in  some  cases  along  the  various  white  tracts,  upward 
along  the  posterior  columns  and  direct  cerebellar  tract,  downward  along  the 
pyramidal  tracts. 

The  nerve-roots  may  become  involved  in  the  inflammation  and  show 
changes  similar  to  those  in  the  cord.  The  motor  nerves  become  aflfected 
with  secondary  degenerative  changes  when  the  gray  matter  with  which 
they  are  connected  is  diseased. 

Symptoms.  The  most  characteristic  symptoms  of  acute  transverse  mye- 
litis, that  is  to  say,  those  which  constitute  the  salient  features  in  the  clinical 
picture,  are  rapidly  developing  paralysis  of  motion  and  sensation  in  the  legs, 
or  legs  and  arms,  loss  of  control  over  the  bladder  and  bowels,  and  alteration 
in  the  reflexes  (increased  or  diminished)  of  the  paralyzed  portion  of  the  body, 
to  which  may  be  added  atrojDhy  of  and  changes  in  the  electrical  reaction  of 
those  muscles  which  are  directly  connected  with  the  diseased  segments  of  the 
spinal  cord.  Nutritive  changes  in  the  skin,  such  as  bed-sores  and  bulla,  later 
enhance  the  picture. 

Such  would  b,e  the  general  appearance  presented  by  a  well-developed  case. 
It  will  be  noticed  that  these  symptoms,  with  the  exception  of  the  nutri- 
tive changes  (which  are  not  essential),  are,  for  the  most  part,  only  the  ex- 


DISEASES  OF  THE  SPINAL  COED.  559 

pressiou  of  the  impairment  of  abolition  of  function  of  the  spinal  cord  (nega- 
tive symptoms),  and  that  the  grouping  of  the  symj^toms  indicates  that  this 
abolition  of  function  extends  through  the  whole  thickness  of  the  cord. 

But  besides  the  grouping  of  the  symptoms,  that  which  distinguishes  this 
form  of  myelitis  from  other  varieties  of  spinal  disease,  is  the  manner  of  outset 
and  development  of  the  symptoms. 

Careful  observation  of  the  latter  is  quite  as  important  for  the  recognition 
of  the  disease  as  the  grouping  of  the  symptoms,  especially  as  considerable 
variations  occur  in  the  symptoms  in  individual  cases,  according  as  the  func- 
tions of  the  cord  are  impaired  in  a  greater  or  less  degree. 

With  variations  in  the  localization  of  the  inflammatory  process,  variations 
which  may  be  longitudinal  along  the  cord  or  lateral  through  its  diameter, 
still  further  differences  occur  in  the  clinical  picture. 

Though  the  distinctively  characteristic  symptoms  are  those  due  to  inter- 
ference with  the  flmctions  of  the  cord,  other  and  general  symptoms  are  some- 
times, though  not  as  a  rule,  observed  at  the  onset  of  the  disease.  These  are 
feelings  of  malaise,  headache,  fever  of  a  mild  degree,  pains  in  the  limbs  and 
back,  sometimes  chills,  and  in  children  convulsions.^ 

These  general  symptoms  may  appear  as  prodromata  or  may  accompany 
the  special  spinal  symptoms.  It  is  possible  that  in  some  cases  at  least  they 
are  to  be  ascribed  to  the  exciting  cause  of  the  disease  and  not  to  the  myelitis 
itself 

It  will  be  noticed  that  these  premonitory  symptoms,  when  they  occur,  are 
not  at  all  indicative  of  the  development  of  a  cord  disease,  and  not  until  the 
patient  begins  to  complain  of  some  weakness  of  the  muscles  or  impairment 
of  sensation,  such  as  numbness  and  "  pins  and  needles  "  feeling,  or,  perhaps, 
in  some  cases,  a  difficulty  in  passing  or  retaining  the  urine,  are  we  likely  to 
suspect  the  true  nature  of  the  disease. 

The  order  of  development  of  the  symptoms  differs  in  individual  cases 
according  as  the  disease  first  attacks  the  motor,  sensory,  or  other  portions  of 
the  cord. 

The  rapidity  of  onset  of  the  spinal  symptoms  varies  sufficiently  to  enable 
us  to  distinguish  three  varieties,  viz.,  the  apoplectiform,  the  acute,  and  the 
subacute.     This  distinction  is  arbitrary,  but  has  some  clinical  value. 

In  the  acute  variety  the  symptoms  develop  in  the  course  of  a  few  hours  or 
a  few  days.  The  patient  notices,  perhaps,  while  walking  or  on  getting  up  in 
the  morning,  that  his  legs  feel  heavy  and  numb.  He  finds  difficulty  in  mov- 
ing them  and  they  tend  to  give  way  beneath  him  when  walking.  If  he  has 
been  exerting  himself,  he  ascribes  the  symptoms  to  tire,  and  rests  for  an 
hour,  but  finds  on  attempting  to  walk  that  instead  of  feeling  better  this 
weakness  has  increased.  He  is  tempted  to  rub  them  to  remove  the  numb 
feeling,  but  without  benefit.  The  weakness  increases  until  in  the  course  of 
a  few  hours  he  cannot  stand  without  support  and  is  obliged  to  take  to  his 
bed.  In  bed  he  can  move  his  legs  up  and  down,  but  in  a  day  or  two  even 
this  power  leaves  him,  and  such  control  as  he  has  becomes  limited  to  feeble 
movements  of  the  toes.  The  numbness  also  increases  and  the  patient 
complains  of  various  paraesthesise,  which  he  describes  as  tingling,  "pins 
and  needles "  feeling,  and  even  pains  in  the  legs.  If  tested,  it  will  be 
found  that  sensation  is  blunted.  With  the  progress  of  the  disease  this 
loss  of  sensation  increases  until  it  may  be  complete.  If  the  disease  is  in 
the  dorsal  region,  a  characteristic  symptom  generally  develops  early,  namely, 
a  painful  feeling  of  constriction,  as  if  a  tight  band  were  bound  round  the 
waist,  the  so-called  girdle  sensation.     This  follows  the  distribution  of  the 

1  Convulsions  have  been  observed  in  adults  (Gowers). 


560  NEEVO US  DISEASES  AND  THEIR  TREATMENT. 

nerves  arising  from  the  level  of  the  lesion.  When  the  disease  is  in  the 
cervical  or  lumbar  region  this  sensation  is  replaced  by  pains  in  the  arms  and 
legs,  respectively. 

Early  in  the  course  of  the  disease  the  patient  finds  he  has  lost  control 
over  his  bladder  and  bowels.  Retention  or  incontinence  of  urine  is  then 
present.  The  more  rapid  the  onset  the  sooner  the  paralysis  of  the  bladder 
and  bowels  develops,  though  naturally  it  may  not  be  called  to  the  attention 
of  the  patient  for  some  hours  after  he  has  noticed  the  motor  or  sensory  symp- 
toms. Only  in  mild  cases  of  limited  extent  do  the  sj)hincters  escape.  The 
exact  character  of  the  loss  of  control  depends  upon  the  seat  of  the  lesion, 
whether  it  involves  the  centre  for  the  bladder  and  rectum  or  is  above  them. 

The  loss  of  power  and  sensation  in  the  legs  may  attain  its  height,  in  the 
course  of  a  few  hours,  or  two  or  three  days  or  a  week  may  elapse  before  the 
maximum  of  injury  has  occurred.  Sometimes  the  paralysis,  notwithstanding 
a  decidedly  acute  onset,  at  first  is  mild  in  degree  and  only  increases  slowly, 
so  that  ten  days  or  more  are  occupied  before  the  final  stage  is  reached.  The 
paralysis  may  then  be  complete. 

As  has  been  said,  the  order  of  development  of  the  individual  symptoms 
varies ;  sometimes  the  motor,  sometimes  the  sensory  are  the  first  to  be  noticed, 
or  it  may  be  that  a  difiiculty  in  passing  the  urine  is  the  initial  spinal  symp- 
tom. The  weakness  of  the  legs  is  naturally  more  likely  to  be  noticed  by  the 
patient,  but  careful  inquiry  is  necessary  to  elicit  the  first  symptom,  as  not 
only  sensory  loss  is  apt  to  be  overlooked,  but  patients  are  not  quick  to  distin- 
guish between  the  sensory  feeling  of  numbness  and  the  motor  feeling  of  heavi- 
ness, often  mistaking  one  for  the  other. 

The  reflexes,  deep  and  superficial,  show  various  changes.  Those  imme- 
diately connected  with  the  diseased  segment  of  the  cord  are  abolished.  Those 
originating  below  it  are  increased,  but  during  the  first  few  days  there  may  be 
a  temporary  diminution  or  loss  of  these,  presumably  from  "  shock." 

The  constitutional  symptoms  are  not  conspicuous,  but  there  may  be  fever 
during  the  first  few  days,  particularly  in  the  severer  cases.  The  thermometer 
may  then  record  102^  or  even  104°.  Similarly  anorexia,  general  malaria, 
headache,  and  perhaps  chills,  may  be  noted. 

At  first  all  the  paralyzed  muscles  are  toneless,  and  in  the  course  of  a  few 
days  the  muscles  directly  in  connection  with  the  inflammatory  focus  waste. 
Those  whose  nerves  originate  below  this  focus  do  not  waste,  but  regain  their 
tone. 

The  electrical  contractility  of  the  wasted  muscles  usually  exhibits  the  reac- 
tion of  degeneration. 

In  this  general  picture  of  acute  transverse  myelitis,  the  paralysis  of  the 
legs  has  been  principally  referred  to,  as  this  is  the  most  usual  distribution  of 
the  paralysis  and  of  the  sensory  loss,  owing  to  the  fact  that  the  dorsal  and 
lumbar  j)ortions  of  the  cord  are  most  commonly  the  seat  of  the  disease ;  but 
when  the  disease  is  higher  up,  the  functions  of  all  the  motor  and  sensory 
nerves  originating  at  or  below  the  lesions  are  impaired.  If  the  disease  is  in 
or  above  the  cervical  enlargement,  the  arms  are  aflfected  as  well  as  the  legs. 

In  severe  cases  the  nutrition  of  the  skin  sufiers  and  bed-sores  develop  with 
great  rapidity  ;  all  the  functions  of  the  body  subserved  by  that  portion  of  the 
.  cord  situated  above  the  lesion  are  performed  as  in  health.  The  intellect  re- 
mains clear,  the  pulse  and  respiration  are  within  normal  limits.  It  is  some- 
times striking  to  see  a  patient  lying  perfectly  helpless  in  bed,  unable  to  move 
hand  or  foot,  not  even  knowing  the  position  of  his  arms  or  legs,  yet  fairly 
comfortable,  Qon versing  with  natural  ease  and  eating  and  sleeping  as  if  almost 
without  an  ailment.  It  seems  as  if  a  live  head  were  attached  to  a  dead 
body.     Owing  to  the  ansesthesia  such  a  person  is  not  conscious  of  what  in 


DISEASES  OF  THE  SPINAL  CORD.  561 

another  would  be  discomfort,  or  of  painful  sensations,  even  when  bed-sores 
or  incontinence  of  urine  and  feces  are  present. 

In  the  subacute  cases  the  same  group  of  symptoms  is  eventually  developed, 
but  the  individual  symptoms  are  much  slower  in  developing.  The  paralysis 
or  ansesthesia  may  occupy  ten  days  or  a  month  or  more  before  reaching  its 
height,  and  then  the  final  degree  of  disability  will  generally  be  much  less  in 
degree.  Sufficient  power  may  even  be  retained  to  enable  the  patient  to  move 
about,  and  he  may  never  actually  take  to  his  bed. 

Individual  symptoms  may  be  absent,  such  as  bladder  paralysis,  or  may  be 
IDresent  in  only  a  mild  form.  But  in  such  cases  a  history  of  a  distinct  and 
sharp  onset,  in  the  midst  of  health,  on  a  particular  day  may  be  obtained, 
though  the  initial  symptoms  may  have  been  mild  in  degree.  In  this  re- 
spect the  subacute  cases  may  be  clinically  distinguished  from  the  chronic 
variety. 

In  the  apoplectic  form  complete  paralysis  comes  on  suddenly  in  the  course 
of  fifteen  minutes  or  half  an  hour.  The  paralysis  may  be  so  sudden  as  to 
be  suggestive  of  hemorrhage,  and  it  may  be  even  impossible  to  determine 
whether  hemorrhage  has  occurred  in  such  cases  or  not ;  but  in  the  majority 
of  such  instances  we  should  probably  be  safe  in  inferring  the  existence  of 
some  hemorrhage. 

Sometimes  a  patient  wakes  up  after  a  night's  sleep  to  find  himself  paralyzed. 
Under  such  circumstances,  as  it  is  impossible  to  determine  the  duration  of 
the  onset,  it  is  often  difficult  to  decide  whether  or  not  hemorrhage  has  occurred. 

It  remains  to  consider  the  individual  symptoms  more  fully  in  detail. 

Sensation.  There  are  three  phenomena  of  disturbed  sensibility  which  should 
be  looked  for :  First,  a  "  girdle  pain  ;"  second,  a  zone  of  hypersesthesia  cor- 
responding to  the  upper  level  of  the  lesion  ;  and,  third,  a  loss  or  diminution 
of  all  forms  of  sensibility,  or  the  retention  in  a  greater  or  less  degree  of  either 
touch  or  pain,  and  the  loss  of  the  other  of  these  two. 

The  well-known  "  girdle  pain  "  or  painful  sense  of  constriction  is  due  to 
the  irritation  of  the  nerves  passing  through  the  upper  edge  of  the  inflam- 
matory focus.  Its  seat  necessarily  varies  with  that  of  the  lesion.  As  the 
dorsal  cord  is  most  commonly  affected,  its  most  common  seat  is  somewhere  be- 
tween the  ensiform  cartilage  and  the  waist  (crest  of  the  ilium). 

Pains  of  an  analogous  character  may  be  present  in  the  arms  and  legs  when 
the  cervical  and  lumbar  cords  are  respectively  only  partially  involved.  When 
these  enlargements  are  totally  affected  the  pains  cease  in  the  limbs. 

The  pain  may  be  felt  about  the  perineum  and  anus.  A  zone  of  hyper- 
sesthesia  will  usually  be  found  at  the  same  level  as  the  girdle  pain  and  corre- 
sponding to  the  same  portion  of  the  cord.  It  is  usually  about  two  inches 
Avide,  and  should  be  carefully  looked  for.  Both  these  phenomena  are  impor- 
tant from  the  fact  that  they  indicate  the  upper  limit  of  the  disease.  The 
girdle  pain  is  also  a  valuable,  though  not  absolute,  evidence  of  organic  disease 
in  the  cord.  The  degree  to  which  sensation  is  lost  varies  in  different  cases. 
The  loss  may  be  absolute  or  slight  only,  though,  as  a  rule,  the  perception  of 
touch  and  pain  and  temperature  is  impaired  to  a  very  marked  degree._  As 
in  the  peripheral  nerves,  the  sensory  fibres  seem  to  have  a  greater  resisting 
power  than  the  motor  fibres,  and  it  is  not  uncommon  to  see  extreme  paralysis 
of  the  muscles,  with  a  slight  or  moderate  amount  of  anaesthesia.  There  is 
always,  however,  some  loss  of  sensation,  or,  in  mild  cases,  parajsthesia,  other- 
Avise  the  lesion  is  not  transverse.  Pain  and  touch  may  be  unequally  afiected, 
and  one  may  be  abolished  without  the  other. 

The  anaesthesia  extends  from  below  upward  to  the  upper  level  ()f  the  lesion, 
and  consequently  is  of  value  as  a  guide  in  determining  this  limit,  especially 
in  the  dorsal  region.    The  line  of  division  between  the  sound  and  affected  por- 

36 


562  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tions  of  skin  is  not,  however,  sharply  defined,  and  some  skill  is  necessary  in 
determining  the  boundary.  The  aneesthetic  line  may  not  be  at  symmetrical 
heights  on  the  two  halves  of  the  body. 

Paralysis.  The  paralysis  may  be  absolute,  so  that  the  affected  muscles 
cannot  be  moved  in  the  slightest  degree,  or  more  or  less  power  of  motion  may 
be  left ;  or  some  movements  of  a  limb  may  be  lost  completely  and  others 
retained.  Aside  from  differences  in  the  intensity  of  the  process,  these  varia- 
tions depend  in  part  (not  wholly)  upon  the  fact  that  the  different  groups  of 
muscles  are  represented  in  more  than  one  level  of  the  cord,  so  that  the  de- 
struction of  any  one  segment  may  not  completely  abolish  the  corresponding 
movement  which  may  be  affected  by  the  next  adjoining  spinal  segment  above. 
But  in  acute  cases  it  is  usual  for  the  degree  of  paralysis  to  be  such  that  the 
affected  limbs  are  of  no  practical  use. 

When  the  paralysis  is  not  absolute  the  flexors  are  said  to  be  more  affected 
than  the  extensors — a  fact  difficult  to  explain,  if  true.  The  distribution  of 
the  paralysis  depends  upon  the  vertical  position  of  the  lesion.  When  the 
lumbar  enlargement  is  alone  involved,  the  paralysis  is  limited  to  the  legs  and 
sphincters.  In  the  dorsal  region  the  corresponding  intercostal  and  abdominal 
and  back  muscles  are  included  in  the  paralysis. 

In  cervical  myelitis  the  arms,  as  well  as  the  legs  and  body,  are  paralyzed. 
If  the  lesion  is  as  high  as  the  third  and  fourth  cervical  segments,  the  diaphragm 
(phrenic  nerve)  is  also  paralyzed,  and  death  takes  j)lace.  In  rare  cases  where 
the  myelitis  was  of  limited  extent  the  diaphragm  escaped,  though  the  neck 
muscles  were  paralyzed  and  wasted. 

The  pupils  may  be  affected  in  cervical  myelitis.  This  may  be  explained 
by  the  fact  that  nerves  for  the  radiating  fibres  of  the  iris  pass  down  the  cord 
from  the  nucleus  of  the  third  nerve  to  reach  the  lowest  cervical  or  first  dorsal 
nerve,  by  which  they  join  the  cervical  sympathetic,  and  then,  ascending  with 
the  internal  carotid  artery,  pass  to  the  ciliary  ganglion.  Paralysis  of  these 
fibres  would  lead  to  contraction  of  the  pupils. 

Atrophy  and  Electrical  Reactions.  In  consequence  of  the  damage  to  the 
cells  in  the  anterior  cornua  the  muscles  supplied  by  the  nerves  arising  from 
the  diseased  segment  become  flaccid  at  once,  and  waste.  In  the  course  of 
ten  days  or  a  fortnight  electrical  examination  will  shoAV  the  reaction  of 
degeneration  in  these  wasted  muscles.  This  degenerative  atrophy  must  not 
be  mistaken,  as  it  too  often  is,  for  the  simple  wasting  of  muscles  occurring  in 
any  paralyzed  or  immobile  limb.  In  mild  cases,  Avhen  the  atrophy  is  slow,  only 
diminished  contractility  will  be  found.  But  muscles  connected  with  the  cord 
below  the  seat  of  the  disease  do  not  atrophy  or  exhibit  electrical  changes. 
So  that  in  lumbar  myelitis  the  legs,  or  particular  muscles  of  the  legs,  waste ; 
in  cervical  myelitis  the  atrophy  is  limited  to  the  arms,  though  the  leg's 
are  paralyzed. 

Reflexes.  The  reflexes  that  pass  through  the  diseased  segment  are  neces- 
sarily abolished  ;  consequently,  in  lumbar  myelitis  all  the  reflexes — deep  and 
superficial — of  the  legs  (knee-jerk,'^  cremasteric,  etc.,)  are  lost.  In  dorsal 
myelitis  this  loss  is  confined  to  the  trunk  reflexes,  and  in  cervical  myelitis  to 
the  arm  reflexes. 

The  reflexes  that  are  subserved  by  the  segments  below  the  level  of  the  lesion 
may  be  (not  always)  temporarily  lost  Cor  diminished),  presumably  from  shock. 

These  reflexes  may  be  recovered  in  the  course  of  a  few  hours,  and  later 
become  exaggerated ;  or  they  may  remain  absent  for  days  and  weeks.     In 

1  The  knee-jerk  p,nd  other  tendon  phenomena  are  spoken  of  as  reflexes,  although,  in  accordance 
v.'ith  the  observations  of  Gowers,  they  should  more  properly  be  regarded  as  conditions  of  muscular 
(myotatic)  irritability.  But  as  myotatic  irritability  is  dependent  on  the  integrity  of  the  reflex  arc,  it 
is  a  quasi-reflex  phenomenon,  and  clinically  is  more  conveniently  considered  as  a  reflex. 


DISEASES  OF  THE  SPINAL  CORD.  563 

traumatic  cases  Avith  crushing  of  the  cord  they  are  especially  liable  to  be 
lost,  and  may  continue  absent  for  days  or  weeks,  and  in  rapidly  fatal  cases 
may  not  return  at  all.^ 

The  exaggeration  of  the  superficial  reflexes  is  due  to  the  cutting  off  of  the 
normal  inhibitory  influences  from  the  brain.  That  of  the  deep  reflexes 
(myotatic  irritability)  principally  depends  upon  the  secondary  descending- 
degeneration  in  the  pyramidal  motor  tracts,  but  not  entirely  upon  this,  as 
there  is  reason  to  believe  that  loss  of  inhibition  will  also  cause  an  increase  in 
these  reflexes,  and  that  this  is  a  factor  at  first.  Therefore,  in  cervical  myelitis 
with  the  loss  of  the  arm  reflexes,  and  in  dorsal  myelitis  of  corresponding 
trunk  reflexes,  there  are  ankle-clonus  and  increased  knee-jerk,  cremasteric, 
plantar,  and  other  reflexes. 

With  the  development  of  the  descending  degeneration  in  the  pyramidal 
tracts  a  spastic  condition  of  the  legs  develops.  Certain  exceptions  to  this 
statement  occur,  the  explanation  of  which  must  be  considered  in  doubt ;  viz., 
according  to  Bastian,  Avhen  the  transverse  lesion  is  comjyiete  the  reflexes  sub- 
served by  the  cord  below  are  not  increased,  but  lost.  Bastian's  observations 
have  been  corroborated  by  others  (Herter,  Leyden,  Miles,  Babinsky),  but 
the  interpretation  of  them  is  still  an  open  question.  That  of  Gowers,  that 
the  loss  of  reflexes  is  due  to  the  inflammation  having  extended  downward  to 
the  lumbar  enlargement,  is  undoubtedly  correct  in  certain  cases,  though  the 
post-mortem  findings  have  sometimes  only  shown  degenerative  changes  in  the 
contents  of  the  cells,  without  diffuse  inflammatory  softening,  but  the  coexist- 
ence of  atrophy  and  loss  of  faradic  contractility  of  the  muscles  shows  that 
some  sort  of  degenerative  change  must  have  been  present  in  these  cases.  But 
it  remains  to  be  proved  that  a  descending  inflammation  or  some  other  kind 
of  degeneration  always  is  present  in  such  cases. 

Bladder  and  Bowels.  In  complete  transverse  myelitis  there  is  necessarily 
always  loss  of  control  of  the  sphincters,  but  when  the  myelitis  is  only  partial 
they  may  occasionally  escape.  Paralysis  of  the  sphincters  may  be  the  first 
symptom,  and,  on  the  other  hand,  when  recovery  takes  place  control  over 
the  sphincters  may  be  regained,  while  there  is  still  considerable  paral^^sis. 
But  in  mild  cases  only  a  slight  weakness  of  the  bladder  may  be  present,  ren- 
dering it  difiicult  for  the  patient  to  retain  or  expel  his  urine. 

There  are  two  forms  of  incontinence  of  urine  which  maybe  present  accord- 
ing to  the  seat  of  the  lesion,  and  according  as  there  is  paralysis  of  the  sphinc- 
ters or  the  detrusor.  When  the  lower  portion  of  the  lumbar  enlargement  is 
diseased  the  sphincter  is  paralyzed  and  the  urine  dribbles  away  as  fast  as  it 
is  secreted.  When,  on  the  other  hand,  myelitis  is  above  the  lumbar  cord,  the 
vesical  centre  being  intact,  the  sphincter  holds,  and  there  is  a  full  bladder. 
The  bladder  may  then  empty  itself  at  intervals  spasmodically,  or,  as  the 
wall  becomes  weaker  and  the  bladder  empties  itself  more  and  more  imperfectly, 
an  overflow  becomes  established — overflow  incontinence.  It  is  important  to 
determine  which  of  these  two  conditions  is  present,  inasmuch  as  a  persist- 
ently full  bladder  may  lead  to  disease  of  the  kidneys.  Similar  differences  in  the 
form  of  the  rectal  paralysis  occur.  In  lumbar  myelitis  there  is  incontinence 
of  feces  from  paralysis  of  the  sphincter.  This,  however,  may  not  be  obvious 
on  account  of  the  constipation  which  is  usually  present,  and  Avhich  is  a  symp- 
tom of  myelitis  and  dei^endent  upon  the  connection  between  the  sympathetic 
system  and  the  cord.  In  dorsal  and  cervical  myelitis  there  may  be  involun- 
tary evacuation  of  the  rectum  at  intervals. 

There  is  a  tendency  for  the  urine  to  become  alkaline.     This  has  been  at- 

1  Necrotic  changes  in  the  cord  caused  by  injuries  of  this  kind  are  not,  strictly  speaking,  myelitis 
although  they  are  followed  by  inflammation. 


564  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tributed  to  an  alteration  in  the  secretion,  apart  from  the  decomposition  which 
is  liable  to  follow  the  retention.  This  decomposition,  which  is  common,  is 
often,  however,  if  not  always,  due  to  the  introduction  of  unclean  catheters, 
and  can  frequently  be  avoided. 

As  a  result  of  the  decomposition  cystitis  may  develop.  This,  like  the  bed- 
sores, is  probably  facilitated  by  the  cord  lesion  impairing  the  nutrition  of  the 
bladder  and  its  resisting  power.  Cystitis  may  lead  to  ulceration  and  perfo- 
ration of  the  bladder,  peritonitis,  etc.,  and  retention  of  urine  to  disease  of 
the  kidneys. 

Priapism  is  common  when  the  disease  is  above  the  lumbar  enlargement. 

Optic  neuritis  has  been  observed  in  a  few  cases.  It  seems  to  be  more 
common  in  the  diffuse  form,  and  there  is  reason  to  believe  that  it  may  be 
properly  regarded  as  caused  by  some  toxsemic  agent,  the  same  which  has  in 
these  cases  been  the  exciting  cause  of  the  myelitis. 

Trophic  disturbances  are  common.  The  temperature  of  the  skin  of  the 
limbs  is  at  first  raised,  at  times  even  above  that  of  the  mouth.  This  may  be 
explained  by  the  interference  with  the  functions  of  the  sympathetic  vaso- 
motor nerves  through  their  connections  with  the  cord.  Later  the  tempera- 
ture falls  below  normal.  The  nutrition  of  the  skin  suffers,  in  that  it  becomes 
dry  and  harsh,  especially  when  there  is  atrophic  degeneration  of  the  muscles, 
and  the  least  pressure  is  liable  to  produce  bed-sores.  The  resistance  to  the 
electric  current  under  such  circumstances  is  so  great  as  to  make  it  difiicult 
to  obtain  muscular  contractions  without  using  a  battery  of  high  electro- 
motive force,  and  to  lead  to  erroneovis  observations  unless  careful  electrical 
measurements  are  made.  The  most  common  seat  of  bed-sores  is  over  the 
sacrum.  These  should  be  carefiilly  watched  for.  These  bed-sores  are  some- 
times malignant  in  character.  Sloughing  appears  suddenly  under  so  slight 
a  provocation,  such  as  pressure  of  a  hot-water  bottle,  as  to  appear  sponta- 
neous, but  it  may  almost  always  be  attributed  in  part  to  an  external  cause,^ 
although  such  causes  would  have  no  such  effect  in  healthy  persons.  Con- 
sequently such  lesions  are  properly  attributable  to  the  central  lesions.  The 
sloughing  may  involve  not  only  the  soft  parts,  but  even  the  bones  of  the 
spinal  column.  Such  complications  are  to  be  dreaded,  as  in  their  malignant 
form  they  may  lead  to  great  destruction  of  the  tissues,  and  even  septicaemia 
and  death.  Cellulitis  in  the  lower  part  of  the  body,  especially  about  the 
bladder  and  rectum,  has  been  observed  with  subcutaneous  emphysema 
(Gowers). 

Qildema  of  the  paralyzed  limbs  occurs,  and  is  presumably  due  to  vasomotor 
disturbances. 

Joint  disease,  resembling  somewhat  that  occurring  in  tabes,  has  been  ob- 
served^ following  traumatism.  A  case  in  which  spontaneous  fracture  of  the 
thigh,  without  pain,  occurred  has  come  under  my  observation.  The  myelitis 
in  this  case  followed  fracture  of  the  spine.  Such  trophic  lesions  are  rare. 
Why  they  should  be  common  in  such  diseases  as  syringomyelia,  Morvan's 
disease,  and  tabes,  and  so  infrequently  observed  in  myelitis,  is  not  plain,  un- 
less it  be  that  they  are  dependent  upon  changes  in  the  nerve-roots. 

Contractures  and  Spasms.  The  spastic  condition  of  the  legs,  which  develops 
in  the  later  stage  of  the  disease  in  consequence  of  the  secondaiy  descending- 
degeneration,  has  already  been  referred  to.  Although  ordinarily  spasm  of 
the  extensors  preponderates  over  the  flexors,  occasionally  the  reverse  is  the 

1  In  a  traumatic  case  described  by  Hammond  ("Diseases  of  the  Nervous  System"),  three  large 
sloughs  over  the,  sacrum  and  both  hips  occurred  within  six  hours  of  the  injury.  The  trophic 
lesions  observed  in  other  cord  diseases,  as  syringomyelia,  show  that  the  central  lesion  alone  may 
induce  such  necrotic  processes. 

-  Goldthwait :  Transactions  of  the  American  Orthopedic  Assoc,  1892. 


DISEASES  OF  THE  SPINAL  COBB.  565 

case.  Under  these  circumstances,  owing  to  the  continuous  flexion  of  the 
joints  and  the  subsequent  shortening  of  the  muscles,  contracture  develops 
and  the  limbs  become  fixed  in  a  flexed  position. 

Course  of  the  Disease.  The  disease  in  the  acute  form  reaches  its  height  in 
three  or  four  days  or  a  week.  In  the  subacvite  form  this  period  is,  of  course, 
prolonged.  There  may  be  a  succession  of  distinct  acute  attacks,  during  which 
the  paralysis  becomes  more  profound  and  more  extended.  The  disease  may 
be  limited  to  the  segments  first  affected,  or  may  extend  up  and  down  the 
cord.  In  the  former  case  the  disease  remains  stationary  for  a  variable  time, 
and  then  improvement  begins.  In  mild  cases,  after  a  week  some  change  for 
the  better  may  be  noticed.  In  severe  complete  lesions  a  year  may  pass  with- 
out improvement,  and  none  may  take  place  at  all.  Between  these  two  ex- 
tremes all  grades  may  be  observed.  When  the  disease  extends  beyond  the 
segments  first  attacked  the  progression  upward  will  be  indicated  by  the 
paralysis  of  successive  muscles,  by  an  increase  in  the  area  of  anaesthesia,  or  by 
the  implication  of  more  reflexes.  Its  downward  extension  can  only  be  recog- 
nized by  the  condition  of  the  reflexes,  the  state  of  nutrition  and  electro- 
contractility  of  the  muscles,  and  the  condition  of  the  sphincters.  After  the 
disease  has  reached  its  height  its  course  is  slow,  unless  there  has  been  an 
early  extension  of  the  disease  into  the  centres  for  the  respiratory  muscles 
or  into  the  medulla  oblongata,  when,  of  course,  death  occurs.  When  im- 
provement begins  some  return  of  sensation  is  usually  first  noticed,  and  often 
recovery  of  control  over  the  sphincters  is  among  the  earliest  signs.  Sensa- 
tion may  be  nearly  recovered  with  little  or  no  gain  in  motor  power,  and 
control  of  the  sphincters  may  be  established  while  considerable  paralysis 
persists.  Sometimes  recovery  is  complete,  but  months  must  be  counted 
upon  as  necessary  for  this  result,  and  sometimes  it  is  not  until  a  year  or  two 
have  passed  that  the  total  amount  of  improvement  that  will  be  attained  has 
taken  place. 

Though  considerable  improvement  is  not  incompatible  with  a  certain 
amount  of  increased  myotatic  irritability,  a  high  degree  of  spastic  condition 
is  a  bad  omen,  as  it  indicates  descending  degeneration  in  the  voluntary  motor 
tracts  in  the  cord.  Some  cases  pursue  a  relapsing  course.  This  is,  however, 
more  common  in  disseminated  myelitis. 

When  death  takes  place  it  is  either  from  extension  of  the  disease  to  the 
respiratory  centres  or  to  the  medulla,  or  from  exhaustion  consequent  on  bed- 
sores, cystitis,  or  impaired  nutrition.  In  some  cases  there  may  be  a  general 
weakening  of  all  the  vital  forces.  Death  may  take  place  in  consequence 
without  special  local  cause. 

Termination.  If  complete  recovery  does  not  occur,  various  secondary 
changes  usually  persist  in  the  cord  and  produce  characteristic  symptoms. 
The  jDrincipal  are :  1 .  Descending  degeneration,  with  resulting  spastic  paral- 
ysis of  a  greater  or  less  degree.  2.  Ascending  degeneration  along  the  posterior 
column,  producing  ataxia.  3.  The  disease  may  clear  up  from  the  white 
matter  and  leave  permanent  destructive  effects  in  the  anterior  gray  matter 
below.  In  such  cases  a  certain  amount  of  paralysis,  with  atrophy  and  loss 
of  electrical  reaction,  will  persist  in  certain  groups  of  muscles,  and  present  the 
appearance  of  an  anterior  poliomyelitis.  In  all  these  cases,  if  the  patient  is 
seen  for  the  first  time  in  the  very  late  stages  of  the  disease,  only  very  careful 
inquiry  into  the  history  will  enable  us  to  recognize  the  origin  of  the  spinal 
condition. 

It  should  always  be  borne  in  mind  that  neither  motion  nor  sensation  may 
be  completely  recovered,  and  some  loss  of  both  and  some  weakness  of  the 
sphincters  may  persist  during  the  patient's  lifetime. 

Localization.     It  is  often  important  in  traumatic  cases  and  those  secondary 


566 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


to  processes  outside  the  cord  to  determine  the  localization  of  the  inflamma- 
tory focus,  including  its  lower  and  upper  limit.  The  main  points  to  be  relied 
upon  have  already  been  stated  and  need  not  be  repeated.  In  cases  of  partial 
myelitis  involving  the  lumbar  or  cervical  enlargements,  special  groups  of 
muscles  may  alone  be  paralyzed,  according  to  the  height  of  the  lesion  in  the 
cord ;  similarly  the  anaesthesia  may  be  limited  to  special  areas.  The  reflexes 
may  also  be  differently  affected.  A  careful  study  of  Figs.  195  and  196,  Chapter 
XX.,  will  enable  one  to  locate  the  site  of  the  lesion.  But  it  must  be  borne 
in  mind  that  our  knowledge  of  the  localization  of  spinal  functions  is  only  ap- 
proximately correct,  and  we  cannot  count  upon  absolute  accuracy.  Further- 
more, the  evidence  we  have  points  to  the  fact  that  the  various  groups  of  cells 
corresponding  to  the  different  sets  of  muscles  have  their  seat  in  several 
spinal  segments,  and  the  injury  of  one  segment  may  only  weaken  without 
absolutely  paralyzing  the  corresponding  muscles. 

The  accompanying  table  shows  the  principal  symptoms  present  in  lumbar, 
dorsal,  and  cervical  myehtis. 


Paralysis. 


Sensation. 


Atrophy. 


Electrical 
reaction. 


Bladder. 


Bowels. 


Reflexes, 
superficial. 

Reflexes, 
deep. 

Priapism. 


Lumbar  myelitis. 


Paraplegia. 


Pains  in  legs,  or  girdle 
pains  around  loins  ;  hy- 
persesthetic  zone  around 
loins;  anaesthesia  of  legs, 
complete  or  uneven  dis- 
tribution. 


Dorsal  myelitis. 


Of  legs. 


R.D.  in  atrophied  muscles; 
or  in  mild  cases  quanti- 
tative diminution. 


Incontinence  from  paral- 
ysis of  sphincter. 


Incontinence  from  paral- 
ysis of  sphincter,  dis- 
guised by  constipation. 

Lost. 


Lost. 


Absent. 


1.  Dorsal,  abdominal,  and 
intercostal  muscles  ac- 
cording to  height  of 
lesion.    2.  Legs. 

Girdle  pain  and  hyper- 
sesthetic  zone  between 
ensiform  cartilage  and 
pubes. 


Of  dorsal  and  abdominal 
(and  intercostal  muscles, 
not  subject  to  examina- 
tion) corresponding  to 
height  of  lesion  ;  some- 
times mild  and  slow  of 
legs. 

R.  D.  in  dorsal  and  ab- 
dominal muscles ;  slight 
quantitative  changes 
only  in  legs  when  wast- 
ed. 

Retention,  or  intermittent 
incontinence  from  re- 
flex action ;  later  from 
overflow.  Cystitis  com- 
mon. 

Involuntary  evacuation 
from   reflex    spasm,   or 
constipation. 

Temporary  loss,  then  ra- 
pid increase. 

Temporary  loss,  then  slow 
increase. 


Often  present. 


Cervical  myelitis. 


Neck  muscles,  diaphragm, 
arms,  trunk,  and  legs. 


Hypersesthesia  and  pains 
in  certain  nerve  distri- 
butions of  arms ;  below 
this  anesthesia  of  arms, 
body,  and  legs. 


Atrophy  of  neck  muscles 
(rare)  or  more  commonly 
of  arms. 


R.  D.  in  atrophied  muscles. 
Same  as  in  dorsal  myelitis. 

Same  as  in  dorsal  myelitis. 

Same  as  in  dorsal  myelitis. 
Same  as  in  dorsal  myelitis. 
Often  present. 


Diagnosis.  Typical  cases  of  acute  transverse  myelitis  are  easily  diagnosed. 
It  is  only  in  the  mild  or  partial  form  that  there  may  be  a  question  of  the 
diagnosis.  Great  difficulty  may  then  be  met  with.  Chief  reliance  must  be 
placed  upon  a  rapidly  developing  j^aralysis,  with  loss  of  sensation  and  loss  of 
control  of  the  sphincters.  Further  than  this  it  is  not  necessary  to  repeat 
what  has  already  been  said.     Here  can  only  be  mentioned  the  diseases  with 


DISEASES  OF  THE  SPINAL  CORD.  567 

which  transverse  myelitis  is  most  likely  to  be  confused  and  a  few  of  the 
principal  symptoms  which  will  serve  as  the  most  useful  guides.  A  knowl- 
edge of  the  diseases  themselves  will  alone  enable  us  to  make  the  diagnosis  in 
doubtful  cases. 

The  principal  diseases  from  which  acute  transverse  myelitis  is  to  be  dis- 
tinguished are :  Central  myelitis,  poliomyelitis,  disseminated  myelitis,  hem- 
orrhage, embolic  or  thrombotic  softening,  multiple  neuritis,  neuritis  of  the 
sacral  plexus,  Landry's  jDaralysis,  spinal  meningitis,  and  hysterical  paralysis. 

The  distinction  from  central  myelitis  is  difficult.  The  latter  is  the  most 
malignant  form  that  occurs,  and,  being  an  inflammation  of  the  gray  matter 
and  extending  up  and  down  the  cord  for  a  considerable  distance,  produces 
more  difflise  symptoms. 

It  may  be  suspected  when  symptoms  indicative  of  an  intense  myelitis 
develop,  attended  by  fever  and  by  signs  of  damage  to  the  trophic  centres  of 
the  muscular  system  through  a  considerable  vertical  extent  of  the  cord.  A 
focal  central  myelitis  sometimes  follows  trauma.  In  such  cases  there  may 
be  the  dissociation  of  sensation,  combined  with  limited  atrophy  of  certain 
muscular  groups,  such  as  is  observed  in  syringomyelia,  or  the  atrophy  and 
paralysis  may  alone  be  present  without  sensory  loss.  I  have  observed  two 
instances  of  such  a  focal  myelitis,  and  a  few  have  been  reported  in  the 
journals. 

In  poliomyelitis  sensation  is  not  affected,  the  sphincters  escape,  and  there  is 
no  girdle  pain  or  bed-sores.  Hemorrhage  need  only  be  confounded  with  the 
apoplectic  form.  In  cases  of  such  sudden  onset  it  is  difficult  to  make  the 
distinction,  but  we  shall  rarely  go  wrong  if  we  assume  the  occurrence  of  some 
hemorrhage ;  further,  in  hemorrhage  severe  pain  is  much  more  prominent, 
and  when  present  would  be  sufficient  to  make  the  distinction. 

The  distinction  from  disseminated  myelitis  must  be  based  upon  the  fact 
that  the  symptoms  in  this  form  are  more  mixed  and  indicative  of  foci  of  in- 
flammation scattered  through  the  cord.  Instead  of  the  compact  symptoms 
indicative  of  disease  of  one  or  two  segments,  the  sensory,  paralytic,  and 
other  phenomena  will  be  more  scattered  and  appear  as  paralysis  of  distinctly 
separated  groups  of  muscles,  patches  of  anaesthesia,  more  or  less  irregularly 
distributed.  When  the  foci  of  inflammation  are  numerous,  so  as  to  produce 
a  coalescence  of  the  symptoms,  the  differentiation  may  be  difficult. 

In  multiple  neuritis  there  is  rarely  paralysis  of  the  sphincters,  nor  is  there 
a  girdle  pain,  hypersesthesia,  or  bed-sores.  Loss  of  sensation  is  never  so  pro- 
found as  is  sometimes  the  case  in  myelitis.  The  paralysis  is  less  rapid  in 
development,  and  in  some  forms  of  neuritis  the  grouping  of  the  paralysis  is 
characteristic ;  that  is,  the  extensors  are  principally  affected.  On  the  other 
hand,  in  myelitis,  there  is  no  tenderness  of  the  muscles  or  nerves,  and  the 
pain  is  not  so  excessive.  Neuritis  of  the  sacral  plexus  is  distinguished  by 
the  severity  of  the  pain  and  tenderness  of  the  plexus  to  the  touch  on  vaginal 
or  rectal  examination.  The  sphincters  are  less  likely  to  be  affected.  The 
history  of  traumatism,  such  as  labor  with  or  without  instrumental  delivery, 
or  coexisting  pelvic  disease,  is  an  important  aid  to  diagnosis.  When  due  to 
the  former  cause  the  neuritis  generally  involves  the  lumbo-sacral  cord,  and 
the  paralysis  is  generally  limited  to  the  muscles  supplied  by  the  external 
peroneal  nerve. 

In  Landry's  paralysis  there  is  an  absence  of  sensory  disturbances  of  all 
kinds,  the  sphincters  are  not  involved,  there  is  no  atrophy,  and  all  the  re- 
flexes are  lost. 

In  meningitis  there  is  usually  nmscular  spasm,  pain  and  fever  are  more 
prominent,  and  the  sphincters  are  not  aflected. 

Hysterical  paralysis  is  liable  to  be  mistaken  for  myelitis  (nily  when  it  is  of 


568  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  paraplegic  type.  It  may  be  distinguished  by  the  absence  of  atrophy,  of 
changes  in  the  electrical  reactions  of  the  muscles,  and  of  trophic  changes  in  the 
skin.  Sensation  is  not  generally  affected  in  hysterical  paraplegia,  though  the 
reverse  is  the  case  in  hysterical  hemiplegia.  Marked  changes  in  the  reflexes 
are  less  likely  to  be  observed,  and  hysterical  stigmata  may  be  found  else- 
where. 

Prognosis.  Almost  any  case  of  myelitis  must  be  regarded  with  consid- 
erable apprehension,  from  the  point  of  view  of  recovery,  though  not  neces- 
sarily so,  so  far  as  danger  to  life  is  concerned.  The  more  complete  the 
paralysis  and  loss  of  other  functions  of  the  cord  the  less  likelihood  of  complete 
recovery,  and,  vice  versa,  the  milder  the  paralysis  the  greater  the  possibility 
of  recovery.  Complete  recovery  is  not,  however,  incompatible  with  total 
abolition  of  function  of  a  diseased  spinal  segment.  A  tendency  for  the  in- 
flammation to  spread  up  or  down  the  cord  is  an  unfavorable  sign.  Complete 
recovery  is  not  infrequent,  though,  as  a  rule,  some  motor  weakness  or  other 
disturbance  of  function  is  apt  to  remain.  The  longer  the  paralysis  has  lasted 
and  the  more  extensive  the  inflammation  longitudinally  in  the  cord,  the  less 
the  chance  of  recovery ;  but  all  hope  of  recovery  should  not  be  abandoned 
until  a  year  or  more  has  elapsed.  The  danger  to  life  is  greatest  when  the 
myelitis  is  in  the  cervical  region,  on  account  of  inflammation  extending  to 
the  respiratory  centres,  when  death  necessarily  ensues.  In  otlier  cases,  death 
may  occur  from  exhaustion,  especially  when  bed-sores  and  severe  cystitis  are 
present.  Disease  of  the  kidneys,  due  to  retention  of  the  urine,  is  also  an 
unfavorable  and  dangerous  condition. 

A  favorable  symptom  is  the  early  return  of  slight  voluntary  power. 

Treatment.  The  treatment  of  acute  myelitis  is,  for  the  most  part,  empiri- 
cal. Individual  cases  vary  so  widely  in  the  intensity  of  the  inflammatory 
process,  and  consequently  in  the  amount  of  the  resulting  necrosis,  in  the 
cord,  that  it  is  impossible  to  make  a  comparative  estimate  of  the  value  of  any 
sjDCcial  treatment.  When  such  varving  conditions  are  present  it  is  impos- 
sible to  obtain  comparative  statistics,  or  to  detei'mine  with  certainty  the 
amount  of  benefit  derived  from  any  particular  treatment.  When  the  necrosis 
is  extreme  and  the  cord  totally  destroyed  through  its  whole  transverse  ex- 
tent, recovery  under  any  treatment  must  be  hopeless.  When  the  inflamma- 
tory process  is  slight,  there  is  a  tendency  toward  spontaneous  recovery.  Be- 
tween these  two  extremes  there  are  all  grades.  The  difiiculty  is  enhanced 
from  the  fact  that  from  the  degree  of  paralysis  and  other  symptoms  present, 
we  cannot  always  infer  the  amount  of  actual  destruction  present.  Various 
remedies  have  been  i-ecommended,  according  to  the  theories  maintained  as  to 
the  nature  of  the  necrotic  process.  Ergot,  wet  cups  to  the  spine,  and  counter- 
irritation  have  been  recommended  on  the  principle  that  the  disease  is  con- 
gestive in  nature  from  the  outset.  They  may  be  of  value  at  times,  but  the 
success  derived  from  their  use  has  not  been  such  as  to  give  confidence  that 
they  affect  the  course  of  the  disease.  In  cases  clearly  traceable  to  cold  they 
may  be  of  some  value.  When  cold  is  the  cause,  the  recommendation  that 
the  patient  should  at  once  be  placed  in  a  warm  bath  is  rational,  and  should 
be  tried.  To  be  of  any  value  it  must  be  used  early  during  the  congestive 
stage.  The  bath  should  not  be  too  hot,  slightly  under  90°,  and  the  patient 
left  in  long  enough  to  produce  a  decided  effect  on  the  peripheral  circulation. 
It  is  recommended  that  the  bath  should  be  given  daily  for  several  days  in 
succession,  but  it  is  doubtful  whether  any  good  that  might  be  accomplished 
would  not  be  neutralized,  after  the  first  day  or  two,  by  the  necessary  disturb- 
ance of  the  paralyzed  patient.  Spitzka  has  suggested  that  aS  acute  myelitis 
fi-equently  follows  exposure  of  the  lower  extremities,  and  not  of  the  back,  to 
cold,  and  as  the  spinal  cord  is  therefore  vulnerable  to  influences  affecting 


DISEASES  OF  THE  SPINAL  CORD.  569 

the  distal  distribution,  that  we  may  with  plausibility  affect  the  cord  for  good 
through  the  same  chaunels.  He  therefore  recommends  the  use  of  derivation, 
counter-irritation,  etc.,  to  the  legs  rather  than  to  the  back.  He  thinks  he 
has  obtained  good  results  by  this  method.  Both  cold  and  hot  applications 
to  the  spine  have  been  recommended  by  different  writers.  Cold  is  applied  in 
the  form  of  Chapman's  ice-bags,  and  if  employed  should  be  applied  contin- 
uously for  a  number  of  hours  at  a  time. 

Strychnine  has  been  highly  recommended  by  some,  while  others  deny  that 
it  has  any  effect  upon  the  disease.  In  severe  cases,  where  there  is  consid- 
erable necrosis,  it  would  certainly  be  ftitile  to  expect  it  to  have  any  favorable 
influence ;  while  in  mild  cases  it  is  difficult  to  determine  how  much  of  the 
recovery  is  due  to  the  drug.  In  the  last  class  of  cases  only  could  we  expect 
any  benefit,  and  if  given  should  be  administered  in  large  doses,  sufficient 
almost  to  produce  its  physiological  effect. 

But  if  the  beneficial  effect  of  drugs  is  j)roblematical,  we  can  at  least  do 
much  to  prevent  the  disease  being  aggravated  by  injudicious  care.  The 
patient  should  be  at  once  put  to  bed,  and  not  be  allowed  to  sit  up  or  walk 
about,  even  if  he  retains  sufficient  muscular  power  to  do  so.  Physiological 
and  physical  rest  is  to  be  absolutely  enjoined,  and  the  patient  not  subjected 
to  unnecessary  movement.  It  has  been  urged  that  the  back  should  not  be  the 
lowest  part  of  the  body,  and,  therefore,  that  the  patient  should  either  lie  on  his 
side  or  in  the  prone  position.  Whether  the  results  obtained  by  keeping  the 
body  in  these  postures  are  sufficient  to  offset  the  discomfort  to  the  patient  is 
a  question.  Lying  on  the  side  is  the  more  easily  accomplished,  and  much 
assistance  may  be  derived  by  a  board  supporting  the  back.  In  cases  due  to 
syphilis  iodide  of  potash  should  be  given,  although  it  is  true  that  in  a 
minority  only  of  them  has  it  a  specific  effect.  When  a  gumma  is  present  it 
is  of  value,  as  it  is  elsewhere.  It  should  be  given  in  increasingly  large  doses 
until  one  or  two  drachms  are  taken  three  times  a  day.  Under  these  heroic 
doses  the  poisonous  effects  should,  of  course,  be  carefiilly  watched  for. 

When  the  myelitis  is  due  to  caries  of  the  spine,  extension  should  be 
applied  according  to  surgical  principles.  Under  this  treatment  even  ex- 
treme cord  symptoms  usually  subside  and  excellent  results  are  obtained. 
Guttmann  reports  two  cases  of  pressure  myelitis  from  caries  treated  by  sus- 
pension with  great  relief  and  improvement.  Extension  and  rest  in  bed, 
however,  are  preferable. 

The .  necessity  of  taking  early  measures  to  prevent  the  formation  of  bed- 
sores and  cystitis  cannot  be  insisted  upon  too  strongly.  By  neglecting  pre- 
cautions to  this  end  until  these  complications  have  developed,  the  physician 
will  only  increase  his  own  care,  as  well  as  the  suffering  of  his  patient.  Bed- 
sores and  cystitis  are  often  the  cause  of  a  fatal  issue.  The  portions  of  the 
body  on  which  pressure  comes  should  be  kept  scrupulously  clean  and  guarded 
as  much  as  possible  from  pressure.  The  skin  should  be  carefully  watched 
for  the  first  sign  of  necrosis,  and  daily  washed.  Bathing  with  alcohol  and 
water  is  useful.  When  bed-sores  have  developed,  they  should  be  thoroughly 
and  systematically  treated,  according  to  surgical  principles.  Antiseptics 
shoukl  be  employed  with  a  view  to  both  healing  and  the  prevention  of  septi- 
csemia.  Stimulant  lotions,  such  as  myrrh-wash  and  iodoform,  are  often  of 
value.  Hammond's  galvanic  plates  deserve  a  trial.  A  water-bed  is  one 
of  the  best  appliances ;  it  should  be  covered  with  a  sheet.  The  paralyzed 
parts  should  be  kept  warm,  but  care  should  be  taken  that  a  hot-water  bag 
and  l)ottles  should  not  be  at  too  high  a  temperature,  as  a  degree  of  heat  which 
would  be  harmless  to  a  sound  skin  will  sometimes  ])roduce  a  slough.  I  have 
known  severe  sloughs  to  be  caused  unwittingly  in  tliis  way. 

Retention  of  urine  requires  equal  care.     The  urine  should  be  drawn  regu- 


570  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

larly  with  a  catheter,  extra  care  being  taken  to  see  that  the  instrument  is 
thoroughly  aseptic.  When  constant  incontinence  is  present  a  urinal  may 
be  employed  with  males,  although  care  must  be  used,  as  the  friction  of  the 
vessel  sometimes  causes  sloughs.  Gowers  recommends  the  use  of  large  pads 
of  absorbent  cotton  or  oakum  instead  of  a  urinal.  The  wool  or  cotton  should 
be  changed  as  often  as  saturated.  If  cystitis  occurs,  it  must  be  rigidly  treated 
on  surgical  princi]3les. 

In  the  later  periods  of  the  disease  the  patient's  general  strength  and  nutri- 
tion should  be  built  up  with  tonics,  nutritious  food,  etc.  At  this  period  of  the 
disease,  when  repair  is  going  on,  the  return  of  sensation  is  often  hastened  by 
the  judicious  stimulation  of  the  sensory  nerves  by  a  gentle  faradic  current. 
The  condition  of  the  muscles,  when  soft  and  flabby,  may  be  improved  by 
massage  and  electrical  stimulation. 

Chronic  Myelitis.  Chronic  myelitis  may  be  the  sequel  of  a  previous 
acute  process,  which,  instead  of  subsiding,  takes  on  a  chronic  course,  or  it 
may  originate  in  the  chronic  form.  The  first  type  may  for  convenience  be 
termed  secondary,  and  the  latter  primary.  Like  acute  myelitis,  it  may  be 
transverse,  disseminated,  or  more  or  less  diffused.  The  transverse  is  the  most 
common  form. 

Antomically  chronic  myelitis  differs  from  the  acute  process  in  the  greater 
prominence  of  the  growth  of  interstitial  tissue,  the  absence  of  much  vascular 
change,  and  the  comparatively  slight  amount  of  softening  of  the  substance 
that  takes  place,  at  least  in  that  form  which  is  chronic  from  the  beginning. 
In  consequence  of  the  development  of  interstitial  tissue  the  disease  is  some- 
times described  as  sclerosis  of  the  cord,  and  resembles  in  its  anatomical  ap- 
pearance the  system  scleroses,  with  the  difference  that,  instead  of  the  process 
being  limited  to  certain  tracts  in  the  cord,  it  invades  the  whole  substance, 
spreading  from  a  primary  focus  to  the  adjoining  structures. 

As  a  primary  disease  chronic  myelitis  is  as  comparatively  rare  as  the  sys- 
tem scleroses  are  common.  During  an  experience  of  over  ten  years  in  the 
clinic  for  nervous  diseases  at  the  Boston  City  Hospital  I  can  recall  but  few 
cases  of  the  primary  form  which  could  be  properly  diagnosed  as  chronic 
myelitis. 

Etiology.  The  most  common  causes  are  a  previously  acute  myelitis,  com- 
pression (caries,  tumor,  etc.),  hemorrhage,  and  a  traumatism  which  has  caused 
a  bruising  of  the  cord  or  membranes.  As  a  primary  disease  it  may  be  due  to 
syphilis,  which  induces  sclerosis  of  the  vessels  and  interstitial  inflammation. 

Repeated  exposure  to  cold  is  generally  acknowledged  to  be  an  effective 
cause.  The  disease  may  be  excited  by  the  extension  of  inflammation  from 
adjoining  structures  ;  hence,  it  may  follow  chronic  meningitis.  Under  such 
conditions  the  inflammatory  process  extends  into  the  cord,  along  the  pro- 
cesses of  the  pia  mater,  after  which  the  myelitis  may  take  on  an  independent 
course.  We  thus  have  a  meningo-myelitis.  By  some,  chronic  myelitis  is 
thought  to  be  the  direct  sequel  of  an  ascending  neuritis,  as,  for  example,  a 
neuritis  of  the  sacral  plexus  following  injury  in  childbirth.  Traumatism, 
or  so-called  "  spinal  concussion,"  is  said  to  be  a  cause ;  but  in  such  cases  the 
myelitis  is  probably  always  secondary  to  a  small  hemorrhage  within  or  around 
the  cord,  or  to  a  bruising  of  the  cord  itself  by  temporary  dislocation  of  the 
vertebrse  with  spontaneous  reduction.  Dislocations  of  this  kind  are  more 
common  than  is  generally  supposed.  Alcoholism  is  a  common  cause,  and 
some  cases  have  been  ascribed  to  the  poison  of  infectious  diseases  and  gout 
(Gowers). 

Pathological  Anatomy.  The  morbid  process  consists,  in  the  main,  of  a 
destruction  of  the  nervous  elements  and  a  proliferation  of  the  interstitial  tis- 
sues.    In  the  white  substance  the  myelin  of  the  nerve-fibre  disappears,  while 


DISEASES  OF  THE  SPINAL  CORD  571 

at  first  the  axis-cylinders  persist  and  appear  imbedded  in  the  proliferating 
neuroglia  tissues.  The  nuclei  of  this  neuroglia  are  much  increased  in  num- 
bers, and  among  other  varieties  of  cells  "  spider  cells  "  are  found  with  their 
long  processes  extending  into  and  contributing  to  the  formation  of  the  con- 
nective-tissue growth.  The  trabeculse  of  connective  tissue  become  thick- 
ened and  the  normal  network  of  interstitial  tissue  enormously  increased  in 
amount.  This  may  appear  as  fibrillary  or  amorphous  material.  Later  the 
axis-cylinders  disappear  and  nothing  is  left  of  the  nervous  structures,  but  in 
their  places  is  found  shrunken  connective  tissue.  The  bloodvessels  take  part 
in  the  process ;  their  walls  become  studded  with  nuclei  and  thickened,  and 
their  lumen  becomes  diminished  and,  it  may  be,  occluded. 

In  the  gray  substance  changes  practically  of  the  same  kind  take  place,  and 
result  in  the  destruction  and  disappearance  of  the  cells.  The  pia  mater  may 
take  part  in  the  process  if  the  disease  reaches  the  surface  of  the  cord,  or  it 
may  be  the  starting-point  of  the  inflammation — meningo-myelitis.  The  pia 
is  then  thickened  over  the  diseased  areas  and  trabecule  of  the  connective 
tissues  extend  into  the  cord  from  the  surrounding  thickened  membrane. 
The  consequences  of  these  changes  in  the  microscopical  appearance  of  the 
cord  are  to  give  to  the  naked  eye  a  gray  and  discolored  look  to  the  cut  sur- 
face of  the  affected  part,  which  is  harder  than  normal.  The  cord  is  shrunken, 
sometimes  not  being  more  than  one-half  its  normal  size,  and  its  contour  mis- 
shapen. The  whole  thickness  of  the  cord  may  be  more  or  less  involved, 
though  the  whole  diameter  is  not  affected  with  equal  intensity,  while  verti- 
cally the  disease  may  be  limited  to  one  or  two  segments.  Secondary  ascend- 
ing and  descending  scleroses  develop  according  to  the  usual  laws  and  pro- 
duce their  characteristic  symptoms. 

Symptoms.  The  symptoms  of  chronic  myelitis  are  similar  in  their  group- 
ing to  those  of  the  subacute  or  acute  form.  They  differ  principally  in  the 
fact  that  they  are  slower  in  their  development,  and  therefore  a  much  longer 
time  elapses  before  the  disease  has  attained  its  typical  development,  and  the 
affection  may  in  the  early  stages  bear  more  or  less  resemblance  to  other  spinal 
diseases. 

Instead  of  a  rapidly  developing  paralysis  which  compels  the  patient  to  take 
to  his  bed,  he  is  able  to  go  about  for  a  long  time  pursuing  his  ordinary  voca- 
tion, and  complaining  only  of  weakness  and  heavy  feelings  in  the  affected 
limbs.  He  notices  that  his  legs  feel  heavy  and  are  easily  tired,  and  this  may 
exist  for  months,  or  even  years,  before  the  paresis  has  developed  to  so  great  an 
extent  that  he  cannot  get  about.  (See  Fig.  172.)  Sensory  disturbances  are 
also  complained  of,  but  they  are  not,  as  a  rule,  so  marked  as  the  loss  of  power. 
There  may  be  nagging  pains,  not  sufficiently  intense  to  be  a  source  of  great 
suflTering  or  to  call  for  opiates,  but  sufficient  to  be  annoying  and  a  source  of 
discomfort.  Various  forms  of  parsesthesise  also  occur  in  the  form  of  numb- 
ness, pin-and-needle  feelings,  etc.  Later,  loss  of  sensation  develops,  which 
may  at  first  be  confined  to  limited  areas  of  the  limbs  and  body.  The  inten- 
sity of  the  anaesthesia  varies,  but  it  is  rarely  as  great  as  in  the  acute  form,  in 
which  it  is  as  prominent  as  the  accompanying  paresis.  When  the  myelitis 
extends  forward  into  the  anterior  cornua,  atrophy  of  the  muscles  is  added  to 
the  symptom  group.  This  atrophy  is  usually  irregular  in  its  distribution,  and 
is  likely  to  be  limited  to  certain  groups  of  muscles  arising  from  one  or  two 
segments  of  the  cord  into  which  the  myelitis  has  extended.  The  reflexes 
passing  through  the  cord  below  the  lesion  are  increased,  while  those  sub- 
served by  the  diseased  area  are  diminished  or  lost.  Some  loss  of  control 
over  the  bladder  and  bowels  is  likely  to  occur ;  the  patient  may  experience 
a  difficulty  in  retaining  the  urine  or  completely  emptying  the  bladder.  Some 
ataxy  may  be  present  from  damage  to  the  posterior  columns.     Sooner  or 


572  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

later  there  are  grouped  together  all  the  symptoms  that  point  to  the  involve- 
ment of  the  different  structures  of  the  cord,  motor,  sensory,  trophic,  etc.,  and 
which  indicate  that  the  disease  is  not  limited  to  any  one  system,  as  in  the 
other  chronic  degenerative  diseases.  As  the  disease  is  slow  in  its  development, 
it  is  evident  that  for  a  time  the  inflammatory  process  will  be  limited  to  certain 

Fig.  172. 


1 

W^  yV^-rf .HH^^I 

Gait  in  a  case  of  chronic  myelitis.    From  instantaneous  serial  photographs  of  a  patient  of 
Dr.  Dercum,  by  Muybridge. 

parts  of  the  cord,  and  thus  the  disease  may  temporarily  simulate  the  differ- 
ent system  diseases,  especially  primary  spastic  paralysis  and  chronic  polio- 
myelitis. When  the  pyramidal  tracts  are  principally  implicated  there  will 
be  marks  of  spastic  paralysis,  with  the  usual  exaggeration  of  the  reflexes, 
etc. ;  but  a  careful  examination  will  show  that  the  sensory  and  other  elements 
are  more  or  less  affected,  and  the  later  progress  of  the  disease  will  make  it 
clear  that  the  cord  is  transvei"sely  affected.  In  the  disseminated  form,  where 
there  are  a  number  of  diseased  foci  scattered  through  the  cord,  all  possible 
combinations  of  symptoms  may  be  present,  and  when  the  symptoms  of  the 
different  foci  fuse  together  they  may  present  the  picture  of  a  transverse 
lesion.  A¥hen  atrophy  of  the  muscles  is  present,  electrical  changes  will  be 
found,  usually  a  simple  diminution  of  contractility  to  both  faradic  and  gal- 
vanic currents.  Some  qualitative  changes  may  sometimes  be  found,  or  with 
the  loss  of  faradism  galvanic  contractility  may  be  maintained  or  diminished. 

For  a  further  description  of  the  symptoms  the  reader  is  referred  to  the 
account  of  acute  and  subacute  myelitis,  bearing  in  mind  that  the  chief  dif- 
ference is  the  more  gradual  development  of  the  symptoms. 

Erb  has  described,  under  the  name  "  syphilitic  spinal  paralysis,"  a  group  of 
symptoms  which  he  considers  pathognomonic  of  myelitis  when  due  to  syphilis. 
For  a  description  of  this  affection  the  reader  is  referred  to  the  section  on 
Spinal  Syphilis  in  Chapter  XXIV. 

Course  and  Termination  of  the  Disease.  As  has  been  said,  the  course  of 
chronic  myelitis  is  usually  slow,  extending  over  many  years,  but  it  is  gener- 
ally progressive,  though  there  may  be  stationary  periods.  It  may  cease  in 
its  progress  at  any  period.  The  periods  of  cessation  may  be  followed  by 
periods  of  comparatively  rapid  increase  of  the  symptoms.  It  may  remain 
stationary  for  a  .long  period  of  time.  Death  may  take  place  from  involve- 
ment of  the  medulla,  in  rare  cases  from  bed-sores,  more  commonly  from 
intercurrent  disease. 


DISEASES  OF  THE  SPINAL  COED.  573 

Prognosis.  It  must  always  be  difficult  to  forecast  the  future  in  any  indi- 
vidual case,  at  least  without  watching  its  progress  for  some  little  time.  In 
the  great  majority  of  cases,  so  far  as  complete  recovery  is  concerned,  the 
prognosis  must  be  unfavorable.  After  sclerosis  has  been  established  the  im- 
possibility of  removing  it  is  apparent,  but  there  is  always  a  possibility  of  the 
inflammatory  process  stopping  at  any  time,  even  if  we  cannot  say  of  being 
arrested  by  treatment,  and  when  this  has  taken  place  it  is  possible  that 
there  may  be  an  amelioration  of  the  symptoms  and  considerable  restitution 
of  the  lost  functions.  We  can  easily  understand  how  this  can  occur  by  sup- 
posing restoration  of  the  myelin  in  the  fibres  which  still  retain  their  axis- 
cylinders,  and  a  regeneration  of  the  axis-cylinders  which  have  undergone 
only  the  first  stages  of  atrophy.  It  may  also  be  assumed  that  nerve-cells 
that  are  only  degenerated,  not  destroyed,  may  recover  their  normal  con- 
dition, but  such  nerve  structures  as  are  absolutely  destroyed  and  have  their 
places  replaced  by  hypertrophied  neuroglia  tissue  are  lost  forever.  It  is  pos- 
sible also  that  the  functions  of  the  destroyed  fibres  may  be  more  or  less  car- 
ried on  by  other  tracts,  and  in  this  way  a  certain  amount  of  restitution  of  the 
functions  be  obtained.  We  know  this  obtains  in  some  cases  of  posterior 
sclerosis,  in  which  there  has  been  a  disappearance  of  ataxy  and  other  symp- 
toms, although  the  autopsy  has  shown  the  persistence  of  the  sclerosis  of  the 
posterior  columns. 

The  disease  is  not  necessarily  progressive,  and  long  stationary  periods 
occur  in  which  little  or  no  change  can  be  discovered  in  the  symptoms.  It 
may  lead  to  death  in  the  course  of  years,  varying  in  individual  cases  from 
three  to  twenty  (Spitzka).  When  the  disease  is  comparatively  intense  in  its 
development,  even  though  it  is  of  limited  extent,  the  prognosis  is  worse  than 
when  the  disease  is  more  extensive  in  its  distribution  and  mild  in  its  course. 
It  is  also  more  dangerous  to  life  when  it  is  located  in  the  lumbar  enlarge- 
ment, where  it  is  more  likely  to  occasion  bed-sores,  cystitis,  etc. 

When  in  the  upper  cervical  enlargement  there  is  danger  to  life  from  in- 
volvement of  the  respiratory  centres ;  and  in  any  case  when  the  lesion  has 
become  transverse,  or  approximately  so,  there  is  always  danger  from  the 
exhaustion  which  usually,  sooner  or  later,  supei'venes  in  such  cases. 

In  cases  due  to  syphilis  (Erb's  type)  there  is  a  tendency  toward  improve- 
ment under  specific  treatment. 

Diagnosis.  The  principal  and  more  common  diseases  from  which  chronic 
myelitis  must  be  difierentiated  are  spastic  paralysis,  chronic  poliomyelitis, 
progressive  muscular  atrophy,  compression  from  caries  or  tumor.  It  is  only 
in  the  early  stages  that  the  disease  is  likely  to  be  mistaken  for  primary 
spastic  paralysis.  Sensory,  atrophic,  and  other  symptoms  indicative  of  in- 
volvement of  other  parts  of  the  cord  than  the  pyramidal  tracts  will  clear  up 
the  diagnosis.  When  the  chief  incidence  of  the  inflammatory  process  falls 
upon  the  anterior  cornua  the  disease  may  resemble  chronic  poliomyelitis, 
which  by  some  is  considered  a  special  variety  only  of  chronic  myelitis,  while 
others  consider  it  a  distinct  affection.  The  atrophy  in  chronic  myelitis  is 
more  irregular  in  distribution  and  associated  with  sensory  and  other  symp- 
toms. The  development  of  paralysis  in  parts  below  the  level  of  the  cord 
lesion,  with  spastic  symptoms  showing  the  involvement  of  the  pyramidal 
tracts,  will  be  a  sufficient  indication  that  the  disease  is  not  limited  to  the 
anterior  cornua. 

Progressive  muscular  atrophy  is  more  likely  to  be  confounded  with  the 
disease  under  consideration,  but  the  indication  of  damage  to  other  struc- 
tures in  the  cord,  such  as  pain,  loss  of  sensation,  and  paresis  of  the  sphinctess, 
will  sooner  or  later  afford  a  sufficient  basis  for  distinction. 

In  compression  from  caries  the  presence  of  spinal  deformity  will  usually 


574  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

be  sufficient,  though  with  caries  there  is  apt  to  be  some  ruyehtis,  ^vhich  takes 
on  a  chronic  course.  With  tumors  the  pain  is  much  more  intense,  and  in  a 
large  proportion  of  cases  there  is  marked  spasm  or  rigidity  of  the  muscles. 
These  symptoms  of  irritation  are  apt  to  precede  those  indicative  of  damage. 

At  times  symptoms  similar  to  those  of  myelitis  may  be  caused  by  chronic 
pachymeningitis  and  leptomeningitis  and  ataxic  paraplegia.  The  reader  is 
referred  to  the  description  of  those  diseases  for  the  purpose  of  diagnosis. 

Treatment.  We  may  set  before  ourselves  the  fact  that  we  cannot  remove 
the  interstitial  tissue  tlmt  has  been  formed,  nor  restore  nerve  structures  that 
have  been  destroyed,  but  the  possibility  of  arresting  the  disease  and  thereby 
saving  such  neural  structures  as  have  not  been  destroyed,  and  giving  an 
opportunity  to  those  only  partially  disabled  to  recover  their  normal  condition, 
is  one  that  should  always  be  entertained.  At  the  outset  it  is  desirable  to 
search  for  such  causes  as  seem  likely  to  have  in  any  individual  case  incited 
the  disease,  and  may  be  still  acting,  and  to  remove  the  patient  from  their 
influence,  even  though  we  may  not  have  scientific  certainty  that  they  are  the 
etiological  agents.  In  a  disease  of  such  gravity,  and  in  which  the  conse- 
quences are  so  disabling,  it  is  not  wise  to  neglect  every  precaution  in  the 
absence  of  absolute  certainty  of  the  cause.  If  the  patient  continues  to  be 
constantly  exposed  to  cold  and  the  hardships  of  weather,  he  should  be 
warned  against  the  danger,  and  a  change  of  occupation  or  habits  insisted 
upon.  Complete  and  absolute  rest  in  bed  at  first  is  desirable  for  a  while,  but 
in  a  disease  of  such  long  duration  it  is  not  practicable  or  desirable  to  con- 
tinue it  beyond  a  few  weeks.  Overuse  of  the  damaged  nerve  structures 
should  be  avoided,  and,  therefore,  the  patient  should  be  cautioned  against 
overexertion  and  physical  fatigue.  The  daily  use  of  warm  baths  is  recom- 
mended by  some,  with  the  view  of  acting  upon  the  peripheral  nerves  and 
circulation  and  thereby  indirectly  affecting  the  circulation  and  nutrition  of 
the  cord.  In  other  words,  it  is  thought  that  warm  baths  have  an  effect  con- 
trary to  a  cold  one.  They  are  certainly  agreeable  to  the  patient,  seem  to  be 
palliative  and  remove  uncomfortable  symptoms,  and  therefore  seem  to  benefit. 
The  temperature  should  not  be  too  high,  as  extremes  of  heat  and  cold  in 
many  respects  seem  to  have  the  same  physiological  reflex  eflects  on  the  cir- 
culation and  nervous  centres. 

When  possible  it  may  be  desirable  to  send  the  patient  in  the  winter  to  a 
warm  climate.  It  is  generally  considered  that  a  cold  climate  has  a  delete- 
rious effect  on  the  disease  and  a  warm  one  a  favorable  influence.  Spitzka 
considers  every  month  spent  in  a  cold  climate  as  so  much  time  lost.  When 
syphilis  is  present  or  there  is  reasonable  grounds  to  suspect  its  existence,  anti- 
syphilitic  treatment  should  be  energetically  pushed,  for,  besides  the  possi- 
bilities of  cure,  if  syphilis  can  excite  the  morbid  process,  it  is  possible  that 
the  same  influence  may  prevent  its  subsiding.  We  have  not  a  sufficient 
knowledge  of  the  mode  in  which  syphilis  induces  myelitis  to  justify  us  in 
neglecting  any  precaution,  nor  can  we  always  be  certain  that  some  gummatous 
growth  may  not  be  present.  As  was  said  above,  some  cases  of  Erb's  type 
are  cured  and  many  are  improved  by  specific  treatment.  (See  also  Chapter 
XXIV.; 

The  mixed  treatment  should  be  given  and  the  iodides  should  be  pushed 
in  large  doses  at  first ;  later  they  should  be  diminished  and  given  in 
smaller  doses  during  a  long  period.  The  individual  symptoms  should  be 
treated  as  in  other  destructive  diseases  of  the  cord.  Blisters  and  the  cautery 
are  often  useful  for  the  relief  of  pain  when  this  is  present  in  a  sufficiently 
intense  form  to  be  annoying.  One  of  the  best  modes  of  relieving  pain  is 
the  electric  battery.  Faradism,  galvanism,  or  static  electricity  may  be  used  ; 
sometimes  one  is  more  palliative  and  sometimes  another.     The  application 


DISEASES  OF  THE  SPIXAL  CORD.  575 

should  be  continuously  repeated,  either  daily  or  three  times  a  week.  It  must 
not  be  expected  that  electricity  will  directly  affect  the  cord,  but  it  is  of  great 
value  in  keeping  the  patient  comfortable  and  rendering  unnecessary  a  resort 
to  anodynes. 

Faradism  has  the  advantage  that  a  battery  can  be  placed  in  the  patient's 
hands  and  can  be  used  daily  at  home.  Careful  instructions  should  be  given 
as  to  its  use,  otherwise  it  is  likely  that  it  will  be  very  inefficiently  applied. 
The  best  method  for  the  relief  of  pain  is  to  brush  large  surfaces  of  the  skin, 
particularly  the  areas  supplied  by  the  nerves  rising  from  the  seat  of  the  lesion, 
using  a  moderate  current.  When  bed-sores  are  present  they  should  be  looked 
after  with  the  greatest  care,  the  usual  surgical  means  being  employed  for 
this  purpose.  The  method  of  Hammond,  viz.,  using  two  plates,  one  of  zinc 
and  one  of  silver,  connected  by  insulated  wires,  has  been  used  with  success. 
The  silver  plate  is  placed  directly  upon  the  bed-sore  ;  the  zinc  plate  is  covered 
Avith  a  piece  of  flannel  or  absorbent  cotton  wool,  and  is  placed  upon  the  ad- 
joining sound  skin.  The  whole  is  worn  continuously.  This  is  said  to  give 
good  results.  See  also  the  method  of  feedinsf  bed-sores  described  in  Chapter 
XXIII. 

The  general  health  of  the  patient  must,  of  course,  be  built  up  by  tonics, 
food,  and  a  hygienic  course  of  life.  There  is  no  drug  knoAvn  that  has  any 
.specific  influence  upon  the  disease  and  the  use  of  drugs  cannot  be  recom- 
mended. They  have  the  disadvantage  of  diverting  the  mind  of  both  j^hysician 
and  patient  from  the  importance  of  other  measures  eflecting  the  daOy  life  of 
the  patient  such  as  have  been  described,  and  thus  indirectly  lead  to  procras- 
tination and  neglect.  If  paralysis  of  the  bladder  exists,  the  iruportance  of 
guarding  against  the  dangers  of  retention  and  cystitis  cannot  be  too  ui'gently 
insisted  upon. 


THE  CAISSON  DISEASE,  OR  DIVER'S  PARALYSIS. 

Persons  who  have  been  exposed  to  high  atmospheric  pressure  in  a  caisson 
or  diver's  apparatus  are  liable,  on  returning  to  the  outer  air,  to  be  attacked 
with  j)aralysis  Tgenerally  paraplegia)  and  other  nervous  symptoms.  The 
symptoms  are  attributable  to  the  sudden  change  of  atmospheric  pressure,  for 
if  precautions  are  taken  to  make  the  change  of  pressure  sufficiently  gradual 
they  may  be  avoided.  The  increased  pressure  must  be,  as  a  rule,  over  one 
atmosphere,  for  when  it  is  less  than  this  the  symptoms  rarely  ensue.  They 
come  on  shortly  after  returning  to  the  outer  air,  when  they  may  immediately 
ensue  or  they  may  be  delayed  for  an  hour.  They  have  occurred  in  the  lock 
of  a  caisson  where  the  atmospheric  pressure  is  gradually  lowered.  The  symp- 
toms are  both  cerebral  and  spinal.  The  former  consist  of  feelings  of  faint- 
ness,  prostration,  headache,  nausea,  vomiting,  giddiness,  double  vision,  inco- 
herence of  speech,  and  even  coma,  any  one  or  all  of  which  may  precede  or 
accompany  the  paralysis,  which,  in  the  severer  cases,  is  the  most  obtrusive 
symptom.     Vomiting  is  frequently  prominent. 

Xeuralgic  pains  are  present  in  the  majority  of  cases  and  are  generally  one 
of  the  earliest  symptoms.  These  pains  are  of  all  degrees  of  severity,  being 
sometimes  mild  and  sometimes  so  excruciating  as  to  demand  large  doses  of 
morphine;  they  usually  occur  in  paroxysms,  with  intervals  of  remission. 
They  may  be  "  tearing  "  in  character.  They  are  generally  felt  in  the  legs,  but 
may  be  located  in  the  arms,  back,  or  any  part  of  the  ])ody.  Epigastric  pain 
is  common.  These  pains  may  still  continue,  even  thcnigh  complete  anaes- 
thesia is  present  in  the  painful  parts — aua'dhe-na  dolorom.  The  large  joints, 
especially  the  knees,  are  frequently  the  seat  of  pain.     It  is  interesting  to 


576  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

notice  that  the  pains  have  much  similarity  with  the  irritative  root  or  cord 
pains  which  occur  with  tumors  of  the  cord,  and  are  probably  likewise  due  to 
irritation  of  the  sensory  cord  fibres. 

In  mild  cases  the  symptoms  may  be  limited  to  these  pains,  with  nausea, 
vomiting,  giddiness,  or  one  or  more  of  the  symptoms  just  mentioned. 

In  severe  cases,  shortly  after  the  onset  of  the  pain,  the  patient  notices  that 
his  leg's  feel  heavy  and  Aveak ;  this  weakness  increases  and  may  develop  into 
a  complete  paraplegia.  Occasionally  all  four  extremities  are  paralyzed,  and 
in  rare  cases  there  may  be  a  hemiplegia.  With  the  development  of  para- 
plegia sensation  is  diminished  or  lost  in  the  legs.  In  the  more  severe  cases 
the  sphincters  are  affected  and  there  are  a  retention  of  urine  and  constipation. 
In  other  cases  the  onset  is  marked  by  a  sudden  but  temporary  loss  of  con- 
sciousness, lasting  about  fifteen  minutes,  and  followed  by  the  above  paralytic 
symptoms.  Hemorrhage  from  the  mucous  membranes  has  been  sometimes 
noted. 

The  cases  vary  in  severity  from  mild  weakness,  prostration,  with  one  or 
more  of  the  other  symptoms  just  mentioned,  up  to  absolute  paralysis  and  im- 
pairment of  the  functions  of  the  cord. 

In  cases  of  more  violent  onset  the  patient  may  fall  down  unconscious  soon 
after  emerging  into  the  outer  air,  and  death  may  take  place  in  a  few  hours 
without  recovery  of  consciousness.  In  one  case,  for  example,  a  man  came 
out  from  a  caisson  and  washed  himself,  and  then  fell  down  and  died  in  fifteen 
minutes.^ 

In  another  instance,  a  man  complained  of  not  feeling  well  about  one  hour 
after  coming  out  of  the  caisson  and  went  to  his  lodging-house  a  few  rods  dis- 
tant. As  he  passed  through  the  lower  story  of  the  house  on  his  way  to  his 
own  room,  which  was  on  the  story  above,  he  complained  of  pain  in  the  ab- 
domen. While  ascending  the  stairs  he  sank  down  insensible,  and  was  dead 
before  he  could  be  laid  on  his  bed." 

In  these  apoplectiform  cases  there  may  be  delirium  and  convulsions.  A 
man  who  rajDidly  became  unconscious  developed  a  muttering  delirium,  but 
no  paralysis,  and  died  the  next  day.^ 

The  majority  of  cases  recover.  In  mild  cases,  and  even  in  cases  where 
there  has  been  temporary  loss  of  consciousness,  succeeded  by  paralysis,  with 
loss  of  control  over  the  sphincters,  etc.,  recovery  may  take  place  in  a  few 
days  or  even  hours.  The  course  of  the  symptoms  and  the  mortality  vary 
much  according  to  the  conditions  of  exposure.  Of  110  Brooklyn  bridge 
cases  which  were  of  sufiicient  severity  to  come  under  treatment  three  j^roved 
fatal.  At  St.  Louis,  out  of  a  total  of  352  men  employed,  30  were  seriously 
affected  and  12  died.  Paralysis  occurred  in  61  per  cent,  of  the  St.  Louis 
cases  (47  out  of  77  cases  observed  by  Jaminet),  but  in  only  15  per  cent,  of 
the  New  York  cases. 

In  the  severer  cases  the  disease  is  more  protracted,  and  if  recovery  does 
not  occur  within  the  first  six  or  eight  days  typical  symptoms  of  a  dorsal  or 
lumbar  myelitis  develop,  and  the  case  pursues  the  usual  course  of  that  disease. 
In  such  cases,  in  addition  to  the  loss  of  power  and  sensation,  bed-sores, 
cystitis,  pyelitis,  muscular  wasting,  etc.,  may  occur.  In  some  cases  bloody 
urine  has  been  noted.  In  the  fatal  cases,  when  death  does  not  take  place 
within  a  few  hours,  the  symptoms  deepen  and  death  occurs  after  several  days 
or  it  may  be  after  weeks  (eight  or  ten)  from  myelitis.  When  recovery  occurs 
it  may  be  complete  or  only  partial. 

>  Pol,  B.,  et  Wattelle.T.  I.  I  :    Ann.  d'Hyg.  Pub.  et  Med.  Legale,  Paris,  1S54,  2  S.,  t.  i.  pp.  241-279. 
Quoted  by  Van  Rensselaer. 
-  A.  H  Smith  :  The  Physiological.  Pathological,  and  Therapeutic  Effects  of  Compressed  Air,  1SS6. 
^  E.  A.  Clark  :  Med.  Archives,  St.  Louis,  1S70-71,  v.  pp.  130-295-300.    Quoted  by  Van  Rensselaer. 


DISEASES  OF  THE  SPINAL  CORD.  577 

Etiology.  While  the  exciting  cause  of  the  disease  is  exposure  to  high 
atmospheric  pressure,  there  are  several  conditions  which  may  be  regarded  as 
predisposing  causes.  There  seems  to  be  a  predisposition  by  which  certain 
persons  are  more  likely  to  be  affected  than  others.  This  is  only  another  way 
of  saying  that  the  vtiscular  system  of  one  person  has  a  greater  capacity  to 
accommodate  itself  to  altered  conditions  than  that  of  another. 

Alcoholism,  heart  and  kidney  disease,  old  age,  in  fact  anything  tending 
to  lower  the  vitality  of  the  body,  predisposes  to  the  affection.  It  is  generally 
thought  that  fulness  of  habit  and  obesity  are  predisposing  causes.  Smith 
states'  "  that  during  the  progress  of  the  work  on  the  East  River  Bridge, 
there  was  among  those  taken  sick  a  remarkable  preponderance  of  men  of 
heavy  build  with  a  tendency  to  corpulency.  Of  thirty-five  men  of  this  build 
only  three  escaped  sickness,  while  of  fifty-three  lank  and  spare  men  twenty- 
five  men  escaped."  The  mode  in  which  obesity  acts  will  be  stated  in  the 
discussion  on  pathology. 

One  of  the  most  potent  factors  is  inexperience  in  the  work.  In  the  report 
of  the  construction  of  the  great  St.  Louis  Bridge,  Captain  Eads  states  that 
nearly  all  the  deaths  occurred  among  the  inexperienced  workmen.  Several 
of  the  fatal  cases  were  men  who  had  worked  but  one  watch  of  two  hours. 
Those  who  had  begun  to  work  with  the  commencement  of  the  operation,  and 
thus  had  become  accustomed  to  the  increasing  pressure  at  lower  depths,  were 
unaffected  throughout,  and  no  cases  of  importance  occurred  after  the  watches 
were  reduced  to  one  hour,  although  the  work  was  finally  carried  on  at  a 
depth  of  ninety  feet.  In  the  Wyoming  (Pennsylvania)  cases  (reported  by 
Charles  P.  Knapp)  10  per  cent,  of  the  old  hands  and  35  per  cent,  of  the 
new  were  afiected. 

Severe  muscular  exertion  and  chilling  of  the  body  after  leaving  the  lock 
are  thought  also  to  be  predisposing  factors.  Jaminet  considers  that  entering 
the  caisson  fasting  has  a  similar  influence. 

Pathology.''  In  considering  the  patholoy  of  this  affection,  it  is  necessary 
to  take  certain  facts  into  consideration.  The  symptoms  develop,  not  while 
the  individual  is  exposed  to  the  high  pressure,  but  only  after  returning  to 
the  normal  atmosphere ;  other  things  being  equal,  the  longer  a  person  has 
been  exposed  to  a  high  pressure  and  the  greater  the  pressure  the  greater  the 
danger.  In  practical  works  it  is  customary  to  take  advantage  of  this  and  to 
limit  the  length  of  time  during  Avhich  the  workmen  are  exposed.  The  danger 
may  also  be  lessened  or  averted  by  gradually  diminishing  the  pressure  before 
leaving  the  caisson.  For  this  purpose  locks  are  provided.  Constant  expo- 
sure protects,  and  workmen  become  acclimated,  so  to  speak,  within  certain 
limits.     Inexperienced  persons  are  more  liable  to  be  attacked  than  others. 

It  has  also  been  found  that  anything  that  lowers  the  vitality  of  the  body, 
such  as  alcohol  and  old  age,  predisposes  a  person  to  the  disease.  Obesity 
likewise  seems  to  have  this  effect. 

Many  theories  have  been  proposed  regarding  the  nature  of  the  aflTection  ; 
some  of  them  are  very  fanciful.  It  is  only  necessary  to  consider  two  of  them 
at  this  time,  viz. :  the  gaseous  theory  and  the  theory  of  congestion  with  sub- 
sequent stasis. 

According  to  the  gaseous  theory  the  blood  under  the  high  atmospheric 
pressure  becomes  supercharged  with  oxygen,  which  is  retained  in  the  blood 
so  long  as  the  high  pressure  continues.  When  the  pressure  on  the  body  is 
relieved  there  is  a  tendency  for  the  oxygen  to  escape  from  the  bloodvessels, 

1  Pepper's  System  of  Medicine,  vol.  iii.  p.  187.  ^     .       .    ,      ,.       -r,  ,         „  n^i, 

"-  The.  most  complete  discussion  on  the  pathology  of  the  affection  is  by  Van  Rensselaer  '  The 
Pathology  of  the  i;aisson  Disease,"  a  prize  essay.  Philadelphia,  1891.  In  this  paper  will  be  found 
a  complete  bibliography  with  the  post-mortem  reports  in  nearly  all  the  fatal  cases.  A  free  use  of  this 
essay  has  been  made  in  this  account  of  the  affection. 

37 


578  N^^  yO  us  DISEASES  AND  THEIR  TEE  A  TMENT. 

much  as  it  tends  to  escape  from  a  bottle  of  aerated  water  after  the  cork  has 
been  drawn.  The  lungs  cannot  remove  the  excess  of  gas  sufficiently  fast  to 
relieve  the  internal  pi'essure,  consequently  the  gas  escapes  from  the  blood 
and  is  carried  along  in  the  vessels  as  bubbles,  or  escapes  from  the  walls  of  the 
capillaries  into  the  surrounding  tissues.  In  the  soft  parts  this  escape  can 
probably  take  place  into  the  perivascular  spaces  and  surrounding  tissue  with- 
out causing  damage  of  consequence,  or  at  least  of  such  a  nature  as  to  produce 
marked  symptoms ;  but  in  an  organ  like  the  spinal  cord  it  is  presumed  that 
the  bubbles  of  gas  escaping  from  the  blood  would  act  as  emboli,  obstructing 
the  capillaries,  while  the  air  that  escaped  from  the  latter  would  exert  consid- 
erable pressure  upon  the  nerve  elements.  These  conditions  would  tend  to 
interfere  with  the  functions  of  the  cord.  In  extreme  cases  it  would  seem 
probable  that  more  or  less  structural  damage  might  be  caused  and  a  myelitis 
set  up.  As  the  gas  is  gradually  expired  from  the  lungs  and  the  pressure  in 
the  vessels  diminished  there  would  be  a  tendency  to  resorption  of  the  gas 
from  the  tissues,  and  removal  of  the  emboli  by  the  current  of  the  circula- 
tion. With  the  removal  of  the  gas  a  recovery  of  the  spinal  functions  would 
ensue. 

Aside  from  theoretrical  considerations,  there  is  some  evidence  in  support 
of  this  theory  in  the  main.  In  the  first  place,  in  some  of  the  autopsies  that 
have  been  made  gas  has  been  observed  escaping  from  the  tissues  and  in  the 
vessels.  Numerous  experiments  have  been  made  upon  animals,  which  have 
apparently  shown  the  presence  of  gas  in  the  tissues.  The  most  valuable  of 
these  are  those  of  Catsaris,  of  Athens,  who  experimented  by  shutting  dogs  up 
in  a  diver's  apparatus  and  letting  them  down  to  various  depths  in  the  sea. 
The  animals  developed  the  usual  symptoms.  The  dogs  were  then  killed,  and 
Catsaris  observed,  with  the  aid  of  a  magnifying  glass,  bubbles  of  gas  in  the 
vessels  and  in  the  tissue  itself  in  the  lumbar  region  of  the  cord.  In  the  case 
of  one  animal  which  was  killed  on  the  second  day  after  the  paralysis  was 
complete,  there  was  found  advanced  softening  of  the  cord  in  the  lumbar 
region.  The  lateral  and  posterior  columns  were  colored  a  yellowish-gray. 
A  little  below  this  region  the  gray  matter  was  red  ;  above,  the  gray  matter 
was  red,  but  without  softening  ;  there  was  said  to  be  no  congestion.  Bubbles 
of  gas  could  be  seen  in  the  middle  of  the  soft  portion  and  escaping  from  the 
vessels  surrounding  this  part. 

The  theory  of  congestion  followed  by  stasis,  proposed  by  Smith,  supposes 
that  under  the  high  pressure  the  blood  is  driven  from  the  periphery  into  the 
internal  organs,  and  particularly  the  cord  and  brain,  which  being  enclosed 
in  a  hermetically  sealed  and  resifting  bony  canal,  are  not  directly  subjected 
to  the  increased  atmospheric  pressure.  At  the  same  time  the  bloodvessels  of 
the  cerebro-spinal  system,  receiving  no  support  from  the  counter-pressure 
which  is  given  to  them  in  the  other  organs  of  the  body,  will  be  abnormally 
dilated.  Furthermore,  a  greater  quantity  of  blood  would  probably  be  forced 
into  the  cerebro-spinal  vessels  by  the  force  of  the  heart's  action  alone,  as  the 
blood  would  seek  the  easiest  channels,  which  would  be  those  vessels  which  are 
not  compressed  by  the  external  atmospheric  pressure.  By  the  overdistention 
thus  produced  it  is  presumed  that  the  walls  of  the  vessel  are  more  or  less 
paralyzed.  Thus  far,  however,  the  hypersemia  is  purely  an  active  one,  and 
the  blood  flowing  without  impediment,  no  symptoms  are  produced.  When, 
however,  the  external  atmospheric  pressure  is  removed,  the  theory  supposes 
another  condition  of  affairs  to  follow.  The  blood  rushes  to  the  periphery  of 
the  body  through  channels  which  had  been  depressed  and  largely  deprived 
of  their  blood.  -Within  the  spinal  cord  the  blood  pressure  would  in  conse- 
quence be  relieved,  and  the  circulation  would  be  retarded.  The  walls  of  the 
vessels  being  partially  paralyzed  from  overdistention  could  not  contract,  and 


DISEASES  OF  THE  SPINAL  CORD.  579 

thus  help  on  the  blood  curreut.  Thei^e  would  therefore  be  a  comparative 
stasis  of  the  circulation  of  the  brain  and  cord. 

Nixon  and  Birmingham  have  pointed  out  that  the  anatomical  arrangement 
of  the  bloodvessels  supplying  the  lower  portion  of  the  spinal  cord  are  such  as 
to  render  precarious  the  blood  supply  under  conditions  causing  a  sudden 
diminution  of  the  blood  pressure ;  such  a  diminution  would  probably  lead  to 
a  reduction  of  the  blood  supply. 

The  pathological  findings  at  autopsies  have  varied  somewhat,  and  have  not 
afforded  the  information  that  might  be  expected,  owing  to  the  incompleteness 
of  most  of  the  examinations.  Thus  far  a  post-mortem  examination  has  been 
reported  in  twenty-nine  cases,^  but  in  only  four  of  these  was  a  microscopical 
examination  of  the  cord  made.  Inasmuch  as  in  protracted  cases  myelitis 
develops,  the  condition  of  the  cord  in  such  cases  would  not  indicate  the  nature 
of  the  pathological  process  in  those  cases  in  which  the  symptoms  are  of  an 
ephemeral  nature,  or  which  have  a  rapidly  fatal  issue.  It  is  just  these  cases 
that  represent  true  caisson  disease,  and  in  which  the  nature  of  the  patholog- 
ical process  is  in  doubt.  Unfortunately,  in  the  four  autopsies  in  which  the 
cord  was  examined  microscopically  (Leyden,  Schultze,  and  Van  Rensselaer, 
Sharpies),  the  subjects  lived  sufficiently  long  to  allow  of  the  development  of  a 
myelitis,  viz. :  two  weeks,  two  and  a  half  months,  five  weeks  and  nine  weeks, 
respectively.  In  the  apoplectic  form,  or  rapidly  fatal  cases,  which  would 
afford  the  most  light  on  the  subject,  the  post-mortem  examinations  have  been 
incomplete.  Studying  the  reports  as  given,  however,  we  find  that  out  of 
twenty-nine  cases  death  took  place  within  forty-eight  hours  in  ten.  In  none 
of  these  was  the  cord  examined  microscopically,  and  in  only  four  of  the  ten 
cases  was  a  macroscopical  examination  made,  but  in  all  four  cases  it  was 
found  congested.  In  one  case  there  was  an  extensive  effusion  of  blood  pres- 
sing on  the  cord  in  the  lower  dorsal  region,  and  in  another  clots  of  blood 
were  found  on  different  parts  of  the  dura.  The  brain,  or  meninges,  or  both, 
were  reported  as  congested  in  five.  In  six  some  one  or  all  of  the  internal 
organs  were  reported  as  congested  (in  one  no  report)  ;  an  extravasation  of 
blood  in  the  kidneys  was  reported  in  two  cases.^ 

An  effusion  of  serum  under  the  arachnoid  and  dura  of  the  cord  (?)  was 
found  in  one  case.  Subcutaneous  ephysema  was  observed  in  two  cases.  It 
will  thus  be  observed  that  the  cord  was  found  congested  in  all  of  the  cases 
where  it  was  examined.  In  many  of  the  cases  that  pursued  a  chronic  course 
softening  of  the  cord  was  found,  as  might  be  expected.  Taking  all  the  cases 
(twenty-eight),  the  acute  and  chronic,  it  may  be  said  in  general  that  the  most 
constant  appearances  are  congestion  of  the  spinal  cord  and  (generally)  brain 
and  internal  organs  in  the  acute  cases,  and  softening  of  the  cord  with  similar 
congestion  of  the  internal  organs  in  the  more  protracted  cases.  The  efflision 
of  serum  in  the  spinal  canal  in  five  cases  is  worth  noting,  as  well  as  the 
extravasation  of  blood  in  the  dura  of  the  cord  in  four. 

From  all  these  considerations,  it  seems  very  probable  that  the  pathological 
conditions  underlying  the  earlier  symptoms  in  caisson  disease  are  some  kind 
of  disturbances  of  the  circulation  ;  that  congestion  is  present  would  seem  to 
be  shown  by  the  results  of  the  autopsies. 

The  mechanism  by  wdiich  this  congestion  brings  about  the  functional  dis- 
turbances is  not  quite  so  plain.  It  is  evident  that  the  primary  active  hyper- 
semia  is  not  the  exciting  factor,  inasmuch  as,  if  the  theory  of  Smith  be 
correct,  the  hypersemia  of  the  cord  is  most  active  while  the  subjects  are 

1  Van  Rensselaer's  collection  (1891)  includes  twenty-eight  cases.  More  lately  Sharpies  (Journ. 
of  Nerv.  and  Ment.  Dis.,  1894,  xix.  No.  10,  p.  636)  has  reported  an  autopsy  with  microscopical 
examination. 

2  This  explains  the  bloody  urine  sometimes  seen. 


580 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


exposed  to  the  high  barometric  pressure,  whereas  the  symptoms  do  not  de- 
velop until  after  the  pressure  has  ceased  to  exist/  The  exciting  etiological 
factor  must,  therefore,  be  the  supposed  subsequent  stasis  of  the  blood,  though 
of  the  occurrence  of  this  we  have  no  direct  evidence,  though  it  may  be 
theoretically  probable.  On  the  contrary,  it  is  possible  that  the  sudden 
diversion  of  the  blood  from  the  cerebro-spinal  system  to  the  periphery  might 
induce  an  ansemia  of  the  cord,  instead  of  a  passive  engorgement.  Such  an 
angemia  has  been  shown  '^  to  follow  compression  of  the  abdominal  aorta  and 
vena  cava,  and  to  cause  a  sudden  paraplegia ;  such  an  ansemia,  if  long  con- 
tinued, leads  to  myelitis.  It  is  verj^  likely  that  a  stasis  and  ansemia  are 
joractically  the  same  in  their  results,  excepting  that  a  stasis  would  be  more 
likely  to  cause  an  oedema  of  the  tissues,  which  may  be  the  chief  pathological 
factor.  The  fact  that  serous  effusion  into  the  membrane  has  been  found  in 
some  cases  would  lend  support  to  this  view.  It  is  readily  supposable  that  if 
the  oedema  were  absorbed  the  symj)toms  would  disappear,  but  that  when  it  is 
excessive,  in  conjunctiou  with  the  impaired  circulation,  it  would  lead  to 
changes  in  nutrition  and  softening  of  the  cord. 

The  other  pathological  facts  which  Avere  mentioned  above  are  more  in 
harmony  with  the  view  that  involves  changes  in  the  circulation  than  with 
the  gaseous  theory.  The  fact  that  repeated  exposure  protects,  that  the  longer 
the  exposui^e  and  the  more  sudden  the  withdrawal  of  the  increased  atmos- 
pheric pressure,  and  that  obesity,  alcoholism,  and  debility,  heart  and  kidney 
diseases  favor  the  development  of  the  symptoms,  are  all  in  accord  with  the 
former  theory,  while  these  phenomena  cannot  be  so  well  explained  on  the 
theory  of  the  liberation  of  gas  in  the  blood. 


Fig.  173. 


Figs.  173-178,  sections  of  cord  from  Van  Rensselaer's  case,  showing  myelitis  in  dorsal  region 
with  ascending  and  descending  degeneration.  Gray  substance  normal.  Fig.  173,  section  at  level  of 
II.  Cervical  segment. 

In  fat  people  the  amount  of  blood  in  the  periphery  is  greater,  and,  there- 
fore, there  is  a  greater  amount  of  blood  to  be  driven  into  the  interior,  while 
on  relief  of  pressure  the  peripheral  channels  through  which  the  blood  may 
flow,  are  more  numerous,  and,  therefore,  stasis  (or  anaemia)  would  be  more 
marked. 

In  the  light,  however,  of  the  experiments  of  Catsaris  and  others,  as  well 
as  the  frequent  findings  of  emphysema  in  the  tissues  of  the  blood  and  the  air 
in  the  lai-ge  vessels,  in  the  recorded  autopsies,  it  is  impossible  to  exclude 

1  Moxon  (Lancet,  1S81,  i.  p.  528)  has  pointed  out  the  fallacy  of  the  traditional  beUef  that  increased 
arterial  blood  supply  without  venous  obstruction  can  cau=e  nervous  symptoms. 
-  Herter:  "A  Study  of  Experimental  Myelitis,"  Jourual  of  Memaland  Nerv'ous  Diseases,  April, 


DISEASES  OF  THE  SPINAL  CORD. 


581 


gaseous  emboli  as  factors,  at  least,  in  the  pathological  processes.  Such  emboli 
would  certainly  tend  to  increase  the  oedema  and  stasis.  Before  reaching  a 
final  determination  of  the  exact  nature  of  the  pathology  of  the  disease,  it 
will  be  necessary  to  have  before  us  the  results  of  microscopical  examinations 
of  the  cord  in  the  rapidly  fatal  cases.     These  have  not  yet  been  made. 


VIII.  Cervical. 


Fig.  175. 


Fig.  176. 


XII.  Dorsal. 


III.  Lumbar. 


In  the  three  cases  of  Leyden,  Schulze  and  Van  Rensselaer,  in  which  a 
microscopical  examination  of  the  cord  was  made,  a  diffusive  parenchymatous 
myelitis  was  found,  leading  to  degenerative  changes. 

The  greatest  amount  of  degeneration  was  found  in  the  posterior  columns 


582  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  adjacent  portions  of  the  lateral  columns.  This  "would  seem  to  account 
for  the  prominence  of  pain  in  most  of  the  cases.  The  anterior  columns  were 
but  slightly  affected,  the  gray  matter  was  "  for  the  most  part  normal ;  even  in 
the  most  intensely  degenerated  portion  there  is  not  total  destruction  of  all 
the  nerve  substance.  Above  and  below  this  area  of  this  disease,  in  the  lower 
dorsal  region,  are  respectively  the  usual  ascending  degenerations  of  the  columns 
of  Goli,  and  the  direct  cerebellar  tracts,  and  descending  degenerations  of  the 
pyramidal  tract.  In  the  substance  of  the  cord  no  evidence  of  hemorrhage 
could  be  found. "^  In  Sharpies'  case  practically  the  same  changes  were 
found,  the  disease  being  for  the  most  part  limited  to  postero-lateral  Avhite 
colunms.  It  will  thus  be  seen  that  the  condition  of  the  cord  in  the  chronic 
cases  corresponds  with  the  symptoms,  namely,  a  myelitis. 

Treatment.  Prophylaxis  is  extremely  important  for  persons  working  in  a 
caisson.  Xo  one  should  enter  a  caisson  when  sick.  All  workmen,  before 
being  employed,  should  be  obliged  to  submit  to  a  physical  examination,  and 
any  found  suffering  from  serious  disease,  es|)ecially  kidney^  or  heart  disease, 
should  be  rejected.  Persons  known  to  be  addicted  to  or  under  the  influence 
of  alcohol  should  be  refused  employment.  Very  fat  persons  and  those  of 
advanced  age  should  enter  the  caisson  with  caution.  Inexperienced  persons 
should  in  the  beginning  limit  their  first  exjDOSure  to  the  shortest  possible  time 
practicable — one  hour  if  the  pressure  is  at  all  high — and  pass  a  liberal  time  in 
the  lock  where  the  pressure  is  gradually  reduced.  The  length  of  time  during 
which  workmen  and  others  are  daily  exposed  should  be  rigidly  regulated. 
Collingswood's  rule  is  that  the  length  of  time  should  vary  inversely  as  the 
pressure ;  that  is,  if  twelve  hours  be  an  ordinary  day's  work  under  normal 
pressure,  under  two  atmospheres  (or  fifteen  pounds  additional  pressure),  it 
should  be  six  hours ;  three  atmospheres,  four  ;  four  atmospheres,  three  hours.'"' 
While  in  the  lock,  where,  in  consequence  of  the  lowering  of  the  atmospheric 
pressure,  the  temperature  is  sometimes  reduced  to  30°  and  upward,  great 
care  should  be  taken  against  chilling  the  body  by  putting  on  warm  clothes. 
It  is  difficult  to  induce  workmen  in  a  body  to  take  these  precautions,  but 
individuals  will  do  so. 

Smith  recommends  that  about  five  minutes  should  be  occupied  in  the  lock 
for  each  atmosphere ;  if  practicable,  even  more  time  than  this  should  be 
given  for  inexperienced  persons. 

At  St.  Louis  those  who  commenced  with  the  works  when  the  pressure  was 
slight  were  unaflected  thi'oughout.  This  acclimation  of  persons  to  high  atmo- 
spheric jDressure  has  been  confirmed  by  general  experience.  It  ls,  therefore, 
desirable  that  Avhen  works  of  magnitude  are  to  be  undertaken  measures 
should  be  adopted  which  will  secure  the  continuous  employment  of  the  same 
men  thi'oughout  the  work.^ 

Jaminet's  view,  that  entering  a  caisson  fasting  predisposes  a  pei'son  to 
being  attacked,  is  thought  by  Smith  to  be  corroborated  by  some  of  his  cases. 

It  is  not  always  well  to  wait  for  a  scientific  demonstration  before  adopting 
a  special  mode  of  treatment,  which,  per  se,  would  be  harmless,  but  to  act  upon 
presumptive  evidence ;  therefore,  while  waiting  further  evidence  on  this 
point,  it  would  be  well  to  enforce  a  rule,  as  has  been  done,  that  no  one  should 
enter  a  caisson  while  fasting. 

1  Van  Rensselaer. 

-  In  one  ease  a  man  with  advanced  Bright's  disease  was  found  unconscious  in  the  lock. 
After  regaining  consciousness  convulsions  set  in,  and  he  died. 

3  While  building  the  St.  Louis  Bridge  it  was  found  necessary  to  reduce  the  length  of  time  of 
each  shift  to  one  hour  at  a  depth  of  ninety  feet.  At  New  York  a  day's  work  was  finally  reduced 
to  four  hours,  divided  into  two  shifts,  separated  by  a  four  hours'  interval. 

i  Smith's  important  monograph  contains  valuable  suggestions  regarding  the  management  of 
works,  and  should  be  consulted  by  those  who  have  the  supervision  and  construction  of  such 
undertakings. 


DISEASES  OF  THE  SPINAL  CORD.  583 

After  the  symptoms  have  set  in  it  has  been  recommended  that  a  person 
should  be  returned  to  the  caisson.  Although  this  has  been  done  with  suc- 
cess it  is  not  always  practicable,  and  probably  only  in  a  few  cases  could  be 
done  within  the  first  few  hours,  when  it  would  be  likely  to  be  serviceable. 
More  practicable  would  be  putting  the  patient  into  a  pneumatic  cabinet, 
where  he  would  be  subjected  to  increased  atmosi^heric  pressure. 

In  large  cities  it  would  not  be  difficult  to  obtain  the  use  of  such  a  cabinet, 
and  it  would  not  be  impracticable  for  contractors  and  others  to  have  such  a 
cabinet  in  readiness  in  case  of  accident  duidng  the  progress  of  the  work. 

When  large  works  are  contemplated  a  temjDorary  hospital,  conveniently 
located,  should  be  provided,  containing  a  chamber  or  cabinet,  in  which  pa- 
tients could  be  again  subjected  to  high  pressure.  This  might  be  a  proper 
siibject  for  legislation. 

For  the  intense  pain  sometimes  observed,  recourse  to  large  doses  of  mor- 
phine must  be  had.     Morphine  also  controls  the  vomiting. 

Smith  states  that  ergot,  though  not  always  successful,  was  very  useful  in 
a  considerable  number  of  cases.  He  says,  for  very  severe  pain,  complete 
relief  has  been  experienced  within  half  an  hour  after  the  administration  of 
a  drachm  of  the  fluid  extract.  Unsteadiness  of  the  limbs  also  yielded 
promptly  to  one  or  two  doses.  This  effect  of  ergot  is  confirmed  by  the  ex- 
perience of  Knapp  in  the  Wyoming  cases.  The  drug  should  be  given  liber- 
ally— one  drachm  every  hour  or  every  two  hours  for  several  doses. 

Various  other  measures  have  been  recommended,  such  as  cups,  douches, 
electricity,  etc.,  but  we  have  no  positive  evidence  that  we  can  favorably  in- 
fluence the  spinal  circulation  in  this  way. 

It  may  be  suggested  that  in  the  way  of  experiment  it  might  be  well  to  try 
bandaging  tightly  the  limbs,  perhaps  the  whole  body,  with  an  Esmarch  or 
some  other  form  of  bandage,  with  a  view  to  imitating  the  action  of  in- 
creased atmosj)heric  pressure  and  driving  the  blood  once  more  into  the  spinal 
cord. 

Later,  after  the  symptoms  of  myelitis  have  developed,  the  principles  of 
treatment  are  the  same  as  when  that  disease  occurs  under  other  circum- 
stances. 


ACUTE  ASCENDING  PARALYSIS  (Landry's  Paralysis). 

This  disease,  which  was  first  described  by  Landry  in  1859,  derives  its  name 
from  the  fact  that  in  a  large  majority  of  cases  it  is  characterized  by  a  rapidly 
developing  motor  paralysis,  which  involves  first  the  legs,  and  then,  in  close 
succession,  the  trunk,  arms,  and  finally  many  of  the  muscular  regions  sup- 
plied by  the  medulla.  Some  authors  describe  also  a  so-called  bulbar  form, 
in  which  the  last-mentioned  regions  are  the  first  to  be  attacked. 

In  both  forms  death  is  the  usual  termination,  if  we  are  to  judge  by  reported 
cases. 

As  a  rule,  there  is  little  or  no  disturbance  of  sensation,  no  atrophy,  no 
alteration  in  the  electrical  excitability  of  nerves  and  muscles,  and  the  sphinc- 
ters ai'e  rarely  involved.     The  disease  is  not  common. 

Etiology.  The  predominating  etiological  factor  in  most  of  the  reported 
cases  is  exposure  to  cold  and  wet,  certain  of  these  having  the  additional  ele- 
ment of  alcoholism.  In  other  cases  the  victims  were  suffering  at  the  time  of 
onset  from  the  weakening  effects  of  some  preceding  infectious  disease,  such 
as  smallpox,  diphtheria,  or  typhoid.  It  has  also  been  known  to  follow  febrile 
diseases  of  obscure  nature  at  an  interval  of  one  or  two  weeks,  and  has  occurred 
after  trauma  when  the  wound  has  apparently  healed. 


584  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Gowers  has  seen  it  follow  an  attack  of  pelvic  cellulitis.  I  have  seen  one 
case  apparently  caused  by  some  sort  of  septicsemic  process,  as  it  followed  a 
false  passage  in  the  urethra  made  by  an  attempt  to  introduce  a  catheter.  It 
has  been  observed  frequently,  too,  in  the  subjects  of  syphilis,  and  has  appar- 
ently been  arrested  by  specific  treatment.  The  form  of  rabies  known  as 
"  paralytic  rabies "  causes  a  disease  apparently  identical  with  Landry's 
paralysis. 

Males  are  affected  with  greater  frequency  than  females,  and  the  period  of 
life  at  which  the  disease  commonly  occurs  is  between  the  ages  of  twenty  and 
forty-five  years,  but  it  has  been  observed  in  young  children  and  in  old  people. 

Symptoms.  Some  cases  present  such  premonitory  symptoms  as  general 
malaise,  dragging  pains  in  head  and  back,  and  tingling  in  the  extremities 
for  some  days,  or,  rarely,  some  weeks. 

The  two  cardinal  symptoms,  and,  in  fact,  almost  sole  symptoms  of  typical 
cases,  are  paralysis  and  loss  of  all  reflexes.  The  contrast  of  profound  and 
widespread  paralysis,  with  httle  or  no  impairment  of  other  functions  of  the 
cord  or  nerves,  makes  a  picture  which  is  characteristic.  The  paralysis  begins 
in  the  legs,  often  one  before  the  other,  and  usually  rapidly  increases  in  degree, 
until  complete  paraplegia  results.  A  distinguishing  peculiarity  of  the  para- 
plegia is,  "as  has  been  said,  its  ascending  course.  After  the  legs,  the  muscles 
of  the  trunk  are  successively  involved — first  of  the  pelvis,  loins,  and  abdo- 
men, then  of  the  thorax.  All  this  may  occur  in  a  few  hours,  so  that  the 
progressive  course  at  first  may  escape  notice,  or  two  or  three  days  may  be 
occupied  before  the  patient  is  helpless. 

After  the  trunk  the  arms  are  affected,  either  both  simultaneously,  or,  like 
the  legs,  one  before  the  other.  Whether  the  individual  muscles  of  the  arms 
and  legs  are  successively  attacked  in  an  order  corresponding  to  the  longitu- 
dinal arrangement  of  the  spinal  centres  remains  to  be  determined  ;  probably 
not,  but  sufficiently  accurate  observations  have  not  yet  been  made  to  establish 
this  point.  The  paralysis  of  the  arms  and  trunk  is  less  apt  than  that  of  the 
legs  to  be  absolute.  The  arms  may  be  only  partially  paralyzed.  The  final 
stage  of  the  disease  is  marked  by  a  still  further  extension  upward  of  the  paral- 
ysis, causing  respiratory  disturbances  and  symptoms  of  bulbar  involvement. 
The  respiration  is  then  labored  and  difficult,  and  the  diaphragmatic  move- 
ments are  weaker.  The  lips,  tongue,  palate,  and  throat  become  involved.  In 
consequence,  dysphagia  results,  and  the  power  to  articulate  is  impaii'ed  or 
lost.  In  certain  cases  partial  facial  paralysis  and  ocular  muscle  disturbances 
have  been  noted. 

Sensation  is  not  usually  affected,  although  there  may  be  a  slight  dulling 
to  all  forms  of  stimulation,  especially  in  the  extremities.  In  two  or  three 
cases  there  has  been  marked  ansesthesia.  The  absence  of  pain  is  conspicuous. 
The  reflexes,  both  cutaneous  and  tendon,  are  diminished  or  wholly  lost,  but 
in  one  case  the  knee-jerks  were  increased  at  the  beginning,  although  abolished 
later  on. 

Although  the  paralyzed  muscles  become  rapidly  flaccid,  they  present  in 
the  large  majority  of  cases  neither  wasting  nor  change  in  electrical  reaction. 
The  normal  character  of  the  reactions  presented  by  such  soft  and  flabby 
muscles  is  often  striking.  In  some  few  otherwise  typical  cases  a  rapid  loss  of 
faradic  muscular  excitability  and  even  polar  changes  have  been  noted.  But 
it  may  be  suspected  that  such  cases,  as  well  as  those  presenting  marked  anaes- 
thesia, were  really  instances  of  multiple  neuritis,  certain  types  of  which  simu- 
late Landry's  paralysis,  and  cases  of  which  have  certainly  been  mistaken 
and  wrongly  reported  as  of  this  affection.  Further,  other  apparent  anomalies 
in  the  clinical  picture  are  caused  by  the  fact,  as  will  presently  be  seen,  that 
in  cases  which  run  a  more  protracted  course,  certain  secondary  changes  in 


DISEASES  OF  THE  SPINAL  CORD.  585 

the  cord  and  nerves  (myelitis  and  neuritis)  often  result,  and  produce  their 
characteristic  symptoms. 

The  sphincters  are  rarely  affected.  The  cerebral  functions  also  are  not 
usually  involved,  although  in  the  rare  cases,  with  high  temperature  and  signs 
of  general  infection,  there  may  be  some  stupor  or  mild  delirium.  In  the 
overwhelming  majority  of  cases  there  is  no  elevation  of  temjDerature.  In  a 
few  cases  a  slight  rise  has  been  noted.  Profuse  sweatings  and  splenic  enlarge- 
ment are  frequent.  Irregular  forms  of  the  disease  are  sometimes  met  with, 
in  which  the  arms  are  involved  before  the  legs,  or  the  diaphragm  before  the 
intercostals.  When  bulbar  symptoms  begin  first,  death  may  occur  by 
involvement  of  the  cardiac  centre  before  the  arms  are  affected. 

The  course  of  the  disease  is  usually,  though  not  always,  rapid  and,  as  a  rule, 
fatal.  Of  four  cases  which  have  come  under  my  own  observation,  and  which 
presented  typical  symptoms  of  Landry's  paralysis,  two  died.  The  mortality 
is  very  high,  and  many  cases  end  fatally  in  a  week.  The  paralysis  may  run 
a  still  more  rapid  course,  attacking  the  cardiac  or  respiratory  centres — the 
usual  mode  of  death — ^in  forty-eight  hours.  In  other  cases,  again,  the  pro- 
gress is  slower,  and  the  patient  may  live  three  or  four  weeks.  When  recovery 
takes  place  it  is  usually  slow. 

Pathology.  In  the  majority  of  cases  the  results  of  autopsies  have  been 
negative,  even  in  most  competent  hands.  Again,  in  other  cases  that  have 
been  apparently  typical,  varied  pathological  findings  have  been  reported. 
It  is  exceedingly  probable  that  the  primary  cause  of  the  paralysis  is  some 
toxic  principle  which  has  an  affinity  for  the  nervous  motor  elements,  either 
in  the  spinal  cord  or  nerves,  or  both.  This  hypothesis  is  supported  by  analogy 
with  other  morbid  processes  which  are  known  to  be  caused  by  such  influences, 
such  as  diphtheritic  paralysis,  which  it  is  now  known  is  due  to  the  action  of 
the  toxin  of  the  Klebs-Loefiler  bacillus  upon  nerve  structures. 

It  is  highly  probable  that  the  paralytic  symptoms  at  the  onset  are  due  to 
the  chemical  affinity  of  the  poison  for  the  nervous  motor  elements,  while  the 
continuous  action  of  the  poison  may  cause  various  secondary  changes  in  the 
nerves  and  cords,  and  perhaps  in  the  muscles.  This  would  be  in  harmony 
with  the  entire  absence  of  anatomical  changes,  which  is  the  rule,  as  well  as 
the  varied  and  dissimilar  lesions  found  in  other  cases,  such  as  neuritis,  polio- 
myelitis, etc.  Baumgarten,  in  one  case,  found  in  the  spinal  cord  many  rods 
like  the  bacilli  of  malignant  pustule.  In  Curschmann's  case  the  typhoid 
bacillus  was  found  in  the  same  region.  Catanni  found  bacilli  in  the  endo- 
neural lymph-spaces  of  many  of  the  peripheral  nerves.  Eisenlohr  demon- 
strated various  kinds  of  bacilli,  and  in  one  rather  typical  case,  found  staphy- 
lococci in  various  organs  of  the  central  nervous  system.  In  some  cases  dis- 
seminated inflammatory  patches  or  ecchymoses  were  found  in  the  medulla, 
especially  in  the  motor  tract,  and  in  others  similar  alterations  in  the  cord. 
Particularly  marked  was  the  swelling  of  axis-cylinders  in  the  crossed  and 
uncrossed  motor  tracts.  In  still  other  cases,  what  was  found  corresponded 
to  the  lightest  form  of  poliomyelitis.  Pitres  and  Vaillard  found  nothing- 
abnormal  in  the  gray  matter  of  the  spinal  cord,  and  few  alterations  in  the 
spinal  nerve-roots,  but  found  the  peripheral  nerves  degenerated  to  such  an 
extent  that  in  many  fibres  nothing  remained  but  an  empty  sheath  of 
Schwann.  Watson  found  nothing  but  a  congestion  of  the  spinal  meninges. 
Luigi  Villa  found  in  his  case  in  "the  peripheral  nerves  and  in  the  nerve-roots 
the  lesions  of  parenchymatous  neuritis  with  preservation  of  the  axis-cylin- 
ders, but  no  changes  in  the  intra- vertebral  ganglia.  The  axis-cylinders  were 
surrounded  by  accumulations  of  a  substance  having  a  special  morphology 
and  micro-chemical  character,  which  was  also  found  in  the  transverse  sec- 
tions of  the  spinal  cord,  particularly  in  the  periphery.     The  central  canal 


586  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

was  filled  with  cellules  and  globules  which  completely  obstructed  it.  The 
same  condition  existed  in  the  brain  and  cerebellum,  Avhere  the  nervous  ele- 
ments were  Avell  preserved.  In  the  muscles  the  fibres  were  numerous  and 
the  nuclei  of  the  sarcolemma  augmented."  ^ 

Ross,  after  an  analysis  of  ninety-three  cases,  believes  the  disease  to  be  a 
form  of  multiple  neuritis.  Oppenheim  mentions  a  case  in  which  the  exam- 
ination of  a  fragment  of  muscle,  secured  by  means  of  the  harpoon  during  life, 
showed  waxy  degeneration.  It  should  be  said  that  Landry  thought  a  tox- 
aemia to  lie  at  the  base  of  the  disease,  and  this  idea  certainly  acquires  sup- 
port from  the  fact  that  in  it  acute  swelling  of  the  spleen  is  common,  and  of 
the  lymphatic  glands  not  rare.  If  this  view  be  correct,  it  still  remains  to  be 
determined  whether  there  is  a  single  specific  poison  or  whether  there  are 
several  which  can  produce  a  similar  effect  upon  the  nervous  system.  After 
what  has  been  said,  a  little  consideration  will  show  that  our  knowledge  of 
the  nature  and  pathology  of  this  affection  is  in  a  very  confused  state,  and  the 
frequent  occurrence  of  neuritis,  which  has  of  late  been  found,  has  only  added 
to  the  confusion.  Clinically,  this  uncertainty  has  undoubtedly  led  to 
numerous  errors  of  diagnosis.  Supposing  that  the  toxic  principle  has  in- 
duced a  secondary  neuritis,  is  the  disease  to  be  looked  ujDon  as  essentially  a 
toxic  23aralysis,  or  is  it  to  be  claimed  as  one  of  the  numerous  forms  of  mul- 
tiple neuritis  of  a  peculiar  type  (clinically)  ?  If  the  latter,  how  is  it  to  be 
distinguished  from  other  varieties  ?  If,  on  the  other  hand,  the  symptoms  in 
a  given  case  are  plainly  indicative  of  a  neuritis,  can  we  determine  with  posi- 
tiveness  whether  or  not  we  have  to  do  with  a  toxic  principle  in  addition  ? 

At  present  we  have  only  its  course  and  termination  to  guide  us.  The 
fatality  of  Landry's  paralysis  is  certainly  excessive  as  compared  with  ordinary 
multiple  neuritis,  and  jDoints  to  another  factor  as  being  predominant.  As  the 
prognosis  is  so  grave,  the  necessity  of  distinguishing  this  variety  from  other 
varieties  of  neuritis  or  myelitis  is  evident.  It  is  highly  probable  that  occasion- 
ally cases  of  diphtheritic  paralysis  have  been  mistaken  for  Landry's  paralysis. 
It  is  well  known  that  in  the  former  it  is  not  always  possible  to  obtain  evidence 
of  a  preceding  throat  affection,  owing  to  the  fact  that  the  latter  was  very 
mild  or  that  the  primary  lesion  was  confined  to  the  nares.  The  similarity 
between  the  two  varieties  of  paralysis  is  marked  when  there  is  little  sensory 
disturbance  in  the  diphtheritic  form  and  the  paralysis  is  widespread. 

Diagnosis.  This  must  be  made  from  acute  anterior  poliomyelitis,  myelitis, 
neuritis,  diphtheritic  paralysis,  and  paralytic  rabies.  The  recognition  of  the 
disease  described  above  must  rest  upon  the  peculiar  ascending  succession  of 
the  muscles  involved  in  the  paralysis,  the  chai'acter  of  the  paralysis — almost 
entirely  motor — the  preservation  of  electro-muscular  excitability  and  of 
almost  unimpaired  sensation,  the  absence  of  atrophy,  and  the  (usual)  exemp- 
tion of  the  sphincters.  In  diphtheritic  paralysis  there  is  most  commonly  a 
history  of  faucial  or  nasal  infection,  and  paralysis  of  the  palate  and  accom- 
modation as  initial  symptoms.  Sensory  symptoms  also  are  more  common.  In 
paralytic  rabies  we  also  have  usually  additional  aid  in  the  history  of  a  bite 
of  an  animal. 

Prognosis.  This  is  extremely  bad,  although,  as  has  been  said,  recoveries 
may  take  place  oftener  than  statistics  would  indicate. 

Treatment.  Owing  to  the  rarity  of  the  disease  no  extensive  knowledge 
from  the  application  of  therapeutic  measures  has  been  gained.  Probably  no 
remedy  thus  far  employed  has  any  specific  effect.  Possibly  a  line  of  treatment 
similar  to  that  found  useful  in  diphtheritic  paralysis  would  be  most  effective, 
especially  alcohol  and  strychnine,  the  latter  given  subcutaneously.     In  the 

1  Sajous'  Annual,  1894. 


DISEASES  OF  THE  SPINAL  CORD.  587 

early  stages  of  the  disease  a  vapor  bath  has  been  recommended,  if  exposure  to 
cold  has  been  an  etiological  factor,  though  it  is  difficult  to  reconcile  this  treat- 
ment with  the  toxic  theory.  The  bath  should  be  followed  by  counter-irrita- 
tion in  the  form  of  a  long,  narrow  strip  of  mustard-plaster  over  the  spine. 
The  body  should  be  kept  in  as  perfect  a  state  of  rest  as  possible.  Internally 
large  doses  of  ergotin  were  thought  to  be  successful  in  a  case  mentioned  by 
Gowers.  The  other  remedies  used  are  iodide  of  potassium  in  doses  of  10  to 
20  grains,  Avell  diluted,  three  times  a  day  ;  salicylate  and  benzoate  of  sodium  ; 
mercury,  either  in  the  form  of  the  iodide,  internally,  or  the  ointment  by  in- 
unction ;  belladonna,  in  the  form  of  the  fluid  extract,  1  or  2  minijns  once 
or  twice  a  day  ;  and  the  sulphate  of  cjuinine,  2  grains  three  or  four  times  a 
day.  In  cases  that  follow  traumatic  lesions,  especially  if  there  have  been 
any  indications  of  septicaemia,  Gowers  thinks  that  full  doses  of  the  per- 
chloride  of  iron  offer  the  best  means  of  destroying  the  activity  of  the  blood 
state. 

SYRINGOMYELIA. 

Syringomyelia  is  characterized  by  the  formation  of  a  tubular  cavity  or 
cavities  in  the  substance  of  the  cord,  and  the  development  of  ghomatous  tis- 
sue. Its  symptoms  are  at  first  latent  in  their  course  and  slow  in  progression, 
but  finally  in  a  certain  proportion  of  cases  present  certain  peculiar  groupings 
which  allow  the  disease  to  be  recognized.  In  other  cases  they  are  atypical 
and  present  no  definite  grouping.  A  knowledge  of  the  mode  in  which  the 
cavities  and  gliomatous  tissue  are  developed  enables  us  to  understand  the 
relations  between  the  symptoms  and  the  anatomical  changes  in  the  cord. 

It  is  generally  agreed  that  gliosis  is  a  congenital  condition,  due  to  a  defect 
of  development  resulting  in  the  persistence  of  embryological  tissue  with 
subsequent  proliferation  in  the  adult  cord.  Regarding  the  cavities  there  is 
still  a  considerable  difference  of  opinion  as  to  whether  all  have  the  same 
origin  or  whether  there  are  several  ways  in  which  a  cavity  may  be  formed. 
There  is  no  doubt,  however,  that  there  are  at  least  two  modes  by  which  cavi- 
ties originate,  and  all  cavities  associated  with  gliomatous  tissue  may  be  re- 
ferred to  one  or  the  other  of  these  two  modes  of  origin.  First,  a  cavity  may 
be  formed  by  the  persistence  of  the  primitive  tube  of  which  the  embryonic 
cord  is  composed,  and  later  be  enlarged  by  the  breaking  down  of  the  embry- 
onic tissue  forming  its  walls. 

The  second  way  in  which  a  cavity  originates  is  by  the  proliferation  and 
subsequent  breaking  down  of  nests  of  gliomatous  (embryological)  tissue, 
which  has  become  imprisoned  in  the  posterior  gray  matter  in  the  course  of 
development ;  consequently  some  cavities  may  represent  the  original  tube,  and 
others  may  be  entirely  new  formations.  The  developmental  process  by  which 
this  is  brought  about  is  as  follows :  In  the  beginning  the  spinal  cord  is  a  sim- 
ple tube  composed  of  embryonic  tissue — a  substance  which  is  gelatinous  in 
appearance — and  resembles,  if  it  is  not  identical  with,  gliomatous  tissue.  In 
the  process  of  development  the  tube  becomes  flattened  laterally  and  closes  by 
approximation  by  its  sides  with  the  exception  of  the  anterior  (ventral)  por- 
tion, which  remains  patent  and  persists  as  the  central  canal.  From  the 
walls  of  the  primitive  tube,  by  a  process  of  proliferation  and  transformation, 
various  structures  of  the  cord  are  formed.  When  the  tube  fails  to  com- 
pletely close  a  cavity  is  left,  necessarily  lying  behind  or  corresponding  to  the 
central  canal  and  extending  up  or  down  the  cord  a  greater  or  less  distance. 
When  this  is  the  case  it  is  found  that  some  of  the  surrounding  embryonic 
tissue  also  persists,  and  later  by  a  process  of  growth  increases  in  amount. 
This  proliferating  tissue  surrounding  the  cavity  is  liable  to  break  down,  and 


588  NEB  VO  US  DISEASES  AND  THEIR  TREA  TMENT. 

thus  the  cavity  is  enlarged.  The  walls  of  the  cavity  are  formed  of  per- 
sistent gelatinous  embryonic  tissue  of  varying  thickness. 

It  should  be  observed  that  the  clinical  phenomena  are  conditioned  by  the 
fact  that  the  remains  of  the  tube,  that  is,  the  cavity,  necessarily  occupies  either 
the  position  of  the  central  canal  or  lies  in  the  posterior  half  of  the  develoi3ed 
cord  between  the  posterior  cornua.  In  the  latter  position  the  cavity  may  or 
may  not  connect  with  the  central  canal.  ^Yhether  the  primitive  tube  has 
closed  or  not,  nests  of  embryonic  tissue  may  become  imprisoned  in  the 
posterior  portion  of  the  cord.  These  are  later  also  liable  to  proliferate  as 
ghomatous  growths,  then  degenerate,  and  finally  break  down,  forming  cavi- 
ties. By  the  proliferation  of  the  gliomatous  tissue  a  distinct  tumor  formation 
may  result,  more  or  less  differentiated  from  the  surrounding  tissue. 

vSyringomyelia  is  thus  primarily  a  congenital  disease  due  to  mal-develop- 
ment,  but  it  is  a  condition  liable  to  secondary  changes,  cell-growth  and  dis- 
integration, which  occasion  profound  damage  to  the  neighboring  structures 
of  the  cord.  It  will  be  also  seen  that  the  cavity  may  represent  an  injured 
central  canal  or  may  be  independent  of  it.  It  is  to  be  noticed  also  that  these 
new  formations  necessarily  lie  in  the  gray  matter  and  in  the  posterior  half. 
In  consequence  of  the  fact  that  the  structures  of  the  cord  are  not  necessarily 
injured  until  the  secondary  changes,  growth  and  disintegration,  take  place 
in  the  gliomatous  tissue,  the  disease  may  lie  latent  long  periods  before  it  pro- 
duces symptoms,  and  therefore  it  is  that  there  may  be  no  indications  of  such 
a  cavity  during  life.  The  slow  development  of  the  symptoms  after  their 
onset  corresponds  to  the  slow  growth  of  the  gliomatous  tissue  and  its  dis- 
integration. The  fact  that  these  formations  are  in  the  posterior  gray  matter 
occasions  a  peculiar  grouping  of  the  symptoms  such  as  would  be  due  to 
a  central  lesion.  AVhen,  however,  as  is  often  the  case,  the  development  of 
the  cavities  encroach  upon  the  neighboring  white  matter,  other  symptoms  be- 
come added  to  or  are  substituted  for  those  which  are  referable  to  the  damage 
to  the  gray  matter.  The  symptoms  thus  produced  may  not  exhibit  in  their 
grouping  any  particular  type,  but  may  simulate  various  other  destructive  dis- 
eases of  the  cord.  Therefore  it  is  that  syringomyelia  sometimes  cannot  be  diag- 
nosed during  life,  even  when  clinical  evidence  of  profound  damage  is  present. 

The  extension  of  the  cavity  may  injure  the  ascending  and  descending 
tracts  in  the  white  matter,  thus  producing  paralysis  and  ataxic  symptoms,  or 
it  may  be  into  the  anterior  cornua,  producing  atrophic  changes.  While  the 
majority  of  cases  are  unquestionably  congenital  from  the  presence  of  em- 
bryonic tissue,  in  others  this  origin  must  be  inferred  from  the  similarity  of 
many  of  the  pathological  conditions  present  to  those  in  the  congenital  cases. 
The  following  description  of  the  symptoms  applies  to  those  cases  in  which  the 
symptoms  are  so  grouped  as  to  produce  a  distinct  type.  The  variations  fre- 
quently met  with  will  be  afterward  mentioned. 

Symptoms.  The  symptoms  come  on  insidiously,  are  slow  in  their  develop- 
ment and  at  first  are  apt  to  be  overlooked.  They  are  most  frequently  ob- 
served between  the  ages  of  twenty  and  thirty,  and  therefore  up  to  this  period 
such  congenital  anomalies  as  may  exist  must  be  quiescent.  In  children,  ac- 
cordingly, symptoms  are  rare,  and  in  some  cases  the  manifestations  of  the  disease 
have  not  made  their  appearance  until  middle  life,  or  as  late  as  the  ages  of 
fifty  or  sixty.  The  symptoms  are  almost  always  bilateral,  but  a  few  cases 
have  been  observed  in  which  only  one  side  of  the  body  was  affected.  The 
most  common  situation  for  the  lesion  is  the  cervical  enlargement,  and  hence 
the  distribution  of  the  symptoms  is  most  commonly  in  the  arms.  The  most 
common  type,  the  one  we  are  now  considering,  is  that  in  which  the  most 
salient  features  are  loss  of  perceptions  of  pain  and  temperature,  with  reten- 
tion of  the  tactile  and  muscular  senses  combined  with  atrophy  of  the  arms, 


DISEASES  OF  THE  SPINAL  CORD. 


589 


similar  to  that  observed  in  sjiinal  progressive  muscular  atrophy.  (See  Fig. 
180.)  In  this  type  usually  the  first  symptom  noticed  is  the  loss  of  the  sense 
of  pain  and  of  temperature.  (See  Figs.  179  and  181.)  This  dissociation 
of  the  different  sensory  perceptions  was  at  one  time  thought  to  be  pathogno- 
monic of  syringomyelia.  It  is  now  known  that  this  is  an  error,  and  that 
this  peculiar  dissociation  occurs  in  other  diseases,  as  in  neuritis,  myelitis,  and 
hysteria. 

In  syringomyelia  this  phenomenon  is  best  explained  on  the  theory  that  the 
paths  for  the  conduction  of  the  perception  of  touch  and  pain  take  difierent 
directions  in  the  cord,  and  that  those  for  pain  cross  in  the  posterior  commis- 
sure to  the  antero-lateral  ascending  tract.'  Consequently  a  lesion  of  the  gray 
matter  in  the  posterior  half  of  the  cord  might  obliterate  the  sense  of  pain 
alone.  Further,  the  frequent  association  of  the  loss  of  the  temperature  sense 
with  that  of  pain  in  other  diseases  than  syringomyelia  shows  that  the  two 
paths  probably  lie  close  together.  The  sense  of  touch  is  not  always  preserved. 
In  some  cases  it  has  been  lost  with  the  others,  probably  in  consequence  of  the 
extension  of  the  lesion  into  the  posterior  root  zones. 


Fig.  179. 


Thermo- Anaesthesia ^   and  general 


i  Anaesthesia 


The  distribution  of , 

the  areas  of  .  .  .    \^M       ^^^""    c..:^  

in  a  case  of  syringomyelia.  (Lloyd.)  Excepting  on  the  back,  the  "  dissociated  "  sensory  loss  was 
confined  to  the  left  half  of  the  body.  The  limits  of  the  analgesia  did  not  correspond  with  those  of 
the  thermo-anasthesia. 


Earely  the  temperature  sense  alone  is  lost  for  a  considerable  time,  while 
that  of  pain  is  preserved.  The  thermo-ana?sthesia  usually  is  not  absolute 
for  all  degrees,  but  more  commonly  for  mean  temperatures  only,  but  some- 
times it  is  the  extremes  of  temperatures  that  are  not  recognized,  so  that,  for 
example,  the  perception  of  cold  is  preserved  and  that  of  heat  is  lost.  In  a 
case  of  Dejerine  and  Thuilant^  the  thermal  sense  was  lost  for  all  temperatures 


1  Gowers. 


La  Medecine  Moderne,  Feb.  5,  1891. 


590 


NERVOUS  DISEASES  AND  THEIR  TREATMENl. 


above  68°  F.,  but  preserved  for  all  degrees  below  this  point.  The  sensibility  for 
touch  and  pain  was  preserved.  If  such  patients  are  not  carefully  tested  partial 
defects  in  the  perception  of  sensation  are  liable  to  be  overlooked.  The  loss 
of  sensation  is  more  commonly  coniined  to  the  arms  and  adjacent  portions  of 
the  trunk,  corresponding  to  the  cervical  location  of  the  lesion.  Sensation  in 
the  legs  is  usually  unimpaired  in  this  type,  in  consequence  of  their  sensory 
fibres  having  crossed  below,  and  thus  evaded  the  lesion  in  the  gray  matter 
above,  but  there  may  be  much  variation  in  the  distribution  of  the  analgesia. 
Sometimes  it  is  general.  It  may,  however,  occur  in  the  form  of  a  hemi- 
analgesia. 

Fig.   ISO. 


Syringomyelia  presenting  atrojihy  of  muFfles,  scoliosis,  and  marked  sensory  changes. 
(Philadelphia  Hospital.) 


The  areas  of  the  loss  of  sensibility  for  pain  and  temperature  may  not  cor- 
respond ;  one  may  be  wider  than  the  other,  and  there  may  be  areas  where 
one  is  lost  and  the  other  preserved.  There  may  be  analgesia  on  one  side  of 
the  body  and  thermo-anajsthesia  on  the  other. 

According  to  Bruhl  and  Charcot  the  loss  of  sensation  in  the  arms  occurs 
in  zones,  extending  in  a  circular  manner  around  the  limbs,  as  in  hysteria, 
and  does  not  follow  the  anatomical  distribution  of  the  nerves  as  in  neuritis. 
This  zone  configuration  is  thought  to  correspond  with  the  arrangement  of 
the  sj)inal  centres. 

Symptoms  of  sensory  irritation  are  not  infrequently  observed,  and  may  be 
the  first  thing  complained  of,  such  as  paresthesia  of  different  kinds  (numb- 
ness, prickling  feelings,  etc. ),  and  pains  referable  to  the  arms,  neck,  and  dif- 
ferent parts  of  the  iDody.  These  pains  resemble  in  character  those  occurring  in 


DISEASES  OF  THE  SPINAL  CORD. 


591 


tumors  of  the  cord,  excepting  that  they  are  less  intense,  and  are  the  occasion 
of  annoyance  rather  than  of  suffering.    They  are  very  likely  due  to  the  same 


Fig.  181. 


Sensory  chart  of  patient  shown  in  Fig.  180,  showing  [       |™  ,         „     . 

areas  of T  .  . j \Tliemio- Anaesthesia , 


Analgesia 
VndAndige^a^^^^'    M  ^'^''^'^^  ^naesfTiesra,  and  areas  in  which  the  patients  answer  to 


tests  of  temperature  showed  reversal 


o  o  o 
o  o  o 
o  o  c 


Cold-Hot; 
Hot-Cold. 


mechanism,  viz. :  irritation  of  the  sensory  fibres  by  the  gliomatous  growths 
or  distended  cavities.    After  symptoms  of  impaired  sensibility  have  persisted 


Fig.  182. 


Syringomyelia.    Extensive  arthropathy  of  the  right  shoulder.    (Derccw  ) 


for  some  time  the  extension  of  the  lesion  into  the  anterior  cornua  or  the  effect 
of  pressure  upon  them  begins  to  cause  weakness  and  atrophy  of  the  arms. 

The  atrophy  is  usually  of  the  so-called  Arau-Duchenne  type.     It  may  ap- 
pear in  the  small  muscles  of  the  hand  and  gradually  extend  upward,  involving 


592  NERVOUS  BISEASES  AND  THEIR  TREATMENT. 

consecutively  the  foreai-m,  upper  arm,  and  shoulder  muscles,  or  it  may  first 
appear  in  the  shoulder  and  upper-arm  muscles,  and  later  descend  to  the  hand. 
The  difference  depends  upon  whether  the  lower  cervical  gray  matter  is  first 
affected  with  extension  upward  of  the  process,  or  whether  the  upper  cervical 
enlargement,  in  which  are  located  the  centres  for  the  shoulder  muscles,  is  first 
affected.  Corresponding  with  the  atrophy  there  is  naturally  a  weakness  of 
the  muscles  which  may  go  on  to  complete  paralysis.  The  electrical  changes 
in  the  atrophied  muscles  are  usually  limited  in  accordance  with  electro-physi- 
ological laws  to  quantitative  diminution  to  both  galvanic  and  faradic  currents. 
But  when  the  atrophy  is  rapid,  some  muscles  may  exhibit  the  reaction  of 
degeneration. 

Fibrillary  contractions  in  the  atrophied  muscles  are  not  rare  as  in  progres- 
sive muscular  atrophy. 

Tremor  may  be  present  in  the  affected  limbs,  and  rarely  spasms. 

The  weakness  of  the  spinal  muscles  produces  scoliosis  (see  Fig.  180),  which 
is  a  common  symptom  and  quite  characteristic.  It  is  j)robable  that  a  scoHosis 
of  limited  extent  may  be  due  to  atrophic  changes  in  the  vertebrse  similar  to 
those  that  occur  in  the  joints.  As  the  disease  progresses  damage  to  the  pyra- 
midal tracts  causes  weakness  of  the  legs,  with  spastic  symptoms. 

Trophic  disturbances  are  common.  Changes  in  the  joints  and  bones  very 
similar  to  those  observed  in  tabes  occur  in  about  10  per  cent,  of  the  cases 
(according  to  Ssokolow).  Like  the  other  symptoms  they  more  frequently 
occur  in  the  upper  extremities,  while  those  of  tabes  occur  in  the  lower. 
The  joint  changes  consist  principally  of  enlargement  of  capsular  ligaments, 
looseness  of  the  joints,  thickening  of  the  capsule,  changes  of  form  in  the 
ends  of  the  bones,  and  development  of  bony  spiculse  in  the  capsular  walls. 
The  further  changes  resemble  those  in  tabetic  joints.     (See  Fig.  182.) 

Painless  fractures  of  the  bones  may  occur  from  very  slight  causes,  as  in  a 
case  of  a  man  who  fractured  the  radius  while  kneading  dough  (Schultze). 

Various  atrophic  changes  in  the  skin  are  frequent,  such  as  herpes,  eczema, 
and  even  deep  ulceration  and  gangrene ;  in  rare  cases  amputation  of  a  hand 
may  in  consequence  be  necessary;  or  there  may  be  simply  vasomotor 
changes,  causing  lividity  and  coldness  of  the  skin  or  the  opposite,  or  oede- 
matous  swelling  of  the  hands.  There  may  be  sweating  or  dryness  of  the 
skin.     The  nails  may  become  dry,  cracked  and  brittle,  and  may  drop  off". 

An  obtrusive  symptom  which  is  sometimes  observed  is  the  painless  felon, 
similar  to  that  which  occurs  in  Morvan's  disease.  The  felons  occasion  deep 
ulceration  and  necrosis  of  the  distal  phalanges  of  the  fingers,  so  that  they 
may  drop  off".  Notwithstanding  this  extensive  ulceration,  the  felons  are 
painless,  owdng  to  the  analgesia  present.  In  consequence  of  the  association 
of  these  felons  with  syringomyelia  this  disease  and  Morvan's  have  been  con- 
sidered by  some  as  identical.  This  is  probably  an  error,  though  it  may  be  that 
these  atrophic  lesions  may  be  due  to  the  same  pathological  conditions  in  the 
two  diseases,  viz. :  a  neuritis,  or  possibly  disease  of  the  trophic  centres.  These 
conditions  will  be  more  fully  considered  in  the  section  on  Morvan's  disease. 

In  some  cases  the  disease  takes  on  a  less  typical  form.  As  has  been  said, 
tactile  sensation  may  be  lost  with  that  of  pain  and  heat.  The  secondary 
changes  may  be  located  in  the  dorsal  or  lumbar  regions  of  the  cord,  produc- 
ing corresponding  variations  in  the  symptoms.  When  in  the  lumbar  region, 
the  atrophy,  loss  of  sensation,  trophic  and  other  symptoms  usually  observed 
in  the  arms  occur  in  the  legs.  The  sphincters  are  then  affected  with  the 
usual  secondary  results.  The  disease  may  extend  upward  from  the  cervical 
enlargement  into  the  medulla  and  pons,  producing  bulbar  symptoms  and 
paralysis  of  the  cranial  nerves,  such  as  occur  in  other  forms  of  bulbar  disease. 

Other  changes  in  type  are  due  to  the  irregular  extension  of  the  lesion 


DISEASES  OF  THE  SPINAL  COBD.  593 

transversely  in  the  cord.  One  type  is  that  simulating  amyotrophic  lateral 
sclerosis,  from  damage  to  the  pyramidal  tracts  and  the  anterior  cornua. 
Muscular  atrophy  and  spastic  paralysis  are  then  the  predominating  symp- 
toms. It  may  be  that  a  spastic  hemiplegia  alone  may  be  present,  lasting  for 
years  before  the  development  of  other  symptoms.  A  third  type  is  that  simu- 
lating Morvan's  disease,  in  which  the  loss  of  sensation,  atroj)hy,  and  felons 
are  the  most  salient  symptoms.  It  may  not  be  possible  to  distinguish  this 
type  during  life  from  Morvan's  disease,  and  this  has  given  rise  to  the  view 
just  referred  to  that  the  two  diseases  are  identical.  A  fourth  type  may  be 
called  latent  syringomyelia  in  consequence  of  the  disease  producing  no 
symptoms  whatever. 

Besides  the  symptoms  thus  far  described  others  sometimes  occur.  Very 
marked  ataxy  similar  to  that  in  tabes,  has  been  found  and  is  due  to  the 
secondary  development  of  a  posterior  sclerosis.' 

The  pupils  may  be  unequal  in  size,  and  contracted  from  injury  to  the  fibres, 
innovating  the  radiating  muscles  of  the  iris.  They  respond  to  light  and 
accommodation.  Contraction  of  the  bulb  with  narrowing  of  the  palpebral 
fissure  and  slight  ptosis  have  been  observed.  Contraction  of  the  visual  field 
of  both  eyes  has  been  noted  even  where  the  lesion  has  been  unilateraP, 
though  in  the  latter  case  the  contraction  was  greatest  on  the  side  correspond- 
ing to  the  lesion.  This  symptom  can  only  be  regarded  as  a  functional  com- 
plication. Nystagmus  sometimes  occurs.  The  sphincters  in  most  cases  are 
unaiFected,  but  may  be  involved  in  the  later  stages.  In  advanced  cases  bed- 
sores and  cystitis  may  develop  as  in  other  diseases,  which  cause  transverse 
lesions  of  the  cord.  In  some  of  these  atypical  forms  it  may  not  be  possible 
to  diagnose  the  disease. 

The  course  of  the  disease  is  slow,  usually  extending  over  many  years,  un- 
less there  has  been  a  distinct  tumor  formation  of  gliomatous  tissue,  or  the 
development  of  a  sarcoma  has  occurred,  in  which  case  the  disease  may  be 
shortened,  in  accordance  with  the  usual  course  of  tumors,  or  the  disease  may 
be  shortened  by  an  acute  destructive  process  in  the  gliomatous  tissue.  There 
are  frequently  periods  of  remission  when  the  disease  is  stationary  for  long 
periods,  and  there  may  even  be  periods  of  temporary  improvement.  Death 
may  finally  be  the  result  of  exhaustion,  bed-sores,  cystitis,  or  the  extension 
of  the  disease  into  the  medulla  ;  or  life  may  be  cut  short  by  intercurrent 
diseases  to  which  such  patients  seem  to  be  peculiarly  liable. 

Pathological  Anatomy.  The  most  common  seat  of  the  disease  is  in  the  cervi- 
cal and  upper  dorsal  regions  ;  hence  the  arms  are  most  frequently  affected. 
The  cavities  vary  in  length.  They  may  extend  the  whole  length  of  the  cord 
and  even  upward  into  the  medulla  and  pons.  They  may  end  in  a  solid  mass 
of  gliomatous  tissue.  There  may  be  one  cavity,  or  a  secondary  fissure  may 
form  from  the  disintegration  of  the  tissue. 

They  may  extend  irregularly  in  a  transverse  direction  backward  into  the 
posterior  horn  or  forward  into  the  anterior  gray  matter,  and  even  laterally 
into  the  white  substance,  or  the  cavity  may  be — and  this  is  the  case  especi- 
ally in  children — -simply  a  dilatation  of  the  central  canal  surrounded  by  a 
mass  of  gliomatous  substance.  The  cavity  may  or  may  not  be  lined  by  cellu- 
lar membrane,  which  is  probably  a  rudiment  of  the  original  membrane  lin- 
ing the  primitive  embryonic  tube. 

The  cavity  sometimes  is  in  connection  with  the  central  canal  and  some- 
times is  not.  From  an  examination  of  74  cases  which  he  was  able  to  col- 
lect, Chiari  concluded  that  the  cavity  probably  connected  with  the  central 

'  Two  cases  are  to  be  found  in  the  literature  in  wtiich,  notwitiistanding  the  presence  of  symp- 
toms resembling  those  of  locomotor  ataxia,  the  posterior  columns  were  not  sclerosed. 
2  Dejerine  and  Sotta:  Compt.  Rend.  Hebd.  Soc.  d.  Biol.,  July  23,  1893. 

.38 


594 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


canal  iu  45  (including  those  ■where  the  cavity  was  a  mere  dilatation  of  the 
canal).     In  21  cases  the  cavity  was  thought  to  be  due  to  destruction  of  glio- 

matous  tissue  alone. 

Fig  183. 


Transverse  section  of  the  lumbar  cord,  showing  gliosis  of  the  rx)sterior  cornua  and  central  gray 
matter.  Weigert  stain.  (Figs.  183,  184,  and  186  are  from  specimens  kindly  furnished  me  by  Dr.  E. 
W.  Taylok.) 

Fig.  184. 


Transverse  section  of  the  cervical  cord,  showing  circumscribed  gliosis  of  the  central  gray  matter 
and  adjacent  areas.  The  gliomatous  tissue  lies  between  posterior  horns  and  posterior  to  gray  com- 
missure. A  minute  cavity  is  apparently  just  beginning  to  be  formed  in  the  centre  of  this  tissue. 
Xigrosin  stain. 


It  should  not  be  overlooked  that  the  clinical  phenomena  are  not  coexten- 
sive with  the  cavity  or  the  distribution  of  the  gliomatous  tissue,  but  are 
related  only  to  those  segments  in  which  the  nervous  sub.-tance  has  been  in- 
jured by  pressure,  and,  perhaps,  secondary  inflammation.  So  that  even  when 
the  syringomyelia  extends  the  whole  length  of  the  cord  the  symptoms  may 
be  limited  to  the  arms. 

The  ma.ss  of  gliomatous  tissue  varies  largely.     It  may  be  present  as  a  thick 


DISEASES  OF  THE  SPINAL  CORD. 


595 


wall  lining  the  cavity,  or  it  may  be  so  small  as  scarcely  to  be  found,  and  its 
original  presence  must  then  be  inferred  from  the  nature  of  the  disease. 
There  may  be  a  local  proliferation  so  as  to  form  a  well-defined  tuinor  or  a 
glioma,  which  may  have  a  considerable  veilical  extent.     There  seems  to  be 


Fig.    185. 


Transverse  section  of  the  cervical  cord  in  a  case  of  syringomyelia,  showing  gliosis  with  extensive 
cavity  formation.  The  lateral  tracts  are  also  seen  degenerated.  Carmine  stain.  (From  specimen 
loaned  by  Dr.  Dercum.) 

a  tendency  to  the  development  of  localized  tumors,  which  are  either  glio- 
mata  or  sarcomata,  and  later  not  infrequently  give  rise  to  syringomyelia. 

The  gliomatous  tissue  has  a  gelatinous  transparent  appearance,  and  under 
the  microscope  it  seems  to  be  made  up  of  small  round  cells  with  fine  fibrous 

Fig.  186. 


Transverse  section  of  lumbar  cord,  showing  gliosis  with  formation  of  cavity  between  posterior 
horns  and  posterior  to  central  canal,  the  remiiins  of  which  can  be  seen  to  be  distinct  from  caviiy. 
Degeneration  of  lateral  tracts.    Weigert  stain. 

processes,  and  probably  has  much  in  common  with  embryonic  tissue  and  nor- 
mal neuroglia,  if  not  identical  with  them.  It  is  firmer  than  the  surrounding- 
tissue,  and  when  circumscribed  can  sometimes  almost  be  shelled  out. 

The  pressure  of  the  growth  and  distended  cavities  may  cause  atrophy  of 
the  adjoining  gray  matter,  particularly  the  anterior  cornua,  and  even  of  the 


596  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

neighboring  white  substance.  Hemorrhage,  sometimes  takes  place  into  the 
cavities. 

Cavities  have  been  found  in  the  cord  in  connection  with  other  processes 
than  gliosis,  such  as  myelitis.  In  view  of  the  researches  of  Van  Giesen^ 
who  has  shown  how  easily  such  cavities  may  be  artificial  productions  as  the 
result  of  carelessness  in  the  removal  of  the  cord,  it  is  well  to  suspend  our 
judgment  before  accepting  such  conditions  as  the  result  of  a  pathological 
process.  According  to  Van  Giesen  several  of  the  supposed  cavities  reported 
to  have  been  found  in  the  cords  were  only  artificial  products. 

A  fact  of  considerable  importance  connected  with  the  trophic  phenom- 
ena is  the  degenerative  neuritis  which  has  been  found  both  in  the  sensory 
and  motor  nerves. 

Diagnosis.  The  principal  diseases  with  which  syringomyelia  is  likely  to  be 
confounded  are  leprosy,  Morvan's  disease,  focal  myelitis,  progressive  muscular 
atrophy,  cervical  pachymeningitis,  tumors,  and  neuritis.  The  other  manifes- 
tations of  leprosy  are  sufiicient  to  make  the  distinction,  although,  overlook- 
ing this  fact,  some  writers  have  claimed  the  identity  of  syringomyelia  and 
leprosy,  on  account  of  the  similarity  in  the  sensory  phenomena  observed  in 
both.  Some  cases  cannot  be  distinguished  from  Morvan's  disease  until  at 
least  the  disease  has  progressed  so  far  as  to  produce  symptoms  which  are 
clearly  referable  to  the  cord.  A  focal  myelitis  sometimes  produces  symptoms 
resembling  a  limited  syringomyelia.  Two  cases  have  been  rejDorted  by  Char- 
cot and  Robinson,  respectively,  and  I  have  myself  now  a  case  under  observa- 
tion ;  in  these  the  symptoms  resemble  those  of  the  disease  now  under  discus- 
sion. All  three  cases  immediately  followed  traumatism,  which  will  serve  as 
an  important  point  in  the  diagnosis  in  similar  cases.  The  course  of  the  disease, 
the  tendency  to  improvement  rather  than  to  the  extension,  the  absence  of  the 
peculiar  atrophic  changes  of  syringomyelia,  and  the  comparatively  rapid 
onset  of  the  symptoms  must  ordinarily  be  sufficient  for  diagnosis. 

Progressive  muscular  atrophy  may  be  distinguished  by  the  absence  of  the 
sensory  and  atrophic  disturbances.  Chronic  pachymeningitis  pursues  a  more 
rapid  course  and  causes  much  more  severe  pains,  which  are  prominent  in  the 
disease.  Trophic  changes  other  than  the  muscular  atrophy  are  absent,  and 
the  peculiar  dissociation  of  the  sensory  symptoms  is  not  met  with. 

The  symptoms  may  resemble  those  accompanying  tumors  when  there  is 
a  marked  circumscribed  growth  in  the  cord,  but  in  tumors  symptoms  of  irri- 
tation are  much  more  prominent  and  last  a  longer  time,  as  a  rule,  before  the 
development  of  symptoms  of  damage.  The  peculiar  atrophic  and  dissocia- 
tion symptoms  of  syringomyelia  are  not  met  with.  Neuritis,  in  rare  in- 
stances, simulates  syringomyelia.''  It  is  to  be  distinguished  by  its  rapid  de- 
velopment, the  rarity  of  the  dissociated  sensory  phenomena,  the  relative 
mildness  of  the  anaesthesia,  and  the  limitation  of  the  analgesia  to  those 
nerves  (or  nerve-roots)  which  are  distributed  to  the  atrophied  muscles.  In 
syringomyelia  the  area  of  analgesia  is  more  extensive,  and,  according  to 
Bruhl  and  Charcot,  envelops  the  whole  circumference  of  the  area  instead 
of  following  the  nerve  distribution  as  in  neuritis. 

When  no  symptoms  are  present,  of  course  syringomyelia  cannot  be 
diagnosed  during  life.  Our  knowledge  of  the  relations  between  the  cavity 
formation  and  symptoms  is  far  from  complete,  and,  as  Dejerine^  has  pointed 
out,  the  cavities  are  often  not  located  where  they  are  supposed  to  be  from  the 
grouping  of  the  symptoms,  even  when  the  disease  has  been  correctly  diag- 
nosed. 

The  pathology  of  the  atrophic  disturbances  is  far  from  clear,  although  it  is 

1  N.  Y.  Med.  Journal.  "-  Charcot :  Archiv.  d.  Neurol.,  September  9,  1892. 

3  La  Semaine  Medicale,  February  12,  1S90. 


DISEASES  OF  THE  SPINAL  COED.  597 

probable  that  they  are  dependent  upon  a  neuritis ;  but,  if  so,  it  is  not  plain 
why  the  neuritis  occurring  in  this  disease  produces  such  peculiar  trophic 
changes,  while  they  are  absent  in  the  ordinary  forms  of  neuritis  met  with 
under  other  conditions. 

Prognosis.  The  disease  may  last  many  years,  from  five  to  twenty.  During 
intervals  it  may  be  stationary,  and  even  some  improvement  may  temporarily 
occur. 

Treatment.  There  is  no  known  way  at  present  of  affecting  the  disease. 
The  only  treatment  is  that  called  for  by  the  skin  eruptions,  felons,  paralysis  of 
the  bladder,  bed-sores,  etc. 


MORVAN'S  DISEASE. 

The  name  Morvan's  disease  has  been  given  to  a  group  of  symptoms  which 
were  first  described  by  Morvan,  of  Lannelis,  Brittany,  1883.  The  pathology 
of  the  disease  is  obscure,  but  it  is  probably  a  peculiar  form  of  neuritis.  In 
some  of  its  clinical  features  it  resembles  syringomyelia  so  closely  that 
some  writers  consider  the  two  diseases  identical.  This  is  probably  an  error, 
but  as  cases  of  each  are  sometimes  mistaken  one  for  the  other,  and  consid- 
erable discussion  still  continues  regarding  its  pathology,  it  is  described  here. 
The  disease  is  rare,  but  cases  are  being  reported  from  time  to  time. 

One  of  its  chief  characteristics  is  the  occurrence  of  usually  painless,  deep- 
seated  ulcerations  of  the  terminal  phalanges  of  the  fingers,  or  felons ;  hence 
the  name,  analgic  panaritium,  by  which  it  is  also  known.  These  felons  lead 
to  the  destruction  of  the  bones. 

Symptoms.  The  first  symptom  usually  complained  of  is  neuralgic  pains 
in  one  or  both  hands.  In  some  cases  the  pains  are  distributed  through  both 
limbs  of  the  same  side  of  the  body.  They  may  be  slight  in  intensity  or 
severe,  and  in  some  cases  may  not  be  present  at  all.  Later,  successive  felons 
appear.  These  are  painless,  owing  to  the  loss  of  sensation,  which  examina- 
tion at  this  time  will  show  to  be  present.  Occasionally  ulceration  precedes 
the  loss  of  sensation,  and  in  this  case  the  felons  are  painful,  but  usually  this 
is  true  of  only  the  first  felon. 

The  ulcerations  are  deep  and  sometimes  require  the  amputation  of  the 
phalanges ;  by  the  successive  development  of  these  felons  and  resulting 
necrosis,  one  phalanx  after  another  may  be  lost.  The  intervals  between  the 
development  of  these  ulcerative  processes  may  be  weeks  or  years.  The  loss 
of  sensation,  which  is  always  present,  involves  all  forms  of  sensation  in  the 
great  majority  of  cases.  The  perceptions  of  touch,  pain,  and  temperature 
are  lost.  In  some  cases  the  dissociation  of  sensation  peculiar  to  syringo- 
myelia has  been  observed ;  that  is,  there  has  been  loss  of  the  sense  of  pain 
and  temperature,  with  the  preservation  of  that  of  touch.  It  is  possible  that 
in  such  cases  continued  observation  would  have  shown  the  disappearance  of 
the  tactile  sense  in  the  later  stages  of  the  disease. 

The  loss  of  sensation,  as  a  rule,  is  distributed  over  the  whole  arm,  and  it 
may  include  the  adjoining  parts  of  the  body  and  even  the  face.  Its  area  of 
distribution  is  generally  wider  than  that  of  atrophy  and  paralysis,  which  fol- 
low and  constitute  the  third  cardinal  symptom. 

At  this  time  atrophy  and  paresis  of  the  muscles  of  the  hand  and  of  the 
forearm  will  be  found.  The  muscular  wasting  does  not  seem  to  extend  above 
the  forearm  (?).  In  this  respect  the  disease  exhibits  a  marked  difference 
from  syringomyelia.  After  a  while  the  second  hand  may  be  affected  in  a 
manner  similar  to  the  first.  The  disease  is  therefore  bilateral.  In  rare  cases 
the  legs  may  be  attacked  later  in  the  course  of  the  disease  in  a  similar  man- 


598  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ner.  The  atrophied  muscles  lose  their  electrical  contractility  to  both  gal- 
vanic and  faradic  currents.  The  reflexes  are  unchanged,'  and  the  sphincters 
are  unaffected.  Bulbar  symptoms  have  been  observed.  Other  trophic  dis- 
turbances than  those  of  felons  are  common  and  resemble  those  which  are  ob- 
served in  syringomyelia ;  similar  changes  in  the  joints  occur,  and  deep-seated 
ulcerations  in  the  hands,  much  like  the  perforating  ulcers  of  tabes,  sometimes 
develop,  as  well  as  abscesses  in  the  arms.  The  skin  of  the  hands  becomes 
cracked,  .the  nails  dry,  brittle,  and  fissured.  Vasomotor  changes  of  a 
marked  character  cause  the  skin  to  be  livid  or  pale  and  cold  to  the  touch. 

The  progress  of  the  disease  is  slow,  extending  over  many  years.  During 
this  time  felons  and  other  trophic  disturbances  occur  so  that  one  phalanx 
after  another  may  be  lost.  The  fingers  become  distorted  by  the  contraction 
of  the  interosseous  muscles.  By  reason  of  these  changes,  as  well  as  the 
paralysis  and  atrophy,  the  hands  may  become  useless. 

Pathology.  As  has  been  said,  the  disease  is  thought  by  some  to  be  identi- 
cal with  syringomyelia,  others  being  equally  positive  that  the  symptoms  are 
dependent  upon  a  special  lesion,  viz.,  neuritis.  In  several  cases,'''  which 
were  thought  during  life  to  be  typical  of  Morvan's  disease,  gliomatous  cavi- 
ties were  found  at  the  autopsy.  It  cannot  be  too  strongly  insisted  upon  that 
such  evidence  does  not  show  identity.  We  might  as  well  argue  that  because 
alcoholic  neuritis  and  tabes  have  been  confounded  that  they  are  therefore 
identical.  Almost  any  disease  may  at  times  simulate  another.  It  is  pos- 
sible, in  fact  probable,  that  while  Morvan's  disease  and  syringomyelia  are 
distinct  diseases,  the  lesion  upon  which  the  trophic  disturbances  depend  is 
the  same  in  each,  viz.,  a  neuritis. 

As  we  have  seen,  there  is  reason  to  believe  that  the  trophic  changes  in 
syringomyelia  are  due  to  a  coincident  and  secondary  neuritis ;  likewise  in 
Morvan's  disease  a  neuritis  has  been  found  in  the  stumps  that  have  required 
amputation  for  the  trophic  lesions. 

In  Gombault's'^  case,  which  came  to  an  autopsy,  there  was  found  a  periph- 
eral neuritis  and  a  sclerosis  of  the  posterior  columns  and  of  the  posterior  gray 
matter  of  the  cord.  The  sclerosis  included  the  vessels,  causing  an  occlusion 
of  them  ;  there  were  no  cavities  present.  The  sclerosis  of  the  cord  observed 
in  this  case  was  such  as  might  well  be  secondary  to  the  changes  in  the  periph- 
eral nerves.  A  single  case  like  this  is  of  much  more  value  in  throwing 
light  upon  the  pathology  of  the  disease  than  many  others  in  which,  though 
the  symptoms  simulate  Morvan's  disease,  the  central  changes  of  syringo- 
myelia are  found.  Such  a  case  demonstrates  that  the  group  of  symptoms 
described  by  Morvan  may  develop  from  conditions  other  than  syringomyelia 
and  is  entitled  to  independent  recognition.  The  fact  that  so  many  cases, 
twenty  in  number,  occurred  in  the  practice  of  a  single  individual  in  a  small 
fishing  town  of  5000  inhabitants,  is  strong  evidence  that  this  affection  is  not 
due  to  cavity  formation.  It  is  hard  to  believe  that  so  many  persons  in  a 
small  community  were  affected  by  such  a  rare  disease  as  syringomyelia, 
whereas  it  might  be  possible  that  a  neuritis  of  obscure  and  infectious  origin 
might  easily  affect  a  large  number  of  persons.  It  has  been  too  readily 
assumed  by  those  writers  who  hold  to  the  theory  of  neuritis  that  the  infec- 
tion was  due  to  fish.     If  a  poison  from  fish  would  cause  a  neuritis  of  this 

1  In  some  cases  the  deep  reflexes  of  the  legs  have  been  observed  to  be  increased.  In  consideration 
of  the  fact  that  some  cases  stipposed  during  life  to  be  Morvan's  disease  have  been  shown  at  the 
autopsy  to  be  cases  of  syringomyelia,  it  is  probable  that  those  cases,  in  which  paresis  of  the  legs  with 
increase  of  the  deep  reflexes  without  atrophy  was  observed,  were  really  cases  of  syringomyelia,  as 
such  symptoms  indicate  a  lesion  of  the  cord.  The  symptomatology"  ot  Morvan's  disease  needs 
careful  revision  in  some, of  its  details,  as  in  view  of  recent  autopsies  the  two  diseases  have  undoubt- 
edly been  confused. 

-  JofFrov  (La  Semaine  Medicale,  March  4,  1891)  has  reported  a  second  case. 

3  Archiv.  de  Med.  Exp,,  1891. 


DISEASES  OF  THE  SPINAL  CORD.  599 

kind  the  disease  should  be  common  in  fishing  communities  generally.  Some 
writers '  attempt  to  show  the  identity  of  syringomyelia  and  Morvan's 
disease  by  pointing  out  the  gradual  shading  of  the  symptoms  from  one  dis- 
ease to  the  other  in  graded  cases,  while  admitting  the  existence  of  character- 
istic types  of  each.  Arguments  of  this  kind  are  obviously  fallacious.  A 
judicial  consideration  of  the  evidence  thus  far  submitted  must,  however, 
find  that  the  ^^f^thology  of  Morvan's  disease  is  not  beyond  a  doubt,  but  that 
the  evidence  strongly  leans  toward  the  view  that  it  is  due  to  a  peripheral 
neuritis. 

Prognosis.  Though  few  cases  have  thus  far  died  from  the  disease,  the 
prognosis,  as  far  as  recovery  is  concerned,  must  be  regarded  as  unfavorable, 
but  the  disease  may  remain  stationary  a  long  time,  and  improvement  has 
been  observed  in  a  number  of  characteristic  cases.  If  the  theory  that  the 
disease  is  a  neuritis  is  correct,  there  is  theoretically  no  reason  why  great  im- 
provement or  recovery  should  not  occur  in  mild  cases.  Our  knowledge  is  at 
present  so  limited  and  the  difiiculty  of  distinguishing  individual  cases  from 
syringomyelia  is  so  great  that  we  cannot  at  present  formulate  positive  views 
regarding  the  prognosis. 

Treatment.  All  rational  treatment  must  be  limited  to  the  surgical  treat- 
ment of  the  felons  and  other  trophic  changes.  All  treatment  directed  to- 
ward the  disease  itself  must  be  purely  experimental. 


TUMORS  OF  THE  SPINAL  ENVELOPES  AND  OP  THE  CORD 

ITSELF. 

In  the  present  state  of  our  knowledge  it  is  not  possible  to  distinguish 
clinically  tumors  of  the  cord  from  tumors  of  the  spinal  envelopes  ;  it  is  there- 
fore customary  to  consider  them  together.  Nevertheless  various  attempts 
have  been  made  to  distinguish  one  class  of  tumors  from  the  other,  and  cer- 
tain symptoms  have  been  supposed  to  be  characteristic  of  one  or  the  other 
class.  More  extended  knowledge  has  shown  that  we  have  very  little  that  is 
trustworthy  for  this  purpose. 

The  following  account  is  based  on  an  independent  study  of  133  cases, 
which  include  the  collections  of  Horsley  and  Mills  and  Lloyd,^  and  37 
others. 

Etiology.  Various  causes  have  been  assigned  as  productive  of  tumors  ;  but, 
aside  from  syphilitic,  tubercular,  and  parasitic  growths,  we  know  almost 
nothing  of  the  real  cause  of  tumors.  Traumatism,  "  cold,"  and  emotional 
excitement  have  been  assigned  as  adequate  causes  of  tumor,  and  this  state- 
ment has  been  copied  from  one  text-book  to  another,  but  the  evidence  is  in- 
sufficient to  justify  this  conclusion.  The  etiological  question  is  an  important 
one,  especially  in  connection  with  traumatism,  as  claims  for  damage  are 
likely  to  be  made  and  have  been  made  on  such  statements.  The  chief  reason 
for  assigning  traumatism  as  a  cause  is  that  symptoms  have  been  known  to 
develop  immediately  after  a  fall  or  blow.  Such  evidence  proves  too  much, 
for  tumors  do  not,  like  mushrooms,  spring  up  in  a  night,  and  a  tumor  that 
has  attained  a  size  sufficient  to  produce  symptoms  must  have  existed  in  such 
cases  for  some  time  previous  to  the  accident.  If  the  traumatism  occurred 
at  a  remote  period  it  is  equally  difficult  to  trace  the  cause  and  effect.  At 
most  the  occurrence  of  symptoms  following  traumatism  shows  that  a  blow  or 

1  Kornfeld  :  Wien.  Med.  Wochcnschrift,  May  11.  181)2. 

2  Horsley's  collection  includes  some  of  those  collected  by  Mills  and  Lloyd.  These,  of  course,  are 
only  counted  once.  The  37  additional  cases  have  almost  all  been  published  since  the  date  of  Hors- 
ley's collection  (1888). 


600 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


a  fall  may  have  influence  in  developing  symptoms  of  pressure  which  other- 
wise would  not  have  appeared  till  a  later  period.  Evidence  of  the  correct- 
ness of  this  explanation  is  found  in  those  cases  where  a  similar  train  of 
symptoms  followed  traumatism,  and  yet  the  nature  of  the  tumor  was  such  as 
to  show  that  it  was  due  to  a  specific  cause.  For  example,  ISI'o.  53  of  Horsley's 
collection  was  assigned  to  traumatism  as  a  cause,  and  the  symptoms  of  No. 
16  were  intensely  aggravated  by  a  strain,  yet  the  former  was  a  tubercle  and 
the  latter  an  echinococcus  cyst.  A  case  of  my  own,  in  which  the  diagnosis 
of  a  gumma  was  supported  by  the  results  of  anti-syphilitic  treatment,  was 
ascribed  by  the  patient  to  a  fall. 

There  is  a  class  of  tumors  which  are  probably  really  the  consequence  of 
traumatism,  namely,  cystic  formations  which  develop  from  hemorrhage. 
According  to  Horsley  some  of  the  fibrocystic  tumors  reported  as  fibromata 
were  really  of  this  nature.^  A  hemorrhage  first  occurs  in  the  membranes, 
and  later  undergoes  secondary  organization,  finally  resulting  in  a  fibrocystic 
formation. 

The  effect  of  cold  and  emotional  disturbances  likewise  is  probably  to  excite 
at  most  symptoms  of  a  previously  existing  tumor.  An  analogous  effect  of 
traumatism  has  been  observed  in  other  spinal  diseases  ;  for  example,  tabes 
doi'salis,  in  which  it  sometimes  happens  that  the  disease,  which  has  been 
latent  up  to  the  moment  of  the  injury,  has  suddenly  given  rise  to  marked 
symptoms.  Gliomata,  in  many  cases,  and  perhaps  in  all,  are  the  result  of  a 
proliferation  of  embryonic  tissue  persisting  in  the  cord. 

Pathology.  Tumors  may  grow  from  the  cord  itself  (Figs.  187  and  189),  or 
from  any  of  its  membranes  (pia,  arachnoid,  dura)  (see  Fig.  188  and  Plate 
III)  ;  or  they  may  spring  from  tissues  outside  the  dura  mater,  such  as  the 
fat  lying  between  the  dura  and  the  vertebras,  the  bones  themselves,  or  the 

Fig.  187. 


Sarcoma  of  the  lower  cervical  cord.    (Adamktewicz.) 

intervertebral  cartilages.  Tumors  may  therefore  be  classified  as  extra-dural, 
intra-dural,  and  medullary.  The  most  practical  classification  for  clinical 
purposes  is : 

1.  Medullary  or  tumors  of  the  cord. 

2.  Extra-medullary  or  tumors  of  any  of  the  envelopes. 

This  classification  is  based  on  the  seat  of  the  tumor,  irrespective  of  the 
nature  of  the  tissue  from  which  it  grows. 

Tumors  of  the  cord  are  far  more  rare  than  of  the  envelopes.  Of  130 
cases  there  were  : 

Outside  dura 37 

Between  dura  and  cord ^9 

Outside  cord,  but  exact  location  doubtful  from  report       ....      11 

Total  outside  cord 97 

In  the  cord 19 

Location  doubtful  from  report 14 

130 

1  Nos.  24,  28,  32,  44.  46. 


PLATE  III 


\    U 


Cystic  sarcoma  of   the  arachnoid  coinpressiqg   the  cord   in  the  lower  dorsal 

regior^.      (Leyden.) 


DISEASES  OF  THE  SPINAL  CORD. 


601 


The  different  kinds  of  tumors  met  with  are  indicated  by  the  following 
table.  This  table  also  shows,  with  probably  fair  accuracy,  the  relative  fre- 
quency of  each  kind  : 


Sarcoma  (different  varieties) 

.      36 

Neuroma  .... 

2 

Myxoma    . 

.      15 

Osteoma    .... 

2 

Tubercle    . 

.      15 

Phlegmon .... 

Echinococcus 

.      10 

Aneurism  .... 

Fibroma    . 

8 

Dermoid  cvst    . 

(lumma 

8 

Blood-clot 

Psammoma 

o 

Angio-fibroma  . 

"  Cancer" 

5 

Lvmphangeoma 

Lipoma 

7 

Undetermined 

4 

Glioma 

6 

Fibro-chondro 

lipoma     . 

1 

130 

Fig.  188. 


Of  the  19  tumors  within  the  cord  (included  in  these  130  cases),  5  w^ere 
sarcomata,  4  gummata,  6  were  gliomata,  2  were  tubercles,  and  1  was  an 
echinococcus  cyst  (1  unknown). 

Various  mixed  forms  occur  as  in  other  parts  of 
the  body. 

Tumors  may  be  single  or  multiple.  In  the  great 
majority  of  cases  they  are  single.  When  more 
than  one  occur  they  are  generally  sarcomata  or 
neuromata.  Tubercular  tumors  are  sometimes, 
though  rarely,  multiple.  Spinal  tumors  growing 
within  the  canal  do  not  attain  to  a  large  size,  prob- 
ably owing  to  the  fact  that  before  doing  so  they 
produce  so  much  damage  that  death  takes  place. 
They  vary  from  the  size  of  a  pea  to  a  maximum 
diameter  of  two  to  three  inches.  One  exception 
to  this  is  giiomatous  tumor  springing  from  em- 
bryonal tissue  about  the  central  canal.  Though 
in  diameter  such  growths  are  small,  in  a  vertical 
direction  they  may  extend  through  a  considerable 
length  of  the  cord — sometimes  throughout  its  whole 
length.  They  are  often  combined  with  syringo- 
myelia, and  then  it  is  customary  to  consider  them 
as  a  distinct  affection.  A  diffuse  sarcoma  extend- 
ing from  the  sixth  cervical  to  the  cauda  equina 
has,  been  observed. 

The  effect  of  tumors  outside  the  cord  is  to  com- 
press its  substance,  producing  atrophy,  softening, 
or  myelitis  (pressure  myelitis).  An  indentation 
of  the  cord  corresponding  to  the  tumor  may  be  observed.  The  membranes 
in  the  neighborhood  of  the  tumor  may  be  oedematous  or  congested.  The 
cord  may  be  softened  for  some  little  distance  above  and  below  the  tumor. 
This  secondary  inflammation  may  develop  as  an  acute  process,  as  indicated  by 
the  symptoms.  In  tumors  of  the  cord  substance  the  cord  is  enlarged  at  the 
seat  of  growth,  and  on  cross-section  the  component  structures  of  the  cord  will 
be  observed  to  be  pressed  out  of  their  normal  positions,  wdiile  the  tumor  itself 
will  be  firmer  than  the  normal  cord  substance.  The  surrounding  tissue 
will  be  softer.  The  central  canal  may  be  obliterated  by  pressure  and  dilated 
above  the  point  of  constriction.  The  association  of  giiomatous  growths 
with  cavity  formations  (syringomyelia)  has  already  been  referred  to.  Sec- 
ondary degenerations  usually  occur,  according  to  the  well-known  laws,  i.  e., 
downward  in  the  lateral  columns,  upward  in  the  posterior  columns. 

Symptoms.  The  symptoms  caused  by  tumors,  whether  they  be  within  the 
cord  itself  or  outside  the  cord,  are  of  two  kinds,  namely,  those  due  to  irri- 


Sarcoma  compressing  the  cer- 
vical cord.    (B.  Long  Fox.) 


602 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


tation  of  the  cord  and  the  nerve-roots,  and  those  due  to  destruction  of  the 
cord  and  nerve-roots  or  to  impairment  of  their  functions.  The  clinical 
recognition  of  these  two  sets  of  symptoms  is  important,  as  well  as  that  of 


Fig.  189. 


Gliosarcoma  of  the  cord.    Nigrosin  stain.    (From  specimen  kindly  furnished  by 
Dr.  E.  W.  Tayloe.) 

their  order  of  development.  The  earlier  symptoms  are  in  the  majority  of 
cases  those  of  irritation.  At  a  later  period  symptoms  of  damage  become 
associated  with  those  of  irritation  ;  but  this  order  is  not  always  followed,  as 
sometimes  the  initial  symptoms  are  those  of  damage.  The  symptoms  of  irri- 
tation are  pain  and  spasm  ;  of  damage,  paralysis  of  sensation  and  motion, 
combined  with  the  usual  alterations  in  the  reflexes,  nutrition,  condition  of 
the  sphincters,  etc.,  found  in  transverse  lesions  according  to  the  location. 

Two  stages  can  frequently  be  recognized  :  a  first  stage,  in  which  symptoms  of 
irritation  predominate  ;  and  a  second,  in  which  those  of  paralysis  constitute  the 
principal  objective  feature,  though  pain  still  continues  and  aggravates  the 
sufferings  of  the  patient.  Mills  and  Lloyd  consider  that  these  stages  can 
generally  be  recognized. 

The  differentiation  of  stages  by  symptoms  charcteristic  of  each  cannot  so 
generally  be  made,  as  some  writers  would  have  us  understand.  It  is  true 
that  both  irritative  symptoms  and  damage  symptoms  occur  in  the  great 
majority  of  cases,  and  that  in  a  disease  of  this  nature  the  closing  scene  must 
be  one  of  damage ;  but  the  initial  stage  is  not  so  very  frequently  one  of  irri- 
tation as  is  often  asserted  to  be  the  case.  In  quite  a  large  group  of  cases  (25 
out  of  111)  the  first  symptom  is  one  of  damage  (paralysis  or  anaesthesia),  and 
in  others,  again,  the  two  sets  of  symptoms  appear  simultaneously,  so  that 
the  cases  may  be  arranged  in  two  groups,  a  larger  one  in  which  irritation 
precedes  damage,  and  a  smaller  one  in  which  the  reverse  is  the  case ;  or  both 


DISEASES  OF  THE  SPINAL  CORD.  603 

may  develop  together,  or  signs  of  irritation  may  be  wanting.  After  symp- 
toms of  damage  have  developed  both  classes  of  cases  pursue  the  same  course 
and  end  in  destruction  of  the  cord. 

The  clinical  features  presented  by  individual  cases  of  the  larger  class  (as 
well  as  the  smaller)  vary  much  in  the  grouping,  distribution,  and  mode  of 
development  of  the  symptoms.  The  symptoms  are  usually  slow  in  their 
development,  several  months,  as  a  rule,  elapsing  before  decided  damage  to 
the  cord  has  occurred ;  although  in  syphilitic  tumors  and  tubercles  this 
stage  may  be  reached  much  earlier  (three  to  eight  weeks). 

Initial  Stage.  The  first  symptom'  complained  of  by  a  large  majority  of 
patients  is  pain,  which  may  be  referred  to  the  distribution  of  the  nerves 
arising  at  the  level  of  the  tumor,  and  in  this  case  is  due  to  the  irritation  of 
nerve-roots  (root-pains),  or  it  may  be  located  in  parts  of  the  body  below, 
and  in  this  latter  case  is  due  to  irritation  of  the  sensory  tracts  within  the 
cord  (cord-pains).  Pain  is  also  persistent,  as  a  rule,  throughout  the  whole 
course  of  the  disease.  Out  of  128  cases,  it  was  present  in  107  at  some  period 
of  the  disease.  At  the  onset  the  pain  is  paroxysmal  in  character,  with  in- 
tervals of  freedom.  It  is  described  sometimes  as  burning,  sometimes  as 
sharp,  lancinating,  and  piercing.  When  the  tumor  is  in  the  dorsal  region, 
the  pain  may  produce  a  feeling  of  intense  constriction  around  the  body 
(girdle  pain).  When  in  the  cervical  region,  a  similar  sensation  may  be 
felt  in  the  neck,  causing  a  choking  feeling.  In  severity  the  pain  varies  in 
individual  cases ;  but  while  it  may  be  slight,  as  a  rule,  it  is  severe,  and  is 
often  so  intense  as  to  be  insupportable  without  large  doses  of  morphine.  The 
intensity  depends  in  part  upon  the  nature  and  location  of  the  growth. 

The  statement  is  frequently  made  that  root-pains  are  more  severe  than 
cord^pains,  and  that  in  tumors  of  the  membranes  the  pains  are  more  likely 
to  be  due  to  irritation  of  the  roots,  and  therefore  more  severe  than  in  tumors 
of  the  cord.  This  needs  considerable  qualification.  The  question  is  an  im- 
portant one  for  differential  diagnosis.  From  a  careful  study  of  the  location 
of  the  tumors  and  of  the  character  and  distribution  of  the  pains,  in  69  cases 
available  for  the  purpose,  I  find  that  in  57  the  pains  were  described  as 
"  severe,"  "  very  severe,"  "  atrocious,"  etc.  Of  these  57,  in  all  but  8  the 
tumor  was  outside  the  cord,  and  yet  the  pains  could  only  be  interpreted  as 
due  to  pressure  on  the  cord  itself  in  18,  on  the  nerve-roots  in  18,  and  on  both 
in  6.  In  8  the  report  was  not  sufficiently  detailed  to  enable  the  nature  of 
the  pains  to  be  determined.  In  3  the  pressure  was  upon  the  cauda  equina. 
In  the  remaining  12  of  the  69  cases,  the  pains  were  of  a  comparatively  mild 
character ;  in  3''  the  pains  Avere  due  to  pressure  on  the  cord  ;  in  5  to  pressure 
on  the  roots ;  in  1  to  pressure  on  both ;  in  2  doubtful ;  in  1  to  pressure  on 
the  cauda  equina. 

Taking  all  the  cases  together,  irrespective  of  the  character  of  the  pains,  we 
have :  cord-pains,  21  ;  root-pains,  23  ;  both,  7.  In  two  additional  cases  the 
pain  was  local  in  the  spine  over  the  seat  of  the  tumor,  and,  perhaps,  should 
be  classed  with  the  root-pains.  But  these  figures  are  probably  only  ap- 
proximately correct,  as  it  is  not  easy  in  every  case  to  determine  from  the 
reports  the  origin  of  the  pains. 

From  these  facts  it  will  apj^ear  that  severe  pains  are  quite  as  likely  to 
arise  from  pressure  on  the  cord  as  upon  the  roots,  and  that  cord  pains  are 
as  frequent  in  extra-medullary  tumors  as  root-pains.^ 

1  It  should  he  stated  that  in  the  later,  and  probably  more  accurately  reported  cases,  pain  ia  men- 
tioned as  the  first  symptom  much  more  frequently  than  in  the  earlier  cases,  and  it  is  possible  that 
future  observations  will  accord  with  the  former. 

-  In  one  of  these  there  were  also  pains  which  probably  were  root-pains. 

3  The  fact  is  of  importance  in  diagnosing  the  location  of  the  tumor,  as  when  the  pain  is  due  to 
pressure  upon  the  cord  it  is  impossible  to  determine  from  the  distribution  of  the  pain  how  much 
above  the  corresponding  nerve-roots  the  tumor  may  be  located, 


604  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Whether  tumors  of  the  cord  itself  are  as  likely  to  give  rise  to  as  severe 
pain  as  tumors  of  the  envelopes,  irrespective  of  their  origin  (cord-pains  or 
root-pains),  cannot  be  determined  without  a  greater  number  of  cases  than 
has  thus  far  been  collected.  It  can,  however,  be  said  that  both  kinds  give 
rise  to  severe  pains. 

In  tubercle  the  pain  is  comparatively  mild.^  In  tumors  of  the  cervical 
and  lumbar  enlargement  the  pain  may  radiate  down  the  arms  and  legs,  re- 
spectively, involving  distinct  nerve-regions  according  to  the  nerve-roots  or 
segment  of  the  cord  involved.  In  tumors  of  the  cervical  cord-pains  in  the 
neck  are  most  commonly  observed,  but  they  are  sometimes  felt  in  the  legs 
and  in  the  back,  and  even  a  girdle  pain  around  the  waist  may  be  present. 
When,  at  the  onset  they  are  felt  in  the  neck  or  arms  in  the  nerves  arising 
from  the  cer^dcal  cord,  they  may  at  a  later  period  as  the  tumor  encroaches 
upon  the  cord  substance  appear  in  the  legs  and  body  below.  In  a  few  cases 
the  pain  has  been  felt  in  parts  above  the  seat  of  the  tumor. 

It  is  not  uncommon  for  the  pain  to  begin  on  one  side  of  the  body,  and 
then  extend  to  the  other  side,  after  a  distinct  interval,  or  to  begin  in  one 
arm  and  later  appear  in  the  leg  of  the  same  side  or  in  the  abdomen.  In 
fact,  it  is  not  infrequent  to  meet  with  pains  in  one  part  of  the  body  due  to 
pressure  on  the  roots  and  at  the  same  time  with  pains  in  another  part  of  the 
iDodv  from  irritation  of  the  cord.  Sometimes  the  pain  is  increased  or  the 
paroxysms  are  excited  by  almost  any  movement  of  the  body,  such  as  jolting 
or  jarring,  or  movement  of  the  spine  and  limbs.  Sometimes  the  pain  is  located 
in  the  spine,  and  there  may  be  localized  spinal  tenderness.  In  some  instances 
severe  pains  are  felt  in  the  joints.  The  slightest  movement  of  the  limbs  may 
cause  paroxysms  of  excruciating  pain.  In  such  cases  the  disease  may  be 
mistaken  for  rheumatism.  At  this  stage  of  the  disease  the  patient  may  suffer 
from  pain  alone  for  a  long  period  before  the  development  of  other  symptoms. 
The  length  of  this  stage  varies  according  to  the  nature  of  the  tumor,  from  a 
few  weeks  to  one  or  two  years.''^ 

But  early  in  the  course  of  the  disease  another  symptom  of  irritation — 
spasm — is  apt  to  be  associated  with  the  pain.  The  spasm  may  take  the  form 
of  simple  stifihess  of  the  muscles,  or  of  clonic  jerking  of  the  limbs  at  intervals, 
or  of  contractures.  Some  spasm  in  the  course  of  the  disease  is  common,  but 
it  is  not  so  frequent  a  symptom  as  pain.  It  was  mentioned  as  present  in  one 
of  its  various  forms  in  73  out  of  129  cases.  Like  pain,  it  may  be  due  to  irri- 
tation of  the  nerve-roots  or  of  the  cord  itself.  It  occurs  in  intra-medullary 
as  well  as  extra-medullary  tumors.  In  tumors  of  the  cervical  region  it  may 
be  observed  as  a  rigidity  of  the  neck,  sometimes  producing  a  form  of  torti- 
collis. Spasm  of  the  cervical  muscles  is  more  likely  to  be  recognized  than 
other  spinal  muscles,  owing  to  the  flexibility  of  the  cervical  spine.  In  tumors 
of  this  region  the  sjDasm  may  be  observed  in  the  fingers  or  arm  ;  or,  like  pain, 
it  may  first  and  at  an  early  period  be  noticed  in  the  leg.  AVhen  at  the  onset 
it  is  noticed  in  the  upper  part  of  the  body  it  may  later  in  the  course  of  the 
disease  appear  in  the  muscles  of  the  abdomen  or  legs.  In  tumoi-s  of  the 
dorsal  and  lumbar  regions  spasm  is  necessarily  limited  to  the  muscles  of  the 
back,  abdomen,  or  legs.  Sometimes  the  spasms  are  very  painful,  and  may, 
like  pain,  be  excited  by  any  movement  of  the  limbs  or  body,  according  to 
their  location. 

Besides  the  pain  already  spoken  of,  patients  may  complain,  in  the  early 
and  middle  stages,  of  still  other  sensory  disturbances,  such  as  par^esthesiae,  a 
feeling  of  numbness,  prickling,  and  "  pins-and-needle  "  sensations,  and  when 

1  Herter's  26  cases.    Journal  of  Nervous  and  Mental  Diseases,  1890. 

-  In  one  case  excruciating  pains  alone  persisted  without  other  symptoms  for  eight  years,  when 
death  took  place  apparently  from  exhaustion. 


DISEASES  OF  THE  SPINAL  CORD.  605 

pain  is  not  present  an  examination  may  show  the  presence  of  the  analogous 
symptom,  hypersesthesia.  Sometimes,  when  sensory  symptoms  are  not  present 
in  the  initial  period,  this  stage  of  irritation  may  still  be  recognized  by  the 
presence  of  some  form  of  spasm. 

In  some  instances,  in  the  earliest  stages,  the  patient  may  notice  a  certain 
amount  of  weakness  of  certain  groups  of  muscles.  In  a  large  minority  of 
cases  (25  out  of  111),  instead  of  symptoms  of  irritation,  paralytic  symptoms 
make  up  the  initial  stage.  The  disease  begins  then  with  gradually  develop- 
ing paraplegia,  or,  in  a  few  instances,  paralysis  of  one  side  of  the  body,  or  all 
four  limbs.  Occasionally  the  ]3aralysis  has  come  on  suddenly  after  some 
exciting  cause,  such  as  exposure  to  cold. 

Pain  in  this  class  of  cases  may  appear  later,  though  in  most  of  them  this 
is  not  recorded  in  the  published  report.  It  would,  therefore,  seem  that  in 
this  class  of  cases  the  early  development  of  the  paralysis  was  dependent  on 
the  site  of  the  disease.  In  a  few  cases,  as  was  just  mentioned,  paralysis 
and  pain  appear  together  at  the  onset,  or  some  form  of  spasm  may  be  asso- 
ciated with  the  paresis.  Occasionally,  instead  of  pain,  the  initial  symptom  is 
muscular  twitching  or  cramps,  ataxia  or  vasomotor  symptoms  (cedema-redness 
of  skin,  etc.).  The  occurrence  of  paralysis  as  the  initial  symptom,  or  coinci- 
dently  with  pain,  seems  from  the  data  at  hand  to  be  relatively  more  frequent 
with  intra-medullary  tumors,  but  the  nvimber  of  cases  of  this  kind  at  our 
disposal  is  too  small  to  make  it  safe  to  draw  such  inductions. 

When  a  primary  irritative  stage  has  been  present,  as  the  disease  progresses 
and  the  nerve-roots  and  the  cord  become  more  compressed,  all  the  irritation 
symptoms  increase  in  intensity,  and  may  become  more  widely  distributed. 
Symptoms  indicative  of  damage  are  now  added  to  the  clinical  picture. 

Paralysis,  if  it  has  not  already  appeared,  develops.  One  peculiarity  of  the 
paralysis,  whether  it  follows  a  primary  stage  of  irritation  or  is  the  central 
symptom,  is  that,  with  considerable  frequency,  it  begins  in  one  group  of 
muscles,  as  of  an  arm  or  hand,  and  afterward  extends  to  other  muscles  of  the 
same  limb,  or  the  corresponding  limb  of  the  same  side  of  the  body.  Later, 
with  the  growth  of  the  tumor  the  other  side  of  the  body  becomes  affected. 
When,  however,  the  tumor  is  centrally  located,  the  paralysis  may  be  bilat- 
eral from  the  beginning.  This  transference  from  one  part  to  another,  unfor- 
tunately for  diagnosis,  cannot  always  be  traced,  although  it  is  likely  that 
with  more  careful  observation  it  would  be  recognized  more  frequently  than 
the  published  reports  in  the  past  have  indicated. 

When  the  tumor  is  located  in  the  cervical  enlargement  the  arms  may  be, 
but  not  necessarily,  the  first  to  be  paralyzed.  Instead  of  the  arms,  the  paral- 
ysis may  first  appear  in  the  legs  from  damage  to  the  pyi'amidal  tracts. 

The  slower  the  growth  of  the  tumor,  the  slower  the  development  and  the 
extension  of  the  paralysis,  unless  a  myelitis  lights  up,  as  is  common.  In  the 
latter  case  the  paralysis  may  come  on  rapidly,  as  in  myelitis,  due  to  other 
causes.  Tumors  arising  outside  the  cord  may  cause  paralysis  of  the  nerves 
arising  at  the  level  of  the  tumor  before  affecting  the  cord.  The  final  dis- 
tribution of  the  paralysis  depends  upon  the  location  of  the  tumor.  When  in 
the  dorsal  or  lumbar  region,  paraplegia  results ;  when  in  the  cervical  region, 
all  four  limbs  are  affected.  One  side  of  the  body  may  be  affected  before  the 
other  ;  that  is,  a  spinal  hemiplegia  or  a  Brown-Sequard's  paralysis  may  result. 
Though  the  paralysis  and  other  symptoms,  when  dependent  upon  com})res- 
sion,  steadily  increase,  the  same  symptoms  may,  when  due  to  the  incited 
myelitis,  largely  subside  with  the  inflammation,  and  tluis  a  temporary 
improvement  may  occur. 

About  the  same  time  with  the  paralysis,  though  more  generally  a  little 
after,  anesthesia  develops.    The  sensory  fibres  seem  to  be  more  resisting  than 


606  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  motor,  and,  therefore,  the  loss  of  sensation  is  not  only  apt  to  appear  a 
little  later,  but  may  be  comparatively  slight,  with  great  motor  paralysis. 
"With  increase  of  compression  the  anaesthesia  deepens.  It  will  be  found  either 
in  the  course  of  the  nerves,  arising  at  the  level  of  the  tumor,  or  in  pai'ts  of 
the  body  below  from  damage  to  the  cord  itself  In  the  former  case  isolated 
areas  of  anaesthesia  may  be  found,  and  in  any  case  the  anaesthesia  may  occupy 
the  same  nerve  lesions  that  are  the  seat  of  pains.  This  combination  of  anaes- 
thesia and  pain  in  the  same  area  of  the  body  is  called  arue-sthesia  dolorosa. 
It  is  due  to  destruction  of  the  nerve  fibres  and  irritation  of  their  prox- 
imal ends. 

The  loss  of  sensation  corresponds,  as  a  rule,  with  that  of  motion,  except 
that  when  the  tumor  is  to  one  side  and  fairly  high  up  (above  the  lumbar 
enlargement)  symptoms  of  unilateral  lesion,  or  Brown-Sequard's  paralysis, 
just  spoken  of,  may  at  first  be  present ;  that  is  to  say,  crossed  paralysis  of 
motion  and  sensation.  Sensation  is  lost  on  the  side  opposite  the  tumor,  and 
motor  power  on  the  same  side.  This  is  commonly  exj)lained  by  the  theory 
that  the  sensory  fibres  cross  soon  after  entering  the  cord,  while  the  motor 
fibres  do  not  do  so  until  they  reach  the  pyramids  in  the  medulla  ;  consequently, 
the  sensory  fibres  of  the  opposite  side  and  the  motor  fibres  of  the  same  side  will 
be  affected  by  any  unilateral  lesion.  (As  this  anaesthesia  does  not  quite  reach 
to  the  level  of  the  tumor,  it  is  thought  that  the  sensory  fibres  do  not  cross  at 
once,  but  after  ascending  variable  distances.)  In  unilateral  lesion  there  mav 
also  be  a  zone  of  anaesthesia  on  the  same  side  as  the  paralysis,  corresponding 
to  the  nerves  entering  at  the  level  of  the  tumor.  The  muscular  sense,  when 
this  also  is  involved,  is  affected  on  the  same  side  with  the  motor  paralysis. 

When  the  tumor  is  in  the  lumbar  enlargement,  although  on  one  side,  the 
anaesthesia  is  not  crossed,  but  is  on  the  same  side  with  the  paralvsis,  owing  to 
the  fact  that  the  sensory  nerves  are  affected  before  crossing.  But  it  is  not 
often  that  crossed  paralysis  is  met  with  in  a  pure  form,  as  the  opposite  side  of 
the  cord  is  generally  more  or  less  compressed,  and  some  blunting  of  sensa- 
tion and  weakness  of  the  muscles  is  generally  observed  on  both  sides,  only 
the  symptoms  of  unilateral  lesion  may  predominate. 

At  this  time,  even  after  the  paralysis  and  loss  of  sensation  have  become 
complete — that  is  to  say,  the  lesion  has  become  transverse — the  pains  not 
only  generally  continue,  but  may  extend  to  other  regions  of  the  body  and 
become  intolerable.  Painful  contractures  of  the  limbs  may  develoj) — the 
legs,  for  example,  being  held  in  flexion  or  extension,  and  any  motion  of  the 
joints  may  excite  excruciating  pains.  Sometimes  any  irritation  of  the  para- 
lyzed limbs  may  induce  painful  spasms. 

With  the  symptoms  indicative  of  the  extension  of  the  lesion  transversely 
through  the  cord,  paralysis  of  the  bladder  and  bowels  develops.  The  charac- 
teristics of  this  paralysis  are  the  same  as  in  transverse  myelitis.  When  the 
tumor  is  in  the  lumbar  region  the  sphincter  of  the  bladder  is  paralyzed,  and 
there  is  incontinence  of  urine ;  when  above  the  lumbar  enlargement,  reten- 
tion, Avith  reflex  evacuation  or  overflow.  The  same  is  true,  midatis  mutandis, 
of  the  bowels. 

At  this  stage  there  is  a  marked  tendency  for  bed-sores  to  form.  These 
sometimes  commit  frightful  I'avages.  The  necrosis  may  extend  to  the  bone 
and  open  the  vertebral  canal.  Septicaemia  may  result.  Cvstitis  may  also 
develop,  and,  secondarily,  pyelonephritis.  Oedema  of  the  limbs  sometimes 
occurs.     Priapism  is  common  as  in  other  transverse  lesions. 

The  reflexes  follow  the  general  law  governing  them  in  disease  of  the  cord. 
Those  arising  from  tlie  diseased  segment  are  sooner  or  later  abolished  ;  those 
from  all  lower  segments  are  increased.  The  increase  of  myotatic  irritability 
in  the  muscles  below  the  lesion  leads  to  the  development  in  them  of  a  spastic 


DISEASES  OF  THE  SPINAL  COED.  607 

condition,  and  very  frequently  to  contractures.  An  apparent  exception  has 
been  observed  in  some  cases  in  which,  although  the  tumor  was  in  the  dorsal 
region,  the  knee-jerks  were  abolished  ;  but  such  cases  may  be  explained,  as 
pointed  out  by  Gowers  and  proven  by  Fancotte,  by  a  descending  myelitis^ 
into  the  lumbar  region.  A  careful  study  of  the  reflexes  gives  valuable  in- 
formation regarding  the  location  of  the  tumor. 

All  paralyzed  muscles  do  not  atrophy,  but  only  those  whose  nutrient  cen- 
times in  the  anterior  cornua  or  whose  motor  nerves  connecting  them  with 
these  centres  are  destroyed ;  hence  the  atrophy  is  limited  to  the  muscles  con- 
nected with  the  compressed  segments  or  nerves,  unless  a  more  diffuse  mye- 
litis has  been  excited.  The  muscles  connected  with  segments  below  are 
not  affected  with  true  atrophy,  but  may  exhibit  a  certain  amount  of  wasting 
from  disuse.  In  consequence  of  the  large  number  of  nerves  coming  from 
the  cervical  and  lumbar  enlargements  there  may  be  much  wasting  of  the 
arms  when  the  tumor  is  in  the  former  locality,  and  of  the  legs  when  in  the 
latter.  Likewise,  of  course,  much  atrophy  of  the  leg  muscles  may  occur  in 
tumors  of  the  cauda  equina.  When  a  descending  myelitis  has  been  super- 
added to  the  compression  the  atrophy  is  necessarily  diffuse. 

The  electrical  excitability  of  the  wasted  muscles  will  vary  considerably 
according  to  the  rate  of  growth  and  rapidity  of  destruction  of  the  gray  mat- 
ter, or  motor  nerves.  When  the  wasting  has  been  slow,  as  is  generally  the 
case  when  myelitis  has  not  been  superadded,  only  a  diminished  reaction  will 
be  observed  to  both  the  galvanic  or  faradic  current. 

If  an  acute  myelitis  has  been  excited,  affecting  the  anterior  gray  matter, 
the  reaction  of  degeneration  will  be  found  in  the  acutely  degenerated  muscles. 
The  excitability  of  the  nerves  that  supply  the  atrophied  muscles  will  be 
diminished  to  both  currents ;  that  of  other  nerves  will  remain  unchanged. 

When  the  tumor  is  in  the  cervical  region,  contraction  or  dilatation  of  the 
pupil  sometimes  occurs,  the  former  being  due  to  paralysis,  the  latter  to  irri- 
tation of  the  nerves  supplying  the  radiating  fibres  of  the  iris  through  the 
sympathetic.  A  number  of  other  symptoms  are  occasionally  observed. 
Among  them  vomiting  and  headache  have  been  noted  in  a  few  cases,  and 
sometimes  dyspnoea  and  dysphagia.  Optic  neuritis  has  been  present  in  a  few 
instances  where  the  tumor  was  located  in  the  cervi co-dorsal  region.  Fever 
may  occur  as  a  consequence  of  bed-sores  or  cystitis,  and  vasomotor  disturb- 
ances in  the  form  of  flushings  of  the  skin,  or  oedema,  are  occasionally  met 
with.  Cough,  dyspnoea,  and  pain  in  the  chest  have  been  noted  in  three 
cases  of  tumor  in  the  cervical  region. 

The  secondary  degenerations  which  follow  transverse  lesions  of  the  cord 
give  rise  to  the  usual  symptoms.     (See  Chapter  XX.) 

Course  and  Duration.  The  course  of  spinal  tumors  has  been  sufficiently 
indicated.  They  necessarily  lead  to  complete  loss  of  those  functions  sub- 
served by  the  cord  below  the  seat  of  the  lesion.  They  eventually  end  in 
death.  The  duration  is  variable,  depending  upon  the  nature  and  seat  of  the 
tumor.  In  tubercular  disease  death  usually  takes  place  in  from  six  to  eight 
weeks  from  the  onset  of  the  symptoms.  (Herter.)  In  other  forms  of  tumor 
the  course  is  much  slower,  and  the  disease  may  last  many  months,  or  even 
several  years  (seven  or  tight  years  in  extreme  cases).  In  one  case  severe 
pains  persisted  for  eight  years,  when  death  took  place,  presumably  from 
exhaustion,  before  even  the  development  of  any  motor  or  sensory  paralysis. 
In  general,  it  may  be  said  that  when  pain  is  the  first  symptom,  it  may,  though 
not  always,  persist  for  a  long  time  before  the  development  of  sym])toms  of 
damage  to  the  cord. 

1  I.dter  observations  of  the  reflexes  in  myelilis  seem  to  indicate  that  the  knee-jerks  may  be  abol- 
ished in  these  exceptional  cases  by  inhibition. 


608  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  diagnosis  of  the  location  of  the  tumor  often  presents  serious  difficulties 
in  the  earlier  stages  of  the  disease.  After  transverse  softening  of  the  cord 
has  occurred  little  difficulty  will  usually  be  met  with,  but  at  this  time  the 
practical  importance  of  accurately  locating  the  tumor  will  have  largely  ceased 
to  exist  in  most  cases. 

Tumors  of  the  meninges  cannot  be  differentiated  from  tumors  of  the  cord. 
As  has  already  been  explained  in  describing  the  symptoms,  the  distribution 
and  character  of  the  pain  afford  no  aid  for  this  purpose.  The  location  of 
the  tumors  in  the  bone  or  inter-vertebral  substance  can  be  done  with  success 
only  when  there  are  external  signs  of  deformity.  This  is  easier  of  detection 
in  the  cervical  than  in  the  dorsal  or  lumbar  spine.  Tumors  of  the  sacrum 
may  often  be  detected  by  vaginal  or  rectal  examination.  The  fact  that  pain 
is  caused  by  movement  is  unreliable  as  evidence  of  the  location  of  the  growths 
in  the  bone.  This  symptom  is  quite  as  likely  to  be  present  when  the  growth 
is  in  the  membranes.  It  should  always  be  borne  in  mind,  however,  that 
tumors  of  the  cord  are  relatively  rare,  and  the  chances  are  greatly  in  favor 
of  any  given  tumor  being  extra-medullary.  The  vertical  location  of  the 
tumor  can  be  determined  sooner  or  later,  according  to  the  number  of  symp- 
toms presented.  No  one  symptom  is  sufficient.  The  distribution  of  the  pain, 
although  an  important  sign,  cannot  alone  be  relied  upon,'  as  it  is  not  possible 
to  distinguish  between  root  pains  and  cord  pains,  and,  therefore,  it  cannot  be 
determined  whether  the  growth  is  pressing  upon  the  roots  of  the  nerves  in 
whose  distribution  the  pain  is  felt,  or  upon  the  cord  higher  up.  In  excep- 
tional cases  the  pain  may  even  be  felt  in  nerves  above  the  tumor.  The  same 
uncertainty  pertains  to  the  indications  offered  by  spasms.  But  when  pain  is 
felt  in  several  nerve-areas,  that  corresponding  to  the  highest  spinal  segment 
is  more  likely  to  be  a  root-pain  and  to  indicate  the  position  of  the  tumor. 
Among  the  most  valuable  localizing  signs  are  the  upper  limit  of  the  anaes- 
thesia, the  condition  of  the  reflexes,  and  the  limitation  of  the  atrophy,  and 
the  abnormal  electrical  reactions  to  certain  groups  of  muscles.  The  distri- 
bution of  the  paralysis  may  or  may  not  be  of  value,  according  to  its  com- 
bination with  other  symptoms.  The  following  are  the  chief  peculiarities  in 
the  grouping  of  the  symptoms  liable  to  be  met  with  in  tumors  of  different 
portions  of  the  cord  : 

In  the  cervical  region  rigidity  of  the  neck  muscles  is  common.  When  the 
arms  are  paralyzed  careful  observation  may  disclose  that  certain  gi'oups  of  mus- 
cles were  affected  before  the  others,  and  that  the  atrophy  is  limited  to  special 
muscular  groups.  For  example,  a  growth  in  the  lower  cervical  region  (seventh 
and  eighth)  would  cause  atrophy  with  corresponding  electrical  changes  lim- 
ited to  the  lower  arm^  group  of  muscles,  even  though  the  body  and  legs  were 
paralyzed.  The  shoulder  and  upper-arm  muscles  (with  the  exception  of  a 
portion  of  the  triceps)  would  escape. 

A  growth  in  the  upper  cervical  segment  would  cause  atrophy  limited  to 
the  shoulder  and  upper-arm  group  of  muscles,  though  all  the  nerves  of  the 
arms  and  legs  were  paralyzed.  If  the  legs  are  paralyzed  before  the  arms, 
reliance  must  be  placed  upon  the  increased  reflexes,  deep  and  superficial,  of 
the  body  and  legs,  and  upon  the  height  of  the  anaesthesia.  If,  in  addition, 
pain  and  spasm  occur  in  the  distribution  of  the  cervical  nerves,  the  tumor  is 

1  For  example,  in  one  ease,  where  the  tumor  was  successfully  removed,  the  localization  of  the 
tumor  must  be  regarded  as  due  partially  to  good  luck,  as,  according  to  the  report,  the  distribution 
of  the  pain  was  largely  relied  upon,  and  the  operation  showed  the  tumor  was  above  the  nerve- 
roots  supposed  to  he  compressed,  and  that  the  pains  must  therefore  have  been  due  to  pressure  on  the 
cord  above.  The  highest  localizing  pains  were  in  the  distribution  of  the  sixth  and  seventh  dorsal 
nerves  on  the  left  side.    The  tumor  was  found  adherent  to  the  highest  root  of  the  left  fourth  nerve. 

-  The  supinator  region  would  probably  escape,  as  its  nucleus  is  in  the  fourth  and  fifth  segment 
with  that  of  the  biceps  groups. 


DISEASES  OF  THE  SPINAL  COBD.  609 

certainly  in  some  part  of  the  cervical  cord.    There  is  retention  of  urine  with 
overflow  or  spasmodic  incontinence  in  tumor  of  the  cervical  cord. 

In  tumors  of  the  dorsal  cord  there  is  paraplegia.  The  height  of  the  anaes- 
thesia and  the  reflexes  must  be  the  chief  guides.  The  seat  of  the  pain  and 
spasms  is  of  value  as  indicating  a  possible  lowest  limit,  as,  excepting  in  rare 
instances,  the  pain  is  never  above  the  tumor.  For  example,  if  pain  around 
the  waist  is  present  the  tumor  may  be  safely  placed  at  the  same  level  or  above 
it.  The  same  is  true  of  abdominal  spasm  and  paralysis.  In  tumors  of  the 
lumbar  and  sacral  segments,  we  have  to  guide  us  the  distribution  of  the 
atrophy,  the  condition  of  the  reflexes,  deep  and  superficial,  and  the  paralysis 
of  the  sphincters,  besides  the  peculiar  distribution  of  the  anaesthesia  and 
paralysis,  according  to  the  exact  segments  compressed.  A  study  of  Figs. 
195  and  196,  pages  616  and  617  will  be  necessary  for  this  purpose. 

The  symptoms  of  tumor  of  the  cauda  equina  simulate  those  of  the  lumbar 
and  sacral  segments,  and,  as  a  rule,  it  is  difiicult  to  distinguish  the  one  from 
the  other.  The  rules  generally  given  are  inadequate.  Only  by  carefully 
weighing  the  symptoms  and  judging  of  the  probability  for  and  against,  can 
tumors  of  the  two  situations  be  difierentiated  from  one  another. 

Diagnosis.  The  diagnosis  of  spinal  tumors  must  depend  upon  the  march 
of  the  symptoms  ;  the  more  common  order  in  which  they  appear  being  pain, 
spasm,  or  muscular  rigidity,  paralysis,  and  anaesthesia.  The  diagnosis  may  be 
aided  by  the  fact  of  syphilis  being  known  to  be  present,  or  tubercular  dis- 
ease existing  elsewhere.  The  presence  of  tumors  also  in  other  parts  of  the 
body  would  point  to  a  probability  of  the  cord  disease  being  due  to  a  similar 
growth.  The  greatest  difiiculty  likely  to  be  met  with  is  when  the  symptoms 
do  not  follow  the  usual  order,  but  when  paralysis  appears  first,  and  pain  either 
is  not  present  at  all  or  comes  on  later.  A  careful  study  of  all  the  conditions 
present  will  alone  enable  us  to  recognize  the  existence  of  tumors  in  such 
cases.  The  chief  diseases  with  which  tumors  are  likely  to  be  confounded  are, 
in  the  early  stages,  neuralgia,  rheumatism,  local  neuritis,  and  hysterical  neu- 
rasthenia ;  and,  later,  focal  chronic  myelitis,  subacute  myelitis,  chronic  pachy- 
meningitis, caries  and  neuritis  of  the  sacral  plexus. 

When  pain  alone  is  present,  it  may  be,  and  often  is,  mistaken  for  that  of 
neuralgia,  rheumatism,  and  local  neuritis.  In  the  early  stages  it  is  not  easy 
to  recognize  the  true  cause  of  the  pain,  and  probably  we  shall  have  to 
wait  until  the  development  of  other  symptoms.  The  main  grounds  for  sus- 
picion would  be  its  severity  and  continuous  reference  to  the  distribution  of 
certain  special  nerve  areas.  A  long-continued  neuralgic  pain,  paroxysmal, 
and  of  great  intensity,  confined  to  a  particular  nerve,  without  evidence  of 
special  cause,  such  as  traumatism  or  disease  of  the  neighboring  parts,  is  sufii- 
cieut  to  justify  the  suspicion  of  irritation  from  pressure  upon  the  cord  or 
nerve-roots.  Further,  in  neuralgia  and  neuritis  we  are  likely  to  obtain,  in 
the  former,  the  various  sensitive  points,  and,  in  the  latter,  tenderness  along 
the  course  of  the  nerve.  This  absence  of  tenderness  in  tumor  is  an 
important  point.  The  pains  of  neuralgia  and  rheumatism  are  also  likely 
to  be  diffiise  and  to  involve  various  nerve  areas  in  different  parts  of  the 
body. 

Neurasthenia  wdth  hysterical  symptoms  sometimes  exhibits  considerable 
resemblance  to  the  earlier  stages  of  tumors.  There  may  be  long-continued 
pains,  limited  to  certain  nerve  areas,  and  even  spasm  of  muscles  and  mus- 
cular weakness,  but  careful  inquiry  will  show  the  predominance  of  the  neuras- 
thenic conditions,  the  lack  of  a  paroxysmal  character  to  the  pains,  and  often 
the  dependence  of  these  upon  temporary  emotional  conditions.  The  mus- 
cular weakness  should  be  easily  distinguished  from  a  real  paralysis.  The 
distribution  of  the  pains  and  the  muscular  symptoms  will  not  harmonize 

39 


610  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

with  any  particular  spinal  localization.  The  presence  of  hysterical  stigmata 
in  other  parts  of  the  body  will  help  to  clear  up  the  diagnosis. 

In  chronic  focal  myelitis  there  is  much  less  likelihood  of  there  being  spasm 
or  rigidity  of  the  muscles ;  the  pains  are  less  severe  and  are  more  likely  to 
be  confined  to  the  distribution  of  the  nerves  originating  from  the  level  of  the 
lesion,  while  in  tumor  they  are  more  likely  to  be  found  in  nerves  originating 
below.  It  is  rare  that  chronic  focal  myelitis  does  not  occupy  a  greater  ver- 
tical extent  of  the  cord,  and  hence  a  careful  examination  will  reveal  more 
extensive  disease  than  occurs  with  tumor. 

Subacute  myelitis  will  only  be  a  source  of  difficulty  when  it  is  secondary  to 
a  tumor.  In  this  case  a  careful  inquiry  will  enable  us  to  recognize  antecedent 
symptoms,  referable  to  the  tumor,  which  have  excited  the  myelitis. 

Chronic  pachymeningitis,  especially  the  hypertrophic  form,  is  more  likely 
to  be  confounded  with  tumor  than  any  other  disease.  The  symptoms  in  their 
grouping  and  development  resemble  very  much  those  of  tumor.  It  is,  how- 
ever, a  rare  disease.  The  chief  points  to  be  depended  upon  for  differential 
diagnosis  are  that  pachymeningitis  affects  a  greater  vertical  area  of  the  cord, 
and,  as  it  usually  completely  surrounds  the  cord,  its  symptoms  are  bilateral 
trom  the  beginning.  The  pains  are  usually  due  to  irritation  of  the  nerve- 
roots  and  not  of  the  cord,  and  the  most  marked  paralysis  and  ansesthesia  are 
likewise  due  to  the  injury  of  the  nerve-roots  rather  than  of  the  cord.  The 
paresis  and  other  symptoms  which  are  consecutive  to  pressure  upon  the  cord 
are  usually  less  prominent,  and  appear  at  a  later  stage  than  in  tumor.  The 
progression  of  the  symptoms  showing  the  successive  affection  of  different 
nerve-tracts  is  less  characteristic  than  in  tumor. 

In  caries  the  pains  are  much  milder,  and  rigidity  of  the  muscles  is  rare. 
It  is  rare  for  the  disease  to  have  progressed  sufficiently  far  to  produce  paral- 
ysis or  ansesthesia  without  producing  some  changes  in  the  spinal  column, 
such  as  thickening  of  the  tissues,  or  deformity. 

Further,  when  paralysis  and  other  cord  symptoms  appear,  they  are  due 
to  an  incited  myelitis,  and,  therefore,  in  their  development  present  the 
clinical  picture  of  that  disease  rather  than  of  tumor.  A  careful  examination 
of  the  spine  will  generally  reveal  the  nature  of  the  disease,  and  in  doubtful 
cases  treatment,  including  extension  of  the  spine,  would  probably  clear  up 
the  diagnosis. 

Treatment.  It  is  only  in  syphilitic  growths  that  medicinal  treatment  can 
be  of  use.  Where  there  is  the  slightest  reason  to  suspect  syphilis,  specific 
treatment  should  be  pushed  with  vigor.  Even  in  syphilis,  it  is  only  in  the 
early  stages  that  treatment  can  be  of  value,  because  after  the  cord  has  been 
damaged  by  the  pressure  of  the  growth  it  will  be  too  late  to  repair  the 
injury ;  therefore  it  is  desirable  to  begin  specific  treatment  at  the  earliest 
possible  moment.  The  iodides  should  be  pushed,  even  to  heroic  doses,  and, 
considering  the  hopelessness  of  the  disease  when  left  to  itself,  and  of  all  other 
treatment,  syphilitic  treatment  should  be  employed  if  there  is  the  slightest 
possibility  of  previous  infection.  After  the  cord  has  been  softened  by  pres- 
sure there  is  little  chance  of  improvement,  even  though  the  gumma  should 
be  absorbed. 

Surgical  treatment  alone  offers  relief  in  other  kinds  of  growth.  The 
autopsies  show  that  a  large  number  of  extra-medullary  tumors  can  be  re- 
moved. Tumors  within  the  substance  of  the  cord,  excepting  in  rare  instances, 
probably  cannot  be  removed  without  producing  as  much  damage  by  the  knife 
as  is  done  by  the  tumor.  Fortunately,  however,  the  greater  number  of  spinal 
tumors  are  extra-medullary.  In  the  present  state  of  our  knowledge  it  is  not 
possible  to  distinguish  by  the  symptoms  the  two  classes,  and  we  can  only 
tell  by  a  surgical  examination  with  which  we  have  to  deal.     It  is  therefore 


DISEASES  OF  THE  SPINAL  CORD.  611 

desirable  in  every  case,  provided  the  disease  has  not  so  far  progressed  as 
to  have  destroyed  the  cord,  to  operate  as  soon  as  we  can  diagnose  and 
localize  the  tumor.  Quite  a  number  of  operations  have  been  performed ; 
several  (Horsley  and  Gowers,  Macewen,  Abbe,  Ray,  Laquer)  with  success- 
ful removal  of  the  tumor  and  recovery  or  improvement  from  the  paralysis.^ 
Further  familiarity  with  the  operation  will  undoubtedly  render  it  less  dan- 
gerous, and  by  operating  earlier  better  results  will  be  obtained. 

Considering  the  hopelessness  of  every  case  when  left  to  itself,  and  the  suf- 
ferings and  helplessness  necessarily  resulting  from  the  damage  to  the  cord,  an 
operation  would  always  be  justifiable,  provided  the  diagnosis  were  made  suflfi- 
ciently  early.  But,  aside  from  the  question  of  operation  for  the  prevention 
of  paralysis,  or  restoration  of  already  damaged  functions,  in  some  cases  other- 
wise hopeless,  it  should  be  considered  whether  it  may  not  be  justifiable  to 
operate  merely  for  the  relief  of  pain,  even  when  there  is  no  hope  of  restoring 
the  use  of  the  damaged  cord.  The  pain  in  some  cases  is  excruciating,  and  the 
sufferings  of  the  patient  so  intense  that  recourse  must  be  had  to  continuously 
increasing  doses  of  morphine.  In  such  cases  an  operation  with  a  view  to 
removing  all  source  of  irritation,  even  though  the  cord  be  destroyed,  is  one 
that  should  be  considered.  I  am  inclined  to  the  belief  that  in  such  cases  an 
operation  would  be  justifiable,  and  that  by  removing  an  extra-medullary 
tumor,  or  by  substituting  a  surgical  incision  for  a  compressing  tumor  lying 
superficially  in  the  substance  of  the  cord,  a  relief  from  suffering,  at  least, 
would  be  given  the  patient. 

All  further  medical  treatment  can  only  be  directed  toward  making  the 
patient  comfortable  and  preventing  many  of  the  secondary  consequences, 
such  as  cystitis  and  bed-sores.  To  relieve  the  pain,  resort  must  be  had  to 
anodynes.  In  the  early  stages  they  should  be  given  sparingly,  but  in  the 
later  stages  with  a  free  hand.  The  greatest  attention  should  be  given  to  the 
bladder  to  prevent  the  development  of  cystitis  and  its  consequences,  and  the 
same  attention  should  be  employed  with  a  view  to  prevent  the  formation  of 
bed-sores.  Great  attention  should  be  given  to  the  cleanliness  of  the  recum- 
bent parts  where  exj^osed  to  pressure.  Means  should  be  taken  to  avoid  the 
latter.  After  bed-sores  have  formed,  antiseptics  and  other  means  should  be 
used  to  prevent  septicaemia.  For  further  details  the  reader  is  referred  to  the 
section  on  Myelitis. 

1  An  interesting  article  by  M.  Allen  Starr  ("  A  Contribution  to  the  Subject  of  Tumors  of  the  Spinal 
Cord,  etc.,"  American  Journal  of  the  Medical  Sciences,  June,  1895),  published  after  these  pages 
had  gone  to  press,  contains  a  collection  ot  19  cases  of  operation  for  the  removal  of  spinal  tumors, 
collected  from  medical  literature.  To  these  the  author  adds  3  personal  cases,  making  22  in  all. 
Of  these  22  the  tumor  was  successfully  removed  in  13,  while  death  followed  the  operation  in  9.  Of 
the  successful  operations,  a  recovery  "from  the  condition  of  paraplegia  occurred  in  6.  As  Starr  says, 
In  explanation  of  these  unfavorable  results,  it  should  be  borne  in  mind  that  in  most  cases  the  opera- 
tion was  not  undertaken  until  so  late  in  the  disease  that  secondary  damage  had  been  caused  to  the 
cord.  Starr  reports  3  other  cases  without  operation.  I  have  been  able  to  include  these  6  cases  in  the 
total  number  of  cases  (133)  analyzed  for  the  purpose  of  this  chapter. 


CHAPTER   XX. 
DISEASES  OF  THE  SPINAL  CORD. 

(Continued.) 
By  FREDERICK  PETERSON,  M.D. 


STEUCTURE  AND  FUNCTIONS  OP  THE  SPINAL  CORD 
AND  LOCALIZATION. 

The  spinal  cord,  while  it  is  a  sort  of  cable  carrying  messages  to  and  fro 
between  the  brain  and  the  body,  is  at  the  same  time  to  be  looked  upon  as  a 
series  of  thirty-one  segments,  piled  one  upon  the  other,  each  segment  being 
connected  with  a  pair  of  spinal  nerves,  and  each  representing  a  trophic,  reflex, 
and  vasomotor  centre.  These  thirty-one  segments  occupy  only  seventeen  or 
eighteen  inches  of  the  spinal  canal,  which  is  twenty-six  to  twenty-eight  inches 
long,  so  that  the  spinal  canal  is  some  nine  or  ten  inches  longer  than  the  cord. 
Thus  the  first  segment  of  the  cord  is  at  the  foramen  magnum,  and  the  thirty- 
first  (or  conus)  is  opposite  the  base  of  the  first  lumbar  vertebra.  The  intra- 
spinal course  of  the  nerves  after  they  emerge  from  the  different  segments  is 
longer  the  lower  we  descend  the  cord,  so  that  the  pairs  from  the  lumbar  and 
sacral  segments,  for  instance,  form  a  large  bundle  (cauda  equina)  which  occu- 
pies the  remaining  space  in  the  spinal  canal  below  the  termination  of  the 
cord  itself.  If  we  take  a  cosmetic  pencil  it  is  very  easy  to  draw  on  a  thin 
person  an  outline  of  the  spinal  cord  upon  the  back  over  the  vertebral  column, 
and  in  this  way  one  obtains  a  clearer  knowledge  of  these  puzzling  relations 
than  by  any  amount  of  reading.     (Fig.  190). 

The  eighth  cervical  and  first  dorsal  segments  lie  immediately  in  front  of 
the  spine  of  the  seventh  vertebra.  The  lumbo-sacral  enlargement  of  the  cord 
begins  just  in  front  of  the  tip  of  the  spine  of  the  tenth  dorsal  vertebra.  The 
conus  lies  at  a  level  with  the  lower  point  of  the  first  lumbar  spine.  Below 
this  the  canal  is  filled  with  the  cauda. 

From  a  pathological  standpoint  the  most  important  parts  of  the  spinal  cord 
are  the  cervical  and  lumbar  portions,  or  enlargements,  the  cervical  portion 
being  enlarged  because  it  contains  the  sensory,  motor  and  trophic  centres  for 
the  arms  (as  well  as  the  cilio-spinal,  wrist-jerk,  elbow-jerk,  scapular,  palmar, 
and  hypochondrium  reflex  centres)  ;  the  lumbar  portion,  because  it  contains 
similar  centres  for  the  legs  (as  well  as  the  reflex  centres  for  the  bladder,  rec- 
tum and  sexual  organs). 

The  cord  consists  of  "  columns  "  of  white  matter  surrounding  the  H-shaped 
central  gray  matter.  The  columns,  or  tracts,  contain  the  long  fibres  which 
carry  peripheral  and  centripetral  impulses  and  are  variously  named  as  in 
the  diagram.     (Fig.  192.) 

The  anterior  columns  are  often  called  the  columns  of  Tiirck,  and  contain 
motor  fibres  from  the  cortex.  The  posterior  are  designated  as  the  columns  of 
Goll  and  Burdach,  the  former  nearest  the  median  line,  carrying  tactile  im- 


DISEASES  OF  THE  SPINAL  CORD. 


613 


pressions  upward  to  the  brain.     The  lateral  columns  are  made  up  chiefly  of 
the  long  motor  fibres  from  the  cortex,  the  crossed  pyramidal  tracts.     Exter- 


FlG    190. 


C  1. 


Fig.  191. 


•loth  Dorsal 
-',     spine 


I  \lst  Lumbal 
spine 


nal  to  this  on  the  periphery  of  the  cord  lies 
the  direct  cerebellar  tract  (carrying  muscu- 
lar sense  impressions)  ;  and  anterior  to  this 
also  on  the  periphery  of  the  cord  is  found 
Gowers's  tract  (conveying  pain  and  tempera- 
ture sensory  impressions  upward  to  the 
brain).  These  are  the  most  important  of 
the  tracts  or  columns.  What  is  known  as 
Clark's  column  is  a  column  of  cells  in  the 
low^er  dorsal  and  upper  lumbar  cord  (eighth 
dorsal  to  second  lumbar  nerves)  lying  in 
front  of  the  column  of  Burdach  in  the  inner 
part  of  the  neck  of  the  posterior  horn  of 
gray  matter ;  and  the  Lissauer  tract  is  a 
very  small  bundle  of  fibres  near  the  periph- 
ery of  the  cord  about  the  posterior  extrem- 
ity of  the  posterior  horn. 

The  reflex,  trophic  and  vasomotor  centres 
are  wholly  in  the  H-shaped  central  gray 
matter  of  the  cord. 

The  white  matter  varies  in  amount  at  dif- 
ferent levels,  and  diminishes  in  quantity 
fi'om  above  downward.  The  gray  matter 
varies  also  in  shape  and  amount  at  different 
levels,  being  largest  in  the  cervical  and  lum- 


d 


2 


-Co 


The  mutual  relations  of  the  verte- 
bral bodies  and  spines  to  the  segments 
in  the  cord  and  to  the  exit  of  the 
nerves.    (Oowers.) 


614 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


bar  intumescences,  especially  the  latter.  To  the  practical  physician  a  knowl- 
edge of  the  structure  of  the  anterior  horns  of  this  gray  matter  is  particularly 
serviceable.     These  contain  the  great  motor  ganglion  cells  connected  on  the 


Fig.  192. 


Fig.  193. 


''^^^'•ior  Boots 
Names  of  tracts  in  left  half,  oi  functions  in  right  half,  of  diagram. 

one  hand  with  fibres  coming  down  from  the  motor  area  of  the  brain  through 
the  crossed  pyramidal  tract  and  column  of  Tiirck,  and  on  the  other  with 

the  fibres  going  out  by  the  anterior  roots 
to  the  muscles.  Volitional  impulses  to 
the  muscles  pass  through  them,  and  they 
are  also  the  trophic  centres  for  the  mus- 
cular fibres.  These  cells  are  arranged  in 
groups  or  clusters  in  each  anterior  horn, 
but  the  arrangement  varies  at  difierent 
levels  of  the  cord.  Thus  in  the  following 
diagram  of  one  anterior  horn  (Fig.  193) 
we  see  median,  anterior,  antero-lateral  and 
postero-lateral  groups. 

In  addition  to  our  consideration  of  the 
cord  as  a  whole  with  long  tracts  of  ascend- 
ing and  descending  fibres,  and  as  a  series  of 
segments  one  upon  the  other,  we  must  also 
remember  that,  like  the  brain,  it  consists  of 
two  symmetrical  halves,  with  sensory  fibres 
crossing  from  one  side  to  the  other  through- 
out the  whole  extent,  and  fibres  uniting  the 
anterior  columns  and  the  anterior  horns  of 
opposite  sides. 

There  are  some  diseases  which  attack  cer- 
tain columns  in  the  cord,  or  certain  portions 
of  gray  matter,  and*  these  are  termed  system  diseases.  These  system-dis- 
eases, such   as   poliomyelitis,    progressive   muscular   atrophy,    amyotrophic 


Diagram  of  clusters  of  ganglion  cells 
in  an  anterior  horn.  Sometimes  there 
is  a  central  cluster.  Doubtless  these 
groups  represent  certain  groups  of  mus- 
cles associated  in  function,  but  accurate 
knowledge  is  still  wanting  on  this  point. 


DISEASES  OF  THE  SPINAL  CORD. 


615 


lateral  sclerosis,  lateral  sclerosis,  ataxic  paraplegia,  and  locomotor  ataxia, 
are  readily  recognized  by  the  peculiar  symptoms  brought  about  by  injury  to 
certain  systems  of  fibres  or  cells.  The  localization  of  such  pathological  con- 
ditions is  quickly  apparent  by  a  glance  at  Fig.  194. 

The  so-called  focal  lesions  of  the  cord,  lesions  of  limited  extent  in  a  par- 
ticular segment  or  segments,  due  to  neoplasms,  pressure,  hemorrhage,  inflam- 
mation, spinal  injuries,  and  the  like,  are  not  so  readily  recognized,  for  the 
symptoms  produced  (reflex,  trophic,  sensory,  motor)  are  extremely  variable, 
depending  as  they  do  upon  the  segment  level  of  the  lesion.  Each  separate 
segment  of  the  cord  has  its  own  particular  functions.  For  instance,  the  reflex 
centres  for  the  bladder  and  rectum  are  situated  in  the  fourth  and  fifth  sacral 
segments  and  in  the  conus  ;  the  ankle-clonus  in  the  fifth  lumbar  segment ;  the 
knee-jerk  in  the  third  lumbar ;  the  wrist  and  elbow-jerks  in  the  sixth  cervical, 

Fig.  194. 


A  diagram  of  the  topographical  .'iituation  of  cercain  pathological  processes  in  the  cord. 


and  so  on.  Motor  and  trophic  functions  are  distributed  in  the  same  manner, 
segmentally  ;  so  that,  for  instance,  the  intrinsic  muscles  of  the  foot  are  repre- 
sented in  the  first  and  second  sacral  segments,  knee  flexors  in  the  fourth  and 
fifth  lumbar,  thigh  muscles  in  the  second  and  third  lumbar,  abdominal  and  spinal 
muscles  in  the  second  to  the  twelfth  dorsal,  thumb,  and  finger  muscles  in  the 
eighth  cervical  and  first  dorsal,  forearm  muscles  in  the  sixth  and  seventh  cervi- 
cal, shoulder  muscles  in  the  fourth  and  fifth,  and  neck  muscles  in  the  second 
and  third.  The  apparent  principle  of  the  arrangement  is  seen  to  be  that  the 
lowest  muscles  in  the  body  are  represented  in  the  lowest  segments  in  the  cord. 
The  sensory  distribution  is  also  segmental,  and  has  peculiarities  of  great  diag- 
nostic value.  Thus,  anaesthesia  of  the  perineum,  scrotum,  rectum,  vagina, 
and  posterior  surface  of  the  penis  is  produced  by  a  lesion  in  the  lowest  part 
of  the  cord,  viz. :  in  the  fourth  and  fifth  sacral  segments  and  conus.  If  the 
lesion  is  higher,  say  at  the  third  sacral  segment,  tlie  auiesthesia  extends  fur- 
ther out  upon  the  buttocks  and  downward  over  the  back  of  the  thiglis,  over 
parts,  in  fact,  which  are  touched  by  the  saddle  in  riding  (hence  the  .so-called 
saddle-shaped  area).  If  the  transverse  lesion  be  as  high  as  the  fifth  lumbar 
segment,  the  anaesthesia  includes,  in  addition  to  the  preceding  area,  the  outer 
sides  of  both  legs,  and  even  at  times  the  outer  surfaces  of  the  feet.     The 


616 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


higher  up  the  lesion,  the  greater  the  area  of  anaesthesia.  The  lower  part  of 
the  surface  of  the  abdomen  is  not  anesthetic  until  the  first  lumbar  segment 
has  been  implicated,  though  before  this  segment  is  reached  all  of  the  lower 
extremities  and  buttocks  have  been  included  in  the  anaesthetic  areas.  Above 
the  first  lumbar  segment  the  ancesthetic  areas  are  limited  by  circles  about  the 
trunk.     The  umbilical  region  is  represented  in  about  the  tenth  dorsal  seg- 

FlG.  195. 


Diaphragm 


Rhonjboidei 
Supinator  longus 
Deltoid 


Brachialis  antious 

Pectoralis 

(Clavicular) 

.Biceps 

Serratus  magnus 


Extensors  of  \vTists 

and  fingers 
Pronators 
Triceps 

Serratus  masriius 
Subscapularis 


Triceps 

Flexors  of  ivrist 
and  fingers 


Diagram  of  cervical  enlargement  of  the  cord,  showing  the  segmental  representation  of  muscles, 
reflexes,  and  sensory  areas. 


ment.  When  the  eighth  cervical  segment  is  afiected  by  a  ti*ansverse  lesion, 
the  anaesthetic  area  is  complete  over  all  parts  below  a  girdle  about  the  nip- 
ples, and  the  inner  sides  of  the  arms  and  ulnar  areas  of  the  forearms  and 
hands  are  included.  Thus,  from  a  careful  study  of  the  segmental  representa- 
tion of  muscles,  reflexes,  and  sensibility,  we  are  enabled  to  arrive  at  a  very 
accurate  diagnosis  of  the  exact  position  of  a  focal  lesion  ;  but  it  must  always 


DISEASES  OF  THE  SPINAL  CORD. 


617 


be  remembered  to  study  in  connection  with  segmental  symptoms  the  effects 
upon  the  great  tracts  running  through  these  segments  between  the  brain  and 
periphery.  In  connection  with  the  facts  just  stated  I  reproduce  here  the 
diagrams  of  the  cervical  and  lumbar  enlargements  first  published  by  me  in 
the  New  York  Medical  Record,  November  12,  1892,  and  which  many  physi- 
cians and  students  have  found  practically  useful  as  an  aid  in  diagnosis  (Figs. 
195  and  196)  as  well  as  a  help  to  the  memory.     As  regards  the  dorsal  por- 


FlG.  196. 


Flexors  of  ankles 
and  toes,  and 
small  muscles  of 
foot 


CONUS  ,  H-     -  /    ^^ 

Diagram  of  the  lumbar  enlargement  of  the  cord,  showing  the  segmental  representation  of  muscles, 

reflexes,  and  sensory  areas. 

tion  of  the  cord,  which  it  is  not  so  important  for  some  reasons  to  study  as  the 
two  enlargements  just  described,  it  mav  be  stated  that  the  nerves  represented 
in  the  second  to  twelfth  dorsal  segments  are  the  intercosto-hu moral,  nitercos- 
tals  and  dorsal  posterior  nerves  ;  the  muscles,  those  of  the  back  and  abdomen, 
and  erectores  spinse,  and  the  reflexes,  the  epigastric  ( fourth  to  seventh  seg- 
ments), and  the  abdominal  (seventh  to  eleventh  segments). 


6  ]  8  ^^^  VO  US  DISEA  SES  AND  THEIR  TBEA  TMENT. 

In  the  diagrams  I  have  mapped  out  the  various  segments  in  such  a  way  as 
to  show  the  muscles  represented  in  each,  and  in  vertical  letters  the  levels  of 
the  reflexes.  The  areas  of  anaesthesia  produced  by  transverse  lesions  are 
shown  in  the  brackets  at  the  right,  corrected  from  my  first  diagrams  accord- 
ing to  the  recent  studies  of  Thorburn  {Brain,  Autumn,  1893).  Lesions  of 
the  Cauda  equina  may  give  rise  to  symptoms  very  much  resembling  those 
of  injury  to  the  lumbo-sacral  enlargement,  because  the  cauda  is  composed  of 
nerve-trunks  derived  from  this  part  of  the  cord ;  but  it  is  to  be  remembered 
that  in  cauda  lesions  there  are  comparatively  extensive  paralyses,  while  sensa- 
tion is  but  slightly  affected. 

There  are  chronic  lesions  in  the  central  gray  matter  of  the  cord,  such  as 
syringomyelia,  which  produce  peculiar  symptoms  according  to  the  segmental 
level  of  the  lesion.  Encroaching  on  the  gray  matter  of  the  anterior  horns, 
of  course,  the  particular  muscles  of  that  segment  are  paralyzed  and  atrophied, 
and  lose  their  reflex  excitability.  Encroaching  around  the  central  canal  and 
toward  the  posterior  horns,  a  peculiar  anaesthesia  is  produced  to  pain  and 
temperature,  distributed,  of  course,  according  to  the  particular  representa- 
tions of  skin  area  at  the  level  of  the  lesion.  This  is  because  the  fibres  for 
pain  and  temperature  sensibility  lie  in  the  central  gray  matter  before  enter- 
ing their  tract  on  the  periphery  of  the  cord  (see  Fig.  192)  to  reach  the  brain 

Lesions  of  the  motor  tracts  in  the  white  matter  of  the  lateral  and  anterior 
columns  produce  muscular  weakness,  or  paresis,  but  without  atrophy.  This 
paralysis  is  naturally  much  more  widespread  than  the  paralysis  caused  by 
injury  to  the  anterior  horn.  For  instance,  a  very  small  lesion,  say  the  size 
of  a  pea,  in  a  lateral  column  will  probably  aflfect  all  of  the  muscles  on  the 
same  side  below  that  point,  the  lateral  tract  being  the  cable  containing  nearly 
all  of  the  long  fibres  of  communication  between  one  side  of  the  body  and 
one-half  of  the  brain.  On  the  other  hand,  the  same  lesion  in  an  anterior 
horn  would  produce  a  very  restricted  paralysis,  affecting  only  the  muscles 
innervated  from  that  particular  segment. 

Another  feature  peculiar  to  paresis  from  lateral  column  injuries  is  the 
spastic  rigidity  with  exaggerated  tendon  reflexes.  Still  another  important 
point  for  differential  diagnosis  is  the  loss  of  faradic  reaction  in  paralysis,  due 
to  lesion  in  the  anterior  horn  or  motor  nerve,  and  the  perfectly  normal  reac- 
tion of  these  muscles  to  faradism  when  the  paralysis  is  due  to  lesion  in  the 
long  fibres  running  from  the  cortex  down  the  lateral  and  anterior  columns 
to  terminate  in  the  large  cells  of  the  anterior  horns. 

Hence  there  are  four  absolutely  opposite  clinical  conditions  or  symptoms 
which  will  serve  to  differentiate  for  us  the  two  distinct  types  of  spinal  paral- 
ysis, the  atrophic  and  the  spastic  ;  and  these  may  be  conveniently  grouped 
as  follows  : 

Atrophic  Spinal  Paralysis.  ISpastic  Spinal  Paralysis. 

1.  Atrophy.  1.  No  atrophy. 

2.  Lost  reflexes  (such  as  knee-jerk,  wrist-jerk,       2.  Exaggerated  reflexes. 

elbow-jerk,  etc.). 

3.  Flabby  relaxed  muscles.  3.  Rigid  muscles. 

4.  No  contraction  to  faradism.    Lesion  in  the       4.  Contraciion  to  faradism.     Lesion  in  the 

anterior  horns.  lateral  columns. 

This  calls  to  mind  the  importance  of  a  complete  understanding  of  the 
knee-jerk  by  the  general  practitioner. 

It  is  of  the  highest  value  among  the  reflex  symptoms.  The  tap  upon  the 
tendon  sends  a  sensory  impulse  to  the  reflex  centre  in  the  anterior  horn  of 
the  third  lumbar  segment  (via  the  sensory  nerve  from  the  knee-area  and 
posterior  root  and  posterior  horn),  whence  an  impulse  is  reflected  outward 
(via  the  anterior  root  and  motor  nerve)  to  contract  the  quadriceps  extensor. 
While  the  knee-jerk  is,  in  truth,  not  a  perfect  representation  of  an  actual 


DISEASES  OF  THE  SPINAL  CORD. 


619 


reflex,  yet  for  all  practical  purposes  it  may  be  so  considered.      (See  also  p. 
21  et  seq.) 

Now,  certain  fibres  from  the  cortex  pass  down  by  way  of  the  lateral  col- 
umns of  the  cord  to  enter  the  anterior  horns,  and  these  hold  a  rein  upon  the 
reflexes,  so  to  say.  They  inhibit  the  jerk.  Thus,  under  normal  conditions, 
the  knee-jerk  is  very  moderate.  If  this  inhibitory  fibre  is  functionally  im- 
paired or  destroyed  the  knee-jerk  is  no  longer  restrained,  but  becomes  exag- 
gerated. If  any  part  of  the  reflex  arc  is  destroyed  (sensor}^  nerve,  posterior 
nerve-roots,  posterior  root-zone,  posterior  horn,  anterior  horn,  or  motor  nerve), 
the  knee-jerk  is  lost.  Thus  cerebral  palsies,  lateral  sclei'osis,  exaggerate  the 
knee-jerk  ;  whereas  neuritis,  locomotor  ataxia,  poliomyelitis,  and  the  like, 
destroy  the  knee-jerk.  Fig.  197  is  oflTered  as  a  diagrammatic  illustration  of 
these  points. 


Fig.  197. 


-< ^ 


Diagram  showing  reflex  arc  and  inhibitory  fibre,  and  some  of  the  diseases  which  exaggerate  or 

destroy  thel^nee-jerk. 

In  lesions  afiecting  the  inhibitory  fibres  anyAvhere  all  the  tendon  reflexes 
below  the  lesions  become  exaggerated.  Thus  ankle-clonus,  not  normally 
present,  develops  when  the  lateral  column  is  affected  above  its  centre  in  the 
fifth  lumbar  segment. 

A  unilateral  lesion  of  the  spinal  cord  gives  rise  to  an  interesting  syndrome, 
generally  termed  Brown-Sequard's  paralysis.  Suppose  that  one  lateral  half 
of  a  segment  of  the  mid-dorsal  region  is  destroyed.  The  result  seen  in  a 
typical  case  some  time  after  the  injury  would  be  : 


Same  Side. 

1.  Atrophic  paralysis  of  muscles  innervated 

by  that  particular  half-segment. 

2.  Spastic  paralysis  of  the  leg. 

3.  Lost  or  impaired  muscular  sense. 

4.  Exaggerated  knee-jerk  and  usually  ankle- 

clonus. 

5.  At  about  the  level  of  the  lesion  a  half-girdle 

of   hyperalgesia,  and   just  below  this   a 
parallel  zone  of  anaesthesia. 


Opposite  Side. 
Loss  of  paiu,  temperature,  and  touch-sense 
below  the  lesion. 


The  wrist-jerk,  under  normal  conditions  rarely  present  or  just  perceptible, 
becomes  very  excessive  in  lesions  of  the  cerebro-spinal  segment  of  the  motor 
tract  above  its  spinal  centre  in  the  sixth  cervical  segment. 

In  the  eailiest  stage  of  an  acute  unilateral  lesion  of  the  cord  the  knee- 
jerk  may  be  absent  for  a  short  time,  which  is  also  true  of  both  knee-jerks  in 


620  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

any  complete  transverse  lesion  above  the  third  lumbar  segment,  but  subse- 
quently it  takes  on  its  overactive  character.  This  is  probably  due  to  the 
fact  that  in  an  acute  lesion  there  is  irritation  of  the  inhibitory  fibres. 

The  reason  that  the  muscular  sense  is  impaired  on  the  same  side  in  a  uni- 
lateral lesion  is  that  the  fibres  for  muscular  sense  do  not  decussate  along  the 
spinal  cord  as  do  the  other  sensory  fibres. 

In  addition  to  the  reflex  centres  already  indicated,  there  are  others  whose 
precise  localization  has  not  yet  been  determined.  For  instance,  there  are 
the  parturition,  erectile,  menstruation,  and  ejaculatory  centres,  and  these  are 
undoubtedly  in  the  lumbar  enlargement,  for  some  of  them  have  been  known 
to  be  destroyed,  and  their  functions  lost,  by  lesions  in  this  part  of  the  cord. 

The  Memhranes  of  the  Cord.  As  is  the  case  with  the  brain,  three  mem- 
branes enclose  the  spinal  cord.  The  outer  or  dura  mater  is  dense  and  fibrous, 
and  separated  from  the  bony  canal  by  fat  and  a  large  plexus  of  veins.  It 
is  slightly  attached  by  its  anterior  surface  to  the  vertebral  canal.  There  is 
therefore  an  epidural  space.  Filaments  from  the  spinal  nerves  supply  the 
dura  with  sensory  nerves.  The  subdural  space  contains  a  small  amount  of 
serum.  The  middle  membrane  or  arachnoid  is  completely  separated  from 
the  inner  or  pia  mater  in  the  spinal  canal,  which  is  not  the  case  in  the  cranial 
cavity.     The  pia  sends  septa  into  the  cord. 

The  Blood-supply  of  the  Cord.  The  cord  receives  its  blood  from  branches 
of  the  vertebral,  intercostal,  and  other  arteries  which  enter  with  the  spinal 
nerves  and  reach  the  cord  along  the  anterior  and  posterior  roots.  Anterior 
branches  pass  to  the  anterior  median  fissure  to  form  there  the  vertical  con- 
tinuous anterior  spinal  artery,  from  which  a  series  of  branches  enter  the 
fissure  to  supply  most  of  the  gray  matter.  Posterior  branches  enter  the 
posterior  fissure  in  a  somewhat  similar  manner.  Twigs  are  given  off  every- 
where from  the  pia  on  the  periphery  of  the  cord  to  the  white  substance.  The 
veins  have  very  much  the  same  distribution.  There  is  a  vertical  continuity 
of  bloodvessels  both  within  and  outside  of  the  cord,  though  it  is  probable 
that  the  circulation  is  horizontal  to  a  very  great  extent.  The  tortuosity  of 
the  arteries  and  the  size  of  the  venous  plexuses  serve  to  prevent  overdisten- 
tion,  rupture,  and  the  dangers  of  high  blood-pressure. 


POLIOMYELITIS. 

Poliomyelitis  Anterior ;  Infantile  Spinal  Paralysis ;  Acute  Atrophic 
Paralysis  ;  Essential  Paralysis  of  Children. 

Poliomyelitis  is  a  disease  of  the  anterior  horns  of  the  spinal  cord  associ- 
ated with  paralysis  and  wasting  of  muscles,  usually  acute  in  onset,  and  ac- 
companied with  fever  and  other  symptoms  of  general  disturbance.  The 
process  is  generally  acute,  but  may  be  subacute  and  more  rarely  chronic.  It 
may  occur  at  any  age,  but  is  commonly  a  disease  of  childhood. 

Etiology.  The  two  sexes  are  about  equally  afilicted — more  than  one-half 
of  the  cases  occur  during  the  first  three  years  of  life.  Ten  times  as  many 
have  their  onset  in  the  first  decade  as  in  all  the  others  put  together.  After 
the  age  of  forty  years  it  is  extremely  rare.  Heredity  seems  to  have  little 
if  any  influence  upon  the  disease.  Sinkler  pointed  out  that  it  is  more  fre- 
quent in  summer  than  in  winter.  Exposure  to  draught,  overexertion  in  walk- 
ing, infectious  diseases,  and  falls  have  been  given  as  antecedent  causes,  but 
it  is  doubtful  if  any  of  these  are  important  factors.  Most  of  the  cases  are 
suddenly  attacked  while  in  good  health.  In  some  instances  a  sort  of  epi- 
demic character  has  been  noted.     By  the  best  authorities  it  is  now  supposed 


DISEASES  OF  THE  SPINAL  CORD 


621 


itself  to  be  a  species  of  infectious  disease,  though  nothing  conclusive  as  to 
this  has  been  determined. 

Symptomatology.  The  onset  is  not  sudden,  though  usually  very  rapid. 
As  a  rule,  there  is  fever,  and  Avith  it  restlessness,  headache,  anorexia,  general 
weakness,  and  at  times  vomiting  and  diarrhoea.  There  is  widespi'ead  paral- 
ysis or  paresis  at  first,  though  later  on  the  majority  of  the  muscles  recover, 
leaving  one  or  two  limbs,  often  only  a  single  group  of  muscles,  permanently 
paralyzed  and  wasted.  The  constitutional  symptoms  often  last  but  a  few 
hours,  but  are  occasionally  protracted  for  several  days.  Rarely  they  are  so 
slight  as  to  escape  notice.  The  paralysis  is  apt  to  be  observed  early  in  the 
attack,  but  may  be  overlooked  if  the  general  symptoms  are  severe.  Pain 
referred  to  the  limbs  or  back,  and  sometimes  even  muscular  tenderness,  is  apt 
to  be  present.  Convulsions  may  occur,  and  cases  have  been  known  to  simu- 
late to  a  certain  extent  cerebro-spinal  meningitis.  Incontinence  of  urine  is 
rare.  Very  infrequently  the  onset  may  be  such  as  to  lead  to  the  suspicion  of 
spinal  hemorrhage.     In  a  few  days  usually  the  disorder  has  reached   its 

Fig.  198. 


Showing  atrophy  and  foot-drop  in  poliomyelitis  of  childhood,  infantile  paralysis.  (Jefferson  Hospital.) 


height  and  improvement  begins.  But  this  period  may  be  protracted  for  weeks. 
In  from  one  to  three  months  recovery  has  taken  place  in  all  but  the  parts 
which  are  to  remain  permanently  disabled,  and  in  these  flaccidity  and  wasting 
are  marked.  At  the  end  of  a  week  from  the  onset  the  loss  of  fai'adic  con- 
tractility in  the  most  affected  muscles  will  be  noted.  The  deep  reflexes  are 
always  absent  in  the  paralyzed  limbs,  although  with  recovery  in  these  parts 
there  is  a  return  of  the  reflexes.  Cutaneous  sensibility  is  almost  never  dis- 
ordered. Retardation  of  growth  of  the  Avhole  member  disabled  occurs,  so 
that  as  the  child  increases  in  stature  the  paralyzed  limb  does  not  keep  pace 
with  the  others.  Besides  wasting  of  muscles  and  stunted  growth  of  liones, 
the  joints  are  often  relaxed  and  singularly  mobile  through  want  of  support 
by  the  tendons  of  paralyzed  muscles  passing  over  them.  Subluxati(ms  of 
such  joints  are  not  uncommon.  Permanent  contractures  often  take  place  in 
normal  opposing  muscles,  thus  producing  deformities.     These  are  especially 


622  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

common  in  the  foot,  where  we  have  many  varieties  of  ckib-foot,  such  as 
talipes  calcaneus,  talipes  varus,  talipes  valgus,  talijjes  cavus,  talipes  equinus, 
and  talipes  equino- varus.  The  permanent  paralysis  is  generally  in  one  of  the 
legs.  In  sixty  cases,  of  which  I  have  notes,  the  leg  below  the  knee  was 
affected  in  21,  the  leg  and  thigh  in  15,  both  legs  and  both  thighs  in  11,  one 
arm  in  6,  one  leg  and  one  arm  in  5,  and  all  four  extremities  in  2.  The  an- 
terior tibial  group  is  paralyzed  most  frequently  of  all.  The  left  leg  is  twice 
as  commonly  affected  as  the  right.  There  are  few  muscles  of  the  body  that 
have  not  been  involved  in  some  reported  cases  of  poliomyelitis.  Shoulder 
and  trunk  muscles,  and  even  those  of  the  face,  have  been  known  to  be  im- 
plicated. Weakness  of  the  S23inal  muscles  may  cause  spinal  curvature.  I 
have  seen  one  instance  in  which  the  abdominal  muscles  of  the  left  side  were 
so  paralyzed  and  wasted  that  the  wall  was  very  thin  and  the  abdominal  con- 
tents bulged  out  markedly  to  that  side.  Universal  paralysis  may  cause 
death  in  the  early  stages,  but  death  from  poliom  velitis  is  very  rare,  though 
possibly  cases  fatal  in  the  first  day  or  two  may  go  undiagnosticated.  Relapses 
and  second  attacks  are  almost  unknown.  Possibly  poliomyelitis  creates  a 
vulnerability  of  the  spinal  cord  to  sequelae,  such  as  progressive  muscular 
atrophy  and  lateral  sclerosis,  for  several  such  cases  have  been  reported.  The 
course  of  the  disease  in  adults  and  children  is  much  the  same.  In  the  sub- 
acute and  chronic  forms  the  general  disturbances  are  naturally  of  a  mild  type 
or  are  absent  altogether. 

Pathology  and  Pathological  Anatomy.  The  systemic  disturbance  found 
in  most  cases  of  poliomyelitis  points  to  a  blood-state,  probably  toxic  in  nature 
and  due  to  a  germ.     The  predilection  show^n  by  this  toxaemia  for  the  anterior 

Fig.  199. 


Poliomyelits  anterior.    Acute  symptoms  at  seventh  year.    Death  at  twentieth  year.    Seventh 
cervical  segment.    Shows  especially  well  the  scar  in  the  affected  horn.    Weigert's  stain. 

horns  of  the  cord  is  analogous  to  that  exhibited  by  other  jDoisonous  agents 
for  other  portions  of  the  nervous  system.  A  sufficient  number  of  autopsies 
have  been  made  in  the  earliest  stages  to  establish  the  fact  that  the  dis- 
order in  the  cord  is  inflammatory  in  character  and  that  the  inflammation 
may  be  either  parenchymatous  or  interstitial.  There  are  cases  in  which  the 
inflammation  extends  further  than  the  anterior  horns,  for  meningeal  and 
cerebral  symptoms  and  peripheral  neuritis  have  been  observed  in  conjunction 
with  this  disease.  In  cases  described  there  have  been  found  congestion  of 
the  capillaries,  with  minute  capillary  ectasias  in  the  gray  matter,  swelling  of 
the  ganglion  cells  and  neurogliar  elements,  and  infiltration  of  leucocytes. 


DISEASES  OF  THE  SPINAL  CORD.  623 

Adjacent  nerve-fibres  may  undergo  degeneration.  Sometimes  only  the  gan- 
glion cells  are  found  affected.  In  later  stages,  months  or  years  after  recovery 
from  the  acute  disorder  the  anterior  cornu  of  the  afiected  side  is  found 
shrunken,  and  its  nervous  elements  replaced  by  connective  tissue  or  shrivelled 
and  diminished  in  number.  Where  the  inflammation  had  evidenth'  ex- 
tended into  neighboring  parts,  such  as  the  antero-lateral  or  lateral  columns, 
such  parts  are  lessened  in  size  and  may  show  sclerotic  changes.  The  affected 
half  of  the  cord  is  smaller  than  the  normal  half,  and  the  gross  changes  are 
visible  to  the  naked  eye.  Descending  degeneration  is  to  be  seen  in  the  motor 
nerve-fibres  corresponding  to  the  segment  or  segments  concerned.  The  mus- 
cular fibres  innervated  by  such  nerves  undergo  degeneration  and  ultimately 
disappear  in  severe  types  of  the  disease.  Not  all  of  the  muscular  fibres  of 
any  one  muscle  are  affected,  and  often  normal  and  even  hypertrophied  fibres 
are  found  in  the  diseased  muscles. 

Diagnosis.  Error  in  diagnosis  is  very  easy  in  the  early  stages  of  an  acute 
attack.  I  have  myself  seen  a  case  in  which  cerebro-spinal  meningitis  was  diag- 
nosticated by  an  excellent  practitioner,  and  it  was  not  until  the  subsidence  of 
the  severe  symptoms  and  the  appearance  of  a  monoplegia  with  wasting  that  the 
true  nature  of  the  malady  became  known.  Fever,  vomiting,  and  diarrhoea, 
rheumatic  pains  and  the  like  are  concomitants  of  a  great  many  other  disorders, 
so  that  their  presence  has  no  particular  significance.  Widesj^read  paresis  is 
a  more  important  indication,  and  when  the  early  stage  is  past  and  the  local 
paralysis  remains,  with  evidence  of  atroj)hy  of  the  member  and  reaction  of 
degeneration  in  the  muscles,  the  diagnosis  is  clear.  Acute  transverse  myeli- 
tis is  not  found  in  children,  and  when  it  occurs  in  adults  is  almost  always  in 
the  dorsal  portion  of  the  cord  and  not  in  the  cervical  or  lumbar  enlargement, 
as  is  the  case  with  poliomyelitis.  The  absence  of  anaesthesia  and  other 
sensory  disturbances  should  be  evidence  in  favor  of  the  latter  disease.  The 
differential  diagnosis  between  peripheral  neuritis  and  poliomyelitis  is  often 
difficult  in  adults,  and  sometimes,  indeed,  impossible,  owing  to  the  occasional 
prominence  of  sensory  symptoms.  Cerebral  palsies  are  readily  distinguish- 
able because  in  these  we  have  increased  rather  than  lost  reflexes,  never  reac- 
tion of  degeneration,  and  never  extreme  muscular  atrophy.  There  should 
never  be  confusion  with  spondylitis,  pseudo-hypertrophic  paralysis  or  spastic 
spinal  paralysis,  if  the  symptomatology  of  the  poliomyelitis  is  carefully 
borne  in  mind.  Congenital  weakness  of  muscles  or  rickety  conditions  may 
in  early  infancy  simulate  poliomyelitis,  but  in  these  conditions  the  normal 
electrical  reactions  and  normal  reflexes  should  make  the  distinction  appaient. 

Prognosis.  When  the  first  period  of  the  disease  is  past  the  prognosis  as 
regards  life  is  wholly  favorable.  In  the  acute  stage  death  may  occur  through 
the  involvement  of  important  nervous  centres  or  of  muscles  of  respiration. 
While  undoubtedly  undiagnosticated  cases  do  die  in  early  stages,  the  vast 
majority  of  cases  of  poliomyelitis  recover  from  the  immediate  effects,  unless 
the  malady  is  complicated  with  jxilmonary  or  other  visceral  disease.  The 
question  Avill  arise  as  what  element  of  the  disorder  will  be  left  as  a  perma- 
nent condition.  It  may  be  stated  that  the  faradic  current  will  aid  us  in  this 
particular.  If  after  a  week  or  ten  days  we  find  faradic  contractility  lost  in  a 
group  or  groups  of  muscles,  we  may  safely  say  that  they  will  remain  for  a 
long  time,  if  not  permanently,  paralyzed.  Some  of  them  will  certainly 
never  recover.  If  the  degenerative  reaction  is  late  in  appearing  the  proba- 
bility is  that  the  muscles  may  recover  in  part,  if  not  wholly.  The  retarda- 
tion of  growth  in  the  affected  member  in  children  must  not  be  forgotten,  and 
the  results  of  such  condition  and  the  effects  of  contractures  should  be  de- 
scribed to  the  friends. 


624  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Treatment.  In  the  acute  stages  perfect  rest  is  requisite.  The  patient 
should  lie  on  the  side.  If  the  fever  is  high  and  there  are  cerebral  symptoms 
an  ice-bag  should  be  applied  to  the  head,  and  cool  ablutions  should  be  given 
in  bed.  A  little  counter-irritation  in  the  way  of  sinapisms  to  the  back  may 
be  used,  but  if  pain  in  the  back  is  severe  hot  fomentations  will  afford  the 
most  relief.  When  there  is  a  tendency  to  nervous  excitement,  delirium,  or 
convulsions,  chloral  and  bromide  should  be  used.  Calomel,  a  half  to  one  grain, 
every  two  or  three  hours,  is  indicated  as  an  intestinal  derivative,  and  drop 
doses  of  tincture  of  aconite  every  half-hour  should  be  administered  for  the 
febrile  condition.  At  the  end  of  three  weeks  after  the  acute  symptoms  have 
subsided  tonics  are  needed,  such  as  iron,  quinine,  and  strychnine,  and  electri- 
cal treatment  may  be  begun,  though  at  first  with  moderation.  We  do  not  ex- 
pect to  restore  nerve  and  muscle  fibres  which  are  destroyed,  but  with  the  gal- 
vanic current  we  can  stimulate  the  partially  degenerated  tissues  and  improve 
the  functions  of  such  fibres  as  have  been  left  uninjured  by  the  disease.  The 
faradic  current  is  of  course  useless  in  the  treatment  of  muscles  which  do  not 
contract  by  its  use.  One  pole  may  be  placed  in  the  hand  or  over  the  spine 
(a  matter  of  indifference),  and  the  other  pole,  in  the  shape  of  a  sponge  elec- 
trode well  wet  in  warm  salt  water,  should  be  stroked  over  the  paralyzed  mus- 
cles. It  is  preferable  to  use  the  anode  for  this  purpose.  The  current  should 
be  strong  enough  to  produce  a  contraction  of  the  muscle  with  each  stroke. 
In  this  way  not  only  is  the  paralyzed  muscle  exercised,  but  tissue  metabolism 
is  influenced  by  the  dilatation  of  the  bloodvessels  induced  and  also  undoubt- 
edly by  the  cataphoretic  property  of  the  galvanic  current.  The  treatment 
should  be  given  for  ten  minutes  every  other  day,  and  later  every  day.  A 
nurse  can  easily  be  taught  the  method  of  application.  AVith  a  child  it  is 
best  to  begin  with  scarcely  perceptible  currents  for  a  few  days  in  order  not 
to  alarm  it  needlessly.  Massage  in  the  shape  of  effleurage  and  kneading  of 
the  muscles  is  a  necessary  part  of  the  treatment.  It  should  be  given  daily,  at 
bedtime,  for  ten  to  fifteen  minutes.  It  is  best  to  rub  upward.  Cocoa  but- 
ter or  vaseline  may  be  used  in  the  rubbing.  With  the  return  of  any  degree 
of  muscular  power  systematic  exercise  must  be  regularly  carried  out.  Where 
there  is  tendency  to  contractures  in  opposing  muscles,  these  should  be  treated 
by  massage,  stretching  exercises,  and  by  orthopedic  devices.  The  sooner  a 
child  with  poliomyelitic  deformity,  or  tendency  to  deformity,  is  properly 
treated  by  orthopedic  measures  the  better,  and  orthopedic  apparatus  must  be 
constantly  adjusted  and  readjusted  to  suit  the  improving  condition  and  to 
adapt  it  to  the  growth  of  the  child. 

Subacute  and  Chronic  Poliomyelitis.  This  subject  hardly  requires 
a  separate  heading,  as  the  adjectives  used  imply  that  these  forms  differ 
chiefly  from  the  acute  disorder  in  the  comparative  slowness  of  onset  and  in 
the  mildness  of  constitutional  symptoms.  Subacute  types  are  such  as  require 
from  a  few  weeks  to  a  month  for  development,  chronic  types  from  a  month 
to  six  months  or  so.  The  chronic  variety  is  relatively  exceedingly  rare,  and 
is  often  diflicult  to  distinguish  from  multiple  neuritis  and  progressive  mus- 
cular atrophy.  While  subacute  poliomyelitis  may  develop  in  childhood  as  well 
as  in  advanced  age,  the  chronic  form  is  almost  wholly  found  in  adults.  The 
absence  of  pain,  anaesthesia,  and  tenderness  should  serve  to  distinguish  these 
conditions  from  mulitiple  neuritis.  They  should  be  differentiated  from  pro- 
gressive muscular  atrophy  by  their  rapidity  of  onset  as  compared  with  this 
very  slowly  developed  disease  ;  by  the  appearance  of  paralysis  in  both  before 
the  atrophy ;  by  the  want  of  fibrillary  contractions ;  by  the  very  early  loss 
of  faradic  contractility ;  and,  finally,  by  the  failure  to  progress,  for  usually 
chronic  poliomyelitis  -becomes  stationary  after  a  few  months,  and  then  im- 
provement begins,  and  recovery  may  even  ultimately  ensue.     There   are 


DISEASES  OF  THE  SPINAL  COBD.  625 

cases  of  this  type,  however,  that  have  a  fatal  issue  by  extension  to  important 
muscular  groups. 

As  to  treatment,  electricity  is  of  considerable  value,  and  should  be  employed 
as  described  above.  Tonics,  and  particularly  the  hypodermic  use  of  strych- 
nine, are  indicated. 


CHRONIC    SPINAL    MUSCULAR    ATROPHY. 

Progressive  Muscular  Atrophy ;  Wasting  Palsy. 

There  are  two  classes  of  progressive  disease,  both  marked  especially  by 
muscular  Avasting,  but  each  having  a  different  pathological  basis.  In  one 
the  disease  is  of  spinal  origin  and  due  to  the  gradual  disappearance  one  by 
one  of  the  trophic  ganglion  cells  of  the  anterior  horns.  In  the  other  the 
disease  is  primarily  muscular  and  produced  by  the  gradual  degeneration  and 
disappearance  of  the  muscular  fibres.  To  the  first  category  belongs  the 
commonest  form  of  progressive  muscular  atrophy — the  type  of  Aran-Du- 
chenne — which  it  is  my  purpose  to  describe  here.  To  the  second  group  of 
primary  muscular  dystrophies  belong  pseudo-hypertrophic  paralysis,  Erb's 
juvenile  form  and  the  tyj)e  of  Landouzy-Dejerine,  described  elsewhere  in 
this  volume. 

Aran  and  Duchenne  were  the  first  to  fully  describe  the  disorder  considered 
here  (1849-50).  Aran  gave  it  the  name  of  "progressive  muscular  atrophy." 
These  men  did  not,  how^ever,  understand  its  pathology,  and  it  remained  for 
others  to  discover  that  it  is  a  spinal-cord  disease.  There  are  cases  in  which 
the  disorder  of  the  anterior  horns  is  combined  with  sclerosis  in  the  adjacent 
lateral  columns,  and  to  this  the  name  amyotrophic  lateral  sclerosis  has  been 
given.  Occasionally  the  anterior  cornual  disease  is  associated  with  sclerosis 
of  the  posterior  columns,  and  we  have  the  phenomenon  of  a  combination  of 
tabes  and  progressive  muscular  atrophy.  But  as  the  anterior-horn  disease 
is  often  encountered  singly,  it  seems  best  to  treat  of  the  Aran-Duchenne  type 
of  progressive  muscular  atrophy  only  in  this  article,  leaving  amyotrophic 
lateral  sclerosis  for  a  subsequent  section. 

Etiology.  Heredity  plays  little  or  no  part  in  the  spinal  form  of  progres- 
sive muscular  atrophy,  whereas  it  is  a  common  factor  in  the  primary  muscu- 
lar dystrophies.  Three  times  as  many  males  fall  a  prey  to  this  disease  as 
females.  It  is  a  disease  of  adult  life  (twenty-five  to  forty-five  years),  but 
cases  have  been  reported  as  early  as  the  age  of  twelve  and  as  late  as  seventy. 
Mental  strain,  exposure,  spinal  concussion,  syphilis,  overuse  of  muscles,  lead- 
poisoning,  and  infectious  diseases  have  been  mentioned  among  causes  by 
various  authors. 

Symptomatology.  In  a  typical  case  the  disease  begins  by  a  wasting  of  the 
thenar  and  hypothenar  muscles  in  one  hand,  especially  the  right.  (See  Fig. 
200.)  It  may  begin  in  both  at  the  same  time,  or  the  shoulder  muscles  may  be 
the  first  to  exhibit  atrophy.  In  nine-tenths  of  the  cases  the  onset  is  in  the 
upper  extremities,  but  in  the  remaining  tenth  it  begins  in  the  lower  limb.  Some 
pain  or  paraesthesia  may  precede  the  wasting  of  the  muscles.  The  disease  is 
extremely  slow  and  progressive,  and  is  always  a  motor  and  trophic  disorder, 
never  accompanied  with  ansesthesia.  The  trophic  disturbance  is  limited  to 
the  muscles  and  never  affects  the  bones  or  skin.  The  wasting  spreads  from 
the  parts  first  affected  to  other  muscles ;  for  instance,  from  the  ball  of  the 
thumb  to  the  interossei  and  lumbricales,  then  to  the  flexors  in  the  forearm 
and  extensors,  and  so  on  up  to  the  limb  ;  but  frequently  a  leap  is  made  from 
the  intrinsic  muscles  of  the  hand  to  the  deltoid  and  other  shoulder  muscles. 
Occasionally  the  upper  arm  and  shoulder  group  are  the  first  afiected,  while 

40 


626 


NERVOUS  DISEASES  AND  THEIR  TREATMENT 

Fig.  200. 


Hand  and  forearm  in  chronic  spinal  muscular  atrophy,  showing  especially  wasting  of 
thenar  and  hypothenar  eminences. 


Fig.  201, 


Progressive  muscular  atrophy,  show- 
ing wasting  and  lordosis. 


the  forearm  and  hand  escape  for  a  long  period. 
Muscles  of  the  back  are  prone  to  take  part  in 
the  wasting  at  an  early  stage,  and  lordosis  is 
not  an  uncommon  deformity  in  this  disease. 
(Fig.  201.)  The  muscles  supporting  the  head 
may  become  so  affected  that  the  head  falls  for- 
ward upon  the  chest,  or  is  carried  far  backward 
as  if  balanced  upon  the  vertebral  column. 
Sometimes  only  portions  of  muscles  atrophy, 
such,  for  instance,  as  the  anterior  half  of  the 
deltoid  and  the  lower  part  of  the  trapezius. 
There  is  generally  a  peculiar  escape  of  the 
upper  bundles  of  the  trapezius,  so  striking  that 
Duchenne  designated  them  as  ultimum  moriens. 
As  the  disorder  progresses  the  muscles  of  resj)i- 
ration  become  involved,  then  of  the  lower  part 
of  the  back,  of  the  hips,  and  of  the  thighs. 
The  disease  gradually  ascends  to  other  groups 
of  ganglion  cells  in  the  cervical  enlargement, 
and  even  upward  into  the  medulla,  so  that  the 
diaphragm  becomes  paralyzed  and  bulbar  symp- 
toms are  manifested.  Usually  the  face  escajDes 
the  widespread  palsy  and  atroj)hy,  but  occa- 
sionally the  lips,  tongue,  and  other  muscles  of 
this  region  may  suffer.  The  wasting  may  be 
so  great  in  parts  that  whole  muscles  disappear. 

The  mechanical  irritability  of  the  affected 
muscles  is  increased,  so  that  contractions  of 
muscle  bundles  are  caused  by  light  blows. 
Continuous  fibrillary  tremor  is  observed  run- 
ning from  one  bundle  to  another,  but  it  is  not 
present  in  every  case,  though  so  frequent  as  to 
be  considered  a  prominent  symptom. 

The  deep  reflexes  are  lost  when  the  reflex 
centimes  are  destroyed,  for  the  groups  of  gang- 
lion cells  are  the  keystones  of  the  reflex  arcs, 
and  when  they  are  gone  the  reflex  is  naturally 
destroyed.      Thus,   the    knee-jerk    disappears 


DISEASES  OF  THE  SPINAL  CORD.  627 

when  the  thigh  muscles  begin  to  be  invaded ;  wrist-jerk  and  elbow-jerk  when 
their  respective  groups  suffer. 

While  rheumatoid  pains  may  be  complained  of,  anaesthesia  never  exists, 
nor  is  there  loss  of  muscular  sense. 

In  the  early  stage  of  wasting  of  a  muscle  the  electrical  reaction  is  apt  to 
be  nearly  normal,  which  is  explained  by  the  fact  that  most  of  the  ganglion 
cells,  motor  fibres,  and  muscular  fibres  are  as  yet  unaffected.  But  after  a  time 
the  whole  phenomenon  of  reaction  of  degeneration  will  be  present  (loss  of 
faradic  contractility ;  anodal  closure,  greater  than  cathodal  closure  con- 
traction with  galvanic  current ;  slow  vermicular  response  of  the  muscle  to 
the  latter).  The  electrical  examination  is  important  in  differential  diagnosis, 
for  in  the  primary  muscular  dystrophies  the  reaction  will  persist  in  a  normal 
way  as  long  as  there  is  a  sufficient  number  of  fibres  left  in  the  muscle  to 
contract.  The  adipose  tissues  waste  as  well  as  the  muscles.  There  are 
no  vasomotor  changes,  or  discolorations  of  the  skin,  or  trophic  disturb- 
ances in  the  nails,  no  sympathetic  derangement,  no  optic  nerve  atrophy, 
no  loss  of  pupillary  reflex,  no  disorder  of  the  sphincters.  There  may  be  in 
some  cases  sexual  impotence,  and  nystagmus  has,  in  rare  instances,  been 
observed. 

The  disease  lasts  usually  ten  or  twelve  years,  but  termination  in  a  year 
has  been  observed,  and  it  has  been  known  to  endure  as  long  as  thirty  years. 
Death  is  generally  due  to  pulmonary  disorders  consequent  upon  palsy  of  the 
respiratory  muscles,  or  to  the  bulbar  palsy  and  difficulty  in  swallowing  and 
deranged  laryngeal  apparatus  ;  but  bed-sores  and  septicsemia  or  other  inter- 
current maladies  may  end  life. 

Pathology  and  Pathological  Anatomy.  The  anterior  cornua  are  the  chief 
parts  affected,  and  usually  they  are  changed  most  in  the  cervical  enlarge- 
naent,  because  the  muscles  most  commonly  affected  (upper  extremities)  have 
their  trophic  centres  here.  The  large  ganglion  cells  have  degenerated  and 
disappeared,  or  may  be  few  and  shrunken  into  angular  or  globular  bodies 
without  processes.  The  nerve  fibrill?e  degenerate  also,  and  connective-tissue 
elements  are  increased  in  quantity.  Larger  bloodvessels  are  found  dilated 
and  the  perivascular  spaces  increased  in  size.  The  size  and  shape  of  the 
cornua  may  not  be  especially  changed.  They  will  be  found  wholly  normal 
in  segments  representing  unaffected  muscle-groups.  In  many  cases  morbid 
changes  may  be  traced  into  the  antero-lateral  white  columns.  Degenerated 
fibred  are  found  in  the  anterior  roots  springing  from  the  diseased  segments  of 
the  cord,  and  correspond  to  the  degenerated  ganglion  cells  in  such  ]3arts.  In 
some  cases  degenerated  fibres  have  been  followed  up  through  the  pyramidal 
tracts,  through  the  medulla,  pons,  crus,  internal  capsule,  and  to  the  cortex, 
where  the  cortical  cells  have  also  been  found  fewer  in  number  and  atrophied. 
Where  there  has  been  bulbar  paralysis  similar  changes  are  observed  in  the 
motor  nuclei  of  the  medulla.  The  posterior  horns,  posterior  columns,  cere- 
bellar tracts,  and  posterior  roots  are  always  normal.  In  the  perii^heral 
nerves  degenerated  motor  fibres  are  found  in  greater  or  less  quantity  accord- 
ing to  the  degree  of  disease  in  the  anterior  horns  and  the  degree  of  muscular 
wasting.  The  muscles  are  found  small  and  pale,  and  the  fibres  narrowed, 
undergoing  fatty  or  vitreous  degeneration,  granular,  at  times  without  stria- 
tion,  and  at  times  presenting  a  longitudinal  striation.  The  interstitial  con- 
nective tissue  is  increased,  and  between  the  fibres  collect  fatty  globules  and 
masses  of  brownish  pigment.  The  disease  is  thus  essentially  a  slow  pro- 
gressive degeneration  of  the  spino-muscular  portion  of  the  motor  tract,  with 
consequent  paralysis  and  atrophy  of  the  muscles.  _  Since  there  is  at  times 
more  or  less  degeneration  of  the  cortico-spinal  portion  of  the  tract,  it  must 


628  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

be  assumed  that  the  same  primary  pathological  cause  may  attack  other 
portions  of  the  nervous  system  than  the  ganglion  cells  of  the  anterior  horn. 
But  the  actual  cause  of  the  beginning  of  the  clegeneratiye  j)rocess  is  un- 
knoAvn. 

Diagnosis.  The  diagnosis  of  this  disease  should  not  be  difficult  if  we  bear 
in  mind  the  distinctiye  features  of  the  malady — the  beginning  in  the  hand 
or  shoulder,  the  slo^v  advance,  the  peculiar  distribution  of  the  wasting  (in 
muscles  more  or  less  remote  from  each  other),  the  absence  of  ansesthesia,  the 
normal  condition  of  the  sphincters,  lost  reflexes,  the  fibrillary  tremor,  and 
the  character  of  the  electrical  reaction.  Local  and  multiple  neuritis  are 
distinguished  by  rapid  onset  and  sensory  symptoms. 

Lead-poisoning  is  usually  marked  by  paralysis  and  atrophy  of  the  exten- 
sors of  the  wrists  and  fingers  only  ;  but  this  is  symmetrical,  and  even  where 
the  wasting  extends  to  shoulder  muscles  and  the  lower  extremities,  which  is 
rare,  it  begins  as  a  characteristic  "lead  palsy."  Besides  the  history  of  expo- 
sure to  lead,  the  blue  line  on  the  gums,  and  examination  of  the  urine  will 
finally  exclude  this  disorder. 

In  diffiise  myelitis  we  find  sensory  and  sphincter  symptoms. 

In  syringomyelia,  where  the  atrophies  may  have  a  similar  distribution  to 
that  of  progressive  muscular  atrophy,  as  this  is  generally  a  disease  of  the 
cervical  enlargement  of  the  cord,  we  find  peculiar  sensory  and  trophic  disor- 
ders and  exaggerated  deep  reflexes. 

In  amyotropliic  lateral  sclerosis  also  the  atrophies  may  be  in  every  respect 
like  those  of  the  disease  in  question,  but  the  deep  reflexes  are  invariably 
exaggerated  to  a  very  marked  degree. 

Chronic  poliomyelitis  has  a  more  rapid  course  at  the  beginning,  then 
reaches  a  point  where  it  becomas  stationary  or  improves.  There  is  first 
paralysis,  then  wasting.     The  reaction  of  degeneration  appears  eai'lier. 

In  pachymeningitis  cervicalis  hypertrophica,  besides  the  muscular  wasting 
in  the  arms,  there  is  pain  and  rigidity  of  the  neck  and  exaggerated  tendon 
reflexes. 

A  local  atrophy  of  muscles  from  overuse  may  be  difficult  to  differentiate 
from  a  beginning  Aran-Duchenne  disease.  Thus,  in  a  young  woman 
whom  I  treated  for  a  year,  there  was  wasting  of  the  thenar  muscles  and 
first  interosseous  in  the  right  hand.  She  had  worked  ten  hours  a  day  for 
ten  years  as  a  jewelry  polisher,  and  the  muscles  affected  were  those  most 
needed  in  her  work.  She  recovered  entirely  by  taking  up  general  house- 
work and  under  electrical  treatment,  but  for  a  long  time  the  diagnosis  was 
impossible. 

The  progressive  muscular  dystrophies  are  often  hereditary.  L'sually  the 
disorder  begins  in  youth.  Some  muscles  are  often  found  to  be  hypertrophied. 
There  is  no  fibrillary  tremor.     The  faradic  reaction  is  normal. 

Prognosis.  As  regards  cure,  the  disease  is  incurable.  The  prognosis,  as 
far  as  life  is  concerned,  is  that  the  disease  may  last  for  an  indefinite  number 
of  years  without  developing  dangerous  symptoms,  such  as  paralysis  of  respira- 
tion and  deglutition,  or  pulmonary  disease. 

Treatment.  Properly  conducted  electrical  treatment,  massage,  systematic 
exercises  of  the  muscles,  and  hypodermic  injections  of  strychnine  in  the 
affected  muscles  (nitrate  of  strychnine  gr.  -^-^)  may  be  used  Avith  a  fair  pros- 
pect of  staying  the  progress  of  the  disease  for  a  time,  and  at  times  even 
occasioning  temporary  improvement.  The  galvanic  current  should  be  em- 
ployed (stroking  the  muscles  Ayith  the  anode  so  as  to  produce  contraction), 
and  when  there  is  am^  response  at  all  to  the  faradic,  that  also  should  be  made 
use  of     In  all  other  respects  the  treatment  should  be  merely  symptomatic. 


DISEASES  OF  THE  SPINAL  CORD. 


629 


LATERAL  SCLEROSIS. 


Primary  Lateral  Sclerosis  ;  Primary  Spastic  Paraplegia ;  Spastic  Spinal 
Paralysis  ;  Spasmodic  Tabes  Dorsalis. 

Lateral  sclerosis  is  a  chi'onic  disease  characterized  by  rigidity  and  weakness 
of  the  limbs  with  enormously  exaggerated  tendon  reflexes,  and  without 
atrophy  or  sensory  or  vesical  disturbance.  Since  Erb,  in  1875,  and  Charcot 
a  little  later,  described  this  syndrome,  its  existence  has  been  frequently  veri- 
fied by  neurologists,  and  yet  no  pathological  evidence  has  thus  far  been 
brought  forward  to  establish  it  as  a  separate  primary  systemic  disease  of  the 
spinal  cord.  But  while  such  evidence  is  wanting,  there  is  good  reason  for 
assuming  a  primary  sclerosis  of  the  pyramidal  tracts  to  be  a  real  pathological 
and  clinical  entity  quite  distinct  from  chronic  dorsal  myelitis,  cerebral  diple- 
gia, or  other  conditions  which  often  give  rise  to  somewhat  similar  symptoms. 

Etiology.  As  to  etiology,  little  can  be  said  except  that  probably  the  same 
causes  which  tend  to  bring  about  other  chronic  S3^stemic  degenerations  in  the 
cord  are  at  work  in  this  case,  excej)t  that  here  the  pyramidal  tracts  are 


Fig.  202. 


Illustrating  the  gait  in  lateral  sclerosis  ;  from  instantaneoias  serial  pHotographs  made  by  Muybridge  for 
Dr.  Dercum.  The  corresponding  figures  of  the  upper  and  lower  series  were  taken  simultaneou-sly. 

elected  for  the  process.  Heredity  plays  a  small  part.  I  have  seen  an  uncle 
and  nephew  affected  with  the  same  disease.  Both  sexes  are  equally  affected. 
Three-fourths  of  the  cases  begin  between  the  ages  of  twenty  and  forty  yeara. 
Syphilis  is  not  as  frequent  an  antecedent  disorder  as  in  posterior  sclerosis. 
Spinal  concussion  and  exposure  are  often  described  as  causes. 


630  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Symptomatology.  At  first  there  is  a  sense  of  fatigue  and  weakness  in  the 
legs.  This  is  followed  by  gradually  increasing  rigidity  and  great  increase  of 
the  deep  reflexes.  The  knee-jerks  become  exceedingly  quick  and  strong,  and 
often  a  quadriceps  clonus  is  obtained.  Ankle-clonus  is  marked.  Although 
most  marked  in  the  lower  extremities,  the  upper  may  also  suffer,  so  that  the 
wrist-jerks,  periosteal,  supinator,  biceps,  and  triceps  jerks  become  excessive. 
There  is  no  wasting  of  muscles ;  on  the  contrary,  they  are  large  and  firm. 
The  spastic  rigidity  is  so  great  that  it  becomes  markedly  manifest  in  the  gait  of 
the  patient,  who  scarcely  flexes  the  knees  in  walking,  drags  his  toes,  and  often 
develops  a  tremor  in  the  legs  (from  ankle-clonus)  as  he  steps  upon  his  toes  in 
moving.  (See  Fig.  202.)  This  spastic  rigidity  is  chiefly  due  to  the  increased 
deep  reflexes  in  all  of  the  muscles,  but  at  times  we  find  spasmodic  movements, 
single  contractions  in  the  legs,  due,  as  in  some  forms  of  myelitis,  to  motor 
irritation.  Reflex  action  of  the  skin  is  often  excessive.  There  are  no  sen- 
sory disturbances.  There  are  no  trophic  changes  in  the  skin  or  joints,  no 
ocular  symptoms,  and  rarely  any  sphincter  trouble  or  loss  of  sexual  power. 
A  cold  atmosphere  increases  the  rigidity  of  the  muscles.  Occasionally  a  jaw- 
jerk  is  found  in  these  cases. 

Pathology  and  Pathological  Anatomy.  There  are  no  recorded  autopsies  in 
cases  of  pure  primary  lateral  sclerosis ;  but  sclerosis  of  the  lateral  columns 
has  been  found  frequently  enough  in  conjunction  with  other  diseases,  as  in 
amyotrophic  lateral  sclerosis,  general  paresis  of  the  insane,  cerebral  diplegia 
of  children,  and  ataxic  paraplegia. 

Diagnosis.  From  a  study  of  the  above  symptoms  and  the  exceedingly 
slow  progress  of  the  disease,  we  should  be  able  to  make  an  accurate  diagnosis. 
At  the  same  time  caution  is  required,  for  what  may  appear  for  years  to  be  a 
primary  lateral  sclerosis  may  turn  out  in  the  end  to  be  a  multiple  sclerosis. 
Such  an  instance  I  saw  not  long  ago  in  a  young  girl,  who  five  years  before 
had  been  pronounced  by  several  eminent  neurologists  to  be  a  case  of  primary 
lateral  sclerosis,  but  who  now  presents  all  of  the  typical  symptoms  of  the 
latter  disease.  Tumors  of  the  cervical  cord,  peculiar  forms  of  transverse 
myelitis,  compression  in  Pott's  disease,  and  hydromyelus  may  each  simulate 
at  times  the  clinical  symptoms  described  above.  Thus  it  behooves  us  to  use 
care  in  our  diagnosis  of  the  character  and  locality  of  the  lesion. 

Prognosis.  The  disease  is  incurable,  but  its  progress  is  exceedingly  slow, 
generally  imperceptible  for  years,  and  the  symptoms  are  never  as  distressing 
as  in  many  other  forms  of  chronic  spinal  cord  disease.  There  is  the  possi- 
bility of  occasional  temporary  improvement  in  these  cases. 

Treatment.  Hydrotherapy  is  of  some  avail  in  these  cases,  especially  for 
the  purpose  of  lessening  the  rigidity,  and  to  this  end  prolonged  warm  baths 
(one  to  two  hours  at  a  temperature  of  90°  to  95°  Fahr.)  are  well  adapted. 
In  cases  with  syphilitic  history,  iodide  of  potash  and  mercurial  inunction  are 
indicated.  Massage  is  of  some  service,  while  electricity  is  absolutely  value- 
less. Strychine,  nux  vomica,  and  other  drugs  which  may  tend  to  increase 
the  spasticity  are  interdicted.  Residence  in  a  hot  climate  is  advantageous, 
where  it  is  feasible,  and  where  there  are  no  objections  on  other  grounds 
against  it.  Arsenious  acid  (gr.  g\f)  and  the  bromides  are  sometimes  useful. 
Solanin  may  be  employed  in  some  cases  to  overcome  rigidity  with  moderate 
success. 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

This  disease  is  clinically  and  pathologically  well  defined,  in  that  it  is  a 
combination  of  the  two"  diseases  hereinbefore  described,  viz. :  lateral  sclerosis 
and  chronic  spinal  muscular  atrophy.     Keeping  the  clinical  pictures  of  these 


DISEASES  OF  THE  SPIXAL  COED.  g31 

maladies  well  in  mind,  it  would  be  difficult  to  make  an  error  in  diagnosis  in 
this  case.  We  are  indebted  to  Charcot  (1869)  and  Joffroy  (1869-1874) 
for  our  first  careful  delineations  of  this  disorder. 

Etiology.  We  do  not  know  what  factors  are  at  work  in  the  jiroduction 
of  amyotrophic  lateral  sclerosis.  Doubtless  when  we  understand  better  the 
etiology  of  other  chronic  systemic  diseases  or  degenerations  of  the  spinal 
cord,  the  causes  in  this  disorder  will  be  clear.  It  is  essentially  a  disease  of 
adult  life  (twenty-five  to  forty-five  years),  but  younger  and  also  older  per- 
sons have  been  subjects  of  it.     It  is  more  common  in  males  than  in  females. 

Symptomatology.  Usually  the  first  symptoms  to  be  noticed  are  those 
belonging  to  progressive  muscular  atrophy,  and  the  wasting  is  prone  to  fol- 
low the  typical  course  of  that  disease,  beginning  in  some  part  of  the  upper 
extremity,  generally  the  thenar  and  hypothenar  eminences  of  one  hand. 
In  addition  to  the  wasting  there  is  a  sense  of  fatigue  and  weakness  in  the 
whole  arm.  The  disease  is  very  slow  in  its  onset  and  extension.  In  six 
months  or  a  year  the  symptoms  of  a  primary  lateral  sclerosis  begin  also  to 
be  manifested,  Aveariness,  weakness,  stiffness,  and  uncertainty  in  the  loAver 
extremities,  combined  with  more  or  less  tremor  in  walking,  such  as  we  know 
to  be  due  in  the  above-named  disorder  to  the  increase  of  the  reflexes.  As  a 
rule,  patients  present  themselves  for  examination  when  these  symptoms  are 
obvious,  and  upon  examination  we  find  atrophy  and  paralysis  of  muscles  of 
the  hands,  arms,  or  shoulders ;  in  fact,  very  much  the  same  state  of  affairs 
as  previously  described  in  the  section  on  Chronic  Spinal  Muscular  Atrophy. 
But  in  addition  to  the  amyotrophy  there  are  symptoms  directly  the  reverse 
of  the  disease  referred  to,  in  that  the  deep  reflexes  instead  of  being  lost  are 
greatly  exaggerated.  They  are  invariably  increased  even  from  an  early 
period.  The  knee-jerks  are  quick  and  extensive  in  response  to  taps  on  the 
patellar  tendons,  top  of  the  patella,  or  muscles.     There  is  ankle-clonus.     The 

Fig.  203. 


Amyotrophic  lateral  sclerosis.    Second  cervical  segment.    The  degeneration  of  the  crossed  pyram- 
idal tract  shows  in  the  characteristic  faint  deepening  of  the  stain  in  this  region.    Carmine  stain. 

wrist-jerks  are  strikingly  apparent.  The  periosteal  biceps  and  supinator-jerks 
and  the  triceps  reflexes  are  very  marked.  This  is  true,  even  though  the 
wasting  in  the  extremities  may  be  considerable.  There  is  thus  a  singular 
combination  of  atrophy  and  spastic  rigidity.  The  gait  is  stiff'  and  spastic 
as  in  lateral  sclerosis.  The  legs  resist  passive  movements,  but  are  found  to 
be  paretic.     Upon  electrical  examination  of  the  atrophied  muscles  we  find 


632  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  same  condition  as  in  spinal  progressive  muscular  atrophy,  viz. :  always 
the  reaction  of  degeneration,  when  the  wasting  is  considerable,  sometimes 
response  to  faradaism,  still,  if  the  atrophy  is  in  an  early  stage.  Sensibility  is 
never  in  any  wise  disturbed.  There  is  no  change  in  the  cutaneous  reflexes. 
The  sphincter  of  the  bladder  is  properly  controlled,  and  that  of  the  rectum 
also  normal  in  function.  As  in  progressive  muscular  atrophy,  bulbar  symp- 
toms come  on  in  the  course  of  years.  Paralysis  of  the  palate  gives  a  nasal 
intonation  to  the  speech.  Difficulty  in  swallowing  is  noted.  The  lips  and 
tongue  become  more  or  less  atrophied  and  paretic,  so  that  labial  and  lingual 
sounds  are  improperly  connected.  Fibrillary  tremor  is  observed  in  these  as  in 
many  other  atrophied  muscles.  At  times  we  find  a  strong  jaw-jerk  present. 
Death  finally  comes  from  respiratory  failure,  inhalation  pneumonia,  or  some 
intercurrent  disease. 

The  increased  reflexes  are  due,  of  course,  to  the  degeneration  in  the  pyram- 
idal tracts  (inhibitory  fibres),  and  apparently  this  degeneration  precedes  to 
a  certain  extent  many  of  the  changes  in  the  anterior  horns.  As  long  as  the 
reflex  arc  is  not  totally  destroyed  the  reflexes  are  increased,  but  as  soon  as 
this  takes  place  there  can  no  longer  be  an  exaggerated  condition  of  the 
tendon-jerks.  As  a  rule,  however,  the  wasting  never  goes  to  such  an  extent 
before  death  that  the  reflex  arc  is  interrupted,  and  consequently  all  of  the 
deep  reflexes  are  apt  to  be  overactive  to  the  last. 

Pathology  and  Pathological  Anatomy.  The  remote  causes  of  this  disease 
are  unknown.  The  morbid  anatomy  of  the  malady  is  clearly  understood 
from  numerous  autopsies.  We  find  in  spinal  cord  well-marked  sclerosis  of 
the  pyramidal  tracts  and  degeneration  and  atrophy  of  the  ganglion  cells  of 
the  anterior  horns.  The  sclerosis  is  observed  in  the  lateral  columns  and 
also  in  the  columns  of  Tiirck,  and  may  be  traced  upward  through  the 
medulla  and  pons  to  the  internal  capsule,  and  rarely  as  far  as  the  Rolandic 
cortical  areas.  The  changes  in  the  anterior  horns  are  such  as  have  been  de- 
scribed in  the  pathology  of  progressive  muscular  atrophy.  Where  bulbar 
symptoms  have  existed,  similar  changes  are  found  in  the  nuclei  of  the  hypo- 
glossus,  vagus,  spinal  accessory,  etc.  From  these  parts  the  degeneration  may 
be  followed  outward  toward  the  periphery  in  the  motor  fibres  of  the  nerves 
affected  as  far  as  the  muscles.  The  muscles  are  small  and  pale,  and  often 
more  than  half  replaced  by  connective  tissue  and  fat.  The  fibres  are 
narrowed,  granular  or  fatty,  without  striation,  as  in  progressive  muscular 
atrophy ;  and  often  quite  normal  fibres  are  to  be  observed  among  the  degen- 
erated ones. 

Diagnosis.  One  is  not  apt  to  confuse  so  clear  a  clinical  picture  with  that 
of  any  other  similar  syndrome.  If  confusion  were  to  arise  it  would  be  from 
too  superficial  an  examination  of  a  case.  The  coexistence  of  muscular  atro- 
phies and  exaggerated  reflexes  is  seldom  noted  in  other  maladies.  We  find 
it  in  syringomyelia  and  other  affections  (tumors)  of  the  cervical  cord,  but 
here  attention  to  the  sensory  disturbances  is  sure  to  lead  to  a  correct  idea  of 
the  case.  Chronic  hypertrophic  cervical  pachymeningitis  might  at  times  mis- 
lead somewhat,  but  the  pain  and  rigidity  of  the  neck  and  the  absence  of  re- 
flexes in  the  wasted  upper  extremities  should  suffice  to  make  the  diagnosis 
evident  in  this  case. 

Prognosis.  There  is  no  hope  of  a  cure  in  amyotrophic  lateral  sclerosis. 
Death  occurs  in  the  course  of  a  few  years.  The  atrophies  often  lead  to  com- 
plete helplessness  after  a  time.  Only  exceptionally  does  the  disease  evince 
any  tendency  to  become  stationary. 

Treatment.  Electrical  treatment  may  be  used  upon  the  atrophied  mus- 
cles, stroking  with  the  anode  so  as  to  produce  contractions  with  the  galvanic 
current.      Massage   may  also  serve   to   stimulate   nutrition.     Warm  baths 


DISEASES  OF  THE  SPINAL  CORD  633 

diminish  the  spastic  rigidity  to  a  certain  extent.  Arsenious  acid  (grain  -gig-) 
may  be  used  internally  in  conjunction  witli  tonic  or  other  treatment  deemed 
advisable  for  coincident  conditions. 


LOCOMOTOR  ATAXIA. 

Posterior  Sclerosis ;  Tabes  Dorsalis ;  Tabes  Dorsualis.  Locomotor  ataxia 
is  a  chronic  j)rogressive  disease  of  the  nervous  system,  with  degenerative 
lesions  chiefly  marked  in  the  posterior  columns  of  the  cords  and  posterior 
roots,  and  characterized  clinically  by  inco-ordination  of  movement,  pains,  loss 
of  knee-jerks,  anaesthesia,  loss  of  the  pupillary  reflex  to  light,  and  various 
visceral  and  trophic  symptoms.  There  is  considerable  variation  in  the  symp- 
toms as  regards  the  degree  of  their  manifestation  and  the  number  of  them 
present,  so  that  complex  and  atypical  forms  are  met  with.  Not  only  are  there 
types  which  may  be  termed  neuralgic  and  paralytic,  and  types  with  initial 
optic  atrophy  and  with  muscular  wasting,  but  there  are  cases  complicated 
with  other  forms  of  disease,  such  as  lateral  sclerosis  and  general  paralysis  of 
the  insane.  There  are  maladies  which  resemble  locomotor  ataxia,  but  which 
should  not  be  classed  with  it,  such  as  hereditary  ataxia  and  cerebellar  heredo- 
ataxia. 

Etiology.  Males  suffer  from  the  disease  much  more  frequently  than 
females.  The  proportion  is  something  like  ten  to  one.  It  is  more  common 
in  middle  life  than  at  any  other  age,  iiilly  half  of  the  cases  developing  be- 
tween thirty  and  forty.  Next  in  frequency  is  the  period  between  forty  and 
fifty,  and  next  between  twenty  and  thirty.  Thus,  almost  all  the  cases  occur 
between  the  ages  of  twenty  and  fifty.  In  very  rare  instances  it  has  been  met 
with  as  early  as  ten  and  as  late  as  sixty  or  more.  Heredity  has  little  to  do 
with  the  disease,  a  general  neurotic  taint  being  present  in  only  about  10  per 
cent,  of  the  cases.  Direct  inheritance  is  extremely  rare,  though  one  or  two 
such  instances  have  been  reported. 

Syphilis  is  by  far  the  most  important  etiological  factor  in  tabes.  Fournier 
places  the  percentage  of  syphilis  in  cases  of  locomotor  ataxia  at  91-98  per 
cent.,  Erb  at  88  per  cent.,  Eumpf  at  80-85  per  cent.,  and  Sachs  at  over  90  per 
cent.  Gowers  found  only  58  per  cent,  of  his  private  cases  syphilitic,  but 
assumes  a  percentage  of  80  among  the  lower  classes.  In  83  cases  of  loco- 
motor ataxia  observed  by  me  at  the  Vanderbilt  clinic,  in  which  this  factor 
was  carefiilly  investigated,  a  specific  history  Avas  verified  in  71  per  cent.  But, 
while  syphilis  is  an  antecedent  in  three-fourths  of  the  cases,  the  syphilitic 
cases  resemble  the  non-syphilitic  as  regards  the  histological  characters  of  the 
lesions,  and  specific  treatment  has  no  effect  whatever  upon  the  cases  with 
syphilitic  history.  Hence  the  malady  is  not  a  syphilitic  disease,  not  a  direct 
sequel  of  syphilis,  but  the  venereal  disorder  prepares  the  constitution  like  a 
cachexia  for  the  development  of  the  degenerative  process.  Inherited  syphilis 
seems  to  be  an  etiological  factor  in  every  case  of  tabes  occurring  in  children. 
The  interval  between  the  contraction  of  syphilis  and  the  development  of  loco- 
motor ataxia  is  commonly  between  six  and  twelve  years,  though  cases  are  on 
record  of  intervals  of  less  than  a  year  and  more  than  twenty  years. 

The  disorder  is  more  common  in  city  than  in  country  populations. 

Concussion  of  the  spine  from  falls  and  the  like  is  sometimes  found  to  be  a 
cause.  Overexertion,  great  fatigue,  exposure  to  damp  and  cold,  some  acute 
diseases  (acute  rheumatism,  typhoid  fever,  diphtheria,  typhus,  pneumonia), 
and  alcoholic  excess  have  been  mentioned  as  causes. 

What  is  known  as  "secondary  tabes"  is  a  form  that  sometimes  succeeds 
myelitis,  tumor,  or  syphilitic  inflammation  of  the  meninges  or  cord. 


634 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Symptomatology.  In  typical  locomotor  ataxia  there  are  peculiar  symp- 
toms in  motor,  sensory,  and  reflex  spheres.  There  is  no  paralysis  or  wasting 
(except  in  certain  rare  cases  to  be  mentioned  later  on),  but  the  motor  symp- 
tom is  an  inco-ordination  of  the  muscles,  an  ataxia  chiefly  observed  in  the 
lower  extremities,  sometimes  in  the  upper.  The  sensory  disturbances  consist 
of  "  lightning  pains,"  aneesthesias  in  the  limbs,  and  the  "  girdle  "  sensation. 
The  reflex  symptoms  are  the  loss  of  the  knee-jerks  and  the  loss  of  the  pupil- 
lary reflex  to  light.  These  are  the  chief  manifestations,  but  there  are  many 
others  that  present  themselves  occasionally,  such  as  optic  atrophy,  diplopia, 
visceral  "  crises,"  difficult  micturition,  impotence,  muscular  atrophies,  and 
trophic  changes  in  the  skin,  joints,  and  bones. 

These  various  symptoms  appear  at  various  periods  in  the  progress  of  the 
disease,  and  it  is  usual  to  consider  three  stages  in  its  course.  They  are  not 
very  distinct,  it  is  true,  but  it  is  convenient  to  have  an  artificial  division  of 
the  kind,  and  the  following  table  will  serve  to  indicate  in  a  general  way  the 
relations  of  the  symptoms  to  each  stage : 


Initial  Period. 


Incoordination,  but  no  change 
of  gait. 

Numbness  of  the  feet. 

Shooting  pains  in  the  legs. 

Diminished  or  lost  knee-jerks, 
one  or  both . 

Sluggish  or  lost  pupillary  reflex 
to  light. 

Weakness  of  sexual  function. 

Transient    diplopia ;     transient 
ptosis. 

Sluggish  micturition. 

Optic  atrophy. 

Trophic  changes  in  the  joints. 

Hemiatrophy  of  tongue. 


Second  Stage. 


Final  stage. 


Greater    inco-ordination,    and 
marked  ataxic  gait. 

More  marked  aneesthesias. 

Pains  worse. 

Lost  knee-jerks. 

Lost   pupillary  reflex    to  light 
and  myosis. 

Impotence. 

Ocular  palsies  rare,  or  marked 
ophthalmoplegia. 

Increased  vesical  weakness. 

Optic  atrophy  rarely  develops. 

Trophic   changes  not  so  com- 
mon. 

Deafness. 

Laryngeal  and  visceral  crises. 

Girdle  sensation. 


Cannot  walk  because  of  ataxia. 

Extensive  aneesthesias. 
Pains  less. 
Lost  knee-jerks. 

Lost  reflex  to  light,  myosis,  par- 
alysis of  accommodation. 

Impotence. 

Ophthalmoplegia. 

Catheterization  needed. 

Blindness. 

More  marked  if  they  began  in 
early  stage. 

Increased. 

Not  so  common. 

Unnoticed. 


There  are  very  rarely  any  mental  symptoms,  the  mind  usually  remaining 
clear  to  the  last,  but  sometimes  we  have  a  comj^lication  with  general  paral- 
ysis of  the  insane  (though  the  presence  of  transient  tabetic  symptoms  in 
paresis  is  not  to  be  considered  as  evidence  of  there  being  a  combination  of 
locomotor  ataxia  proper  with  this  malady ,  see  also  Chapter  XXIII.)  ;  and  I 
have  seen  a  number  of  cases  in  which  insanity,  melancholia,  or  subacute 
mania  has  developed  during  the  course  of  the  affection. 

We  will  now  examine  the  various  symptoms  somewhat  more  in  detail. 

Motor  Symptoms.  The  ataxia  is  a  symptom  of  gradual  development, 
first  showing  itself  by  slight  unsteadiness  in  walking  or  in  standing,  especially 
when  the  eyes  are  closed,  and  when  the  feet  are  placed  closely  together 
("Romberg  symptom"  or  "tabetic  swaying").  A  slight  amount  of  sway- 
ing under  these  circumstances  is  observed  in  a  healthy  person,  and  familiarity 
with  the  test  is  required  for  the  determination  of  what  amount  of  unsteadi- 
ness is  a  morbid  symptom.     The  patient  often  discovers  this  difficulty  with 


DISEASES  OF  THE  SPINAL  CORD 


635 


Fig.  204. 


equilibrium  first  himself  when  getting  out  of  bed  at  night,  walking  on  dimly- 
lighted  stairs,  or  when  out  for  an  evening  stroll.  As  time  goes  on  the  inco- 
ordination increases,  until  walking  and  standing 
are  noticeably  unsteady.  The  feet  are  kept  apart 
in  standing,  in  order  the  better  to  preserve  equilib- 
rium. When  in  bare  feet  the  inco-ordination  is 
more  marked,  and  also  more  readily  discovered  in 
its  early  manifestation.  The  shoes  give  a  stiff  sup- 
port to  the  feet,  and  their  removal  throws  more 
effort  upon  the  unsteady  muscles.  After  a  while 
the  gait  assumes  its  peculiar  characters  (see  Figs. 
205  and  206),  -which  can  readily  be  imitated  by 
walking  with  the  legs  a  little  farther  apart  than 
normally,  throwing  the  feet  a  little  high  in  stepping 
forward,  and  bringing  the  whole  sole  down  upon 
the  floor  at  each  step.  Soon  a  cane,  or  two  sticks, 
or  the  assistance  of  another  person  becomes  neces- 
sary, and  at  last  locomotion  is  altogether  impos- 
sible, owing  to  the  complete  ataxia  of  the  legs, 
which  move  in  every  direction  but  the  one  desired. 

The  arms  are  also  at  times  included  in  the  ataxic 
condition,  occasionally  before  the  inco-ordination 
develoj^s  in  the  legs.  It  may  be  noted  in  writing, 
in  bringing  the  index  fingers  together  with  the  eyes 
shut,  touching  the  nose  with  the  forefinger,  and  so 
on.  Later  it  may  be  impossible  for  the  patient  to 
use  his  fingers  in  picking  up  articles,  buttoning  his 
clothes,  and  so  forth.  Sometimes  the  trunk  mus- 
cles are  also  ataxic,  but  the  inco-ordination  does  not 
affect  the  movements  of  the  face,  tongue,  eyes,  or 
head. 

In  spite  of  all  this  loss  of  control  over  the  mus- 
cles, it  is  unusual  to  observe  any  loss  of  power  in 
them.    There  is  no  paralysis  or  paresis,  even  in  the 
last  stages,  unless,  indeed,  the  disorder  is  conjoined  with  lateral  sclerosis, 
peripheral  neuritis,  or  progressive  spinal  muscular  atrophy. 

Sensory  Symptoms.  Nearly  all  cases  of  tabes  suffer  from  sensory  symp- 
toms of  one  kind  or  another,  either  neuralgic  pains  or  anaesthesias  and  par- 
sesthesias,  or  all  of  them  together.  The  pains  are  peculiar  in  their  shooting 
or  lightning-like  character,  and  in  their  tendency  to  come  on  paroxysmally, 
especially  at  night,  and  usually  in  the  legs,  through  the  arms,  trunk,  viscera, 
or  head  may  be  their  seat.  The  pains  may  be  localized  at  some  particular 
cutaneous  area  or  shoot  through  the  long,  deeply-seated  nerves.  Often  they 
have  no  relation  to  the  nerve-trunks,  and,  as  they  depend  upon  irritation  of 
sensory  roots  at  certain  levels,  they  vary  much  in  their  peripheral  manifes- 
tations. The  pains  may  last  a  few  hours  or  several  days,  may  return  in  the 
same  parts,  or  change  from  one  locality  to  another.  They  are  not  ahvays 
shooting  pains ;  occasionally  they  are  continuous,  dull,  burning,  or  gnawing. 
As  in  rheumatic  and  other  affections,  the  pains  are  often  influenced  by  the 
weather.  They  are  among  the  earliest  symptoms  of  the  disease.  Rarely 
they  are  altogether  absent. 

Another  sensory  symptom  is  the  "  girdle  sensation,"  or  sense  of  constric- 
tion about  the  trunk  at  different  levels,  sometimes  as  low  down  as  the  groins 
or  thighs. 

Parsesthesiifi  in  the  form  of  burning,  prickling,  tingling,  numbness,  cold, 


Attitude  in  locomotor  ataxia, 

advanced  stage. 

(Philadelphia  Hospital.) 


636 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


heat,  or  the  like,  are  noted  usually  in  the  feet  and  legs,  and  often  also  in  the 
hands.     Sometimes  there  is  hypersesthesia,  hyperalgesia,  hypercrysesthesia. 


Fig.  205. 


Gait  in  a  case  of  locomotor  ataxia.    From  instantaneous  serial  photographs  of  a  patient  of 
Dr.  Dercum,  made  simultaneously  from  two  different  point  of  view  by  Muybridge. 


Fig.  206. 


■V   J 


__tejjjjj^   «,,_  _r,  ■ 


V 


Showing  the  same  patient  (as  in  Fig.  205)  on  attempting  to  walk  with  the  eyes  closed. 
From  photographs  by  Muybridge,  as  before. 


DISEASES  OF  THE  SPINAL  COBB.  637 

and  hyperthermsesthesia.  More  commonly  there  is  loss  of  sensibility  in 
parts,  especially  in  the  feet  and  legs,  to  touch,  pain,  cold,  and  heat,  but  there 
is  not  the  dissociation  of  sensibilities  as  in  some  other  diseases,  like  syringo- 
myelia, for  instance.  Delay  in  the  perception  of  sensations,  especially  of 
pin-pricks,  is  rather  common,  the  delay  often  amounting  from  five  to  fifteen 
seconds.  A  single  sensation  may  be  perceived  as  many  (polysesthesia),  or 
referred  to  the  opposite  extremity  (allochiria).  The  sense  of  posture  is  usu- 
ally affected. 

As  regards  the  special  senses,  Gowers  has  recorded  one  case  with  a  double 
temporal  hemianopia,  and  not  long  ago  I  presented  to  the  New  York  Neuro- 
logical Society  a  case  of  tabes  with  homonymous  hemianopia  (or  rather  three 
quadrants  lost  symmetrically  in  each  field).  Optic  atrophy  will  be  mentioned 
later.  Deafness  is  occasionally  met  with,  as  are  also  anosmia  and  ansesthesia 
in  the  distribution  of  the  fifth  nerve. 

Reflex  Symptoms.  The  loss  of  the  knee-jerk  is  the  most  important 
symptom  of  this  class.  It  is  usually  early.  In  the  preataxic  stage  it  is 
sometimes  unequal  on  the  two  sides.  The  plantar  reflex  is  abolished  next  in 
frequency.  As  the  disease  progresses  the  cremasteric,  gluteal,  and  abdomi- 
nal reflexes  are  apt  to  disappear.  Loss  of  the  sexual  reflex  is  usual  and 
generally  one  of  the  earliest  symptoms. 

The  bladder  reflex  is  commonly  much  impaired ;  as  a  rule,  there  is  slow- 
ness of  micturition  and  only  partial  evacuation  of  the  bladder.  Sometimes 
there  is  incontinence,  though  rarely  paralytic.  Constipation  is  frequent,  but 
paralysis  of  the  sphincter  ani  is  not  common. 

Ocular  Symptoms.  It  is  extremely  seldom  that  the  reflex  of  the  iris  to 
light  is  not  lost.  In  nearly  every  case  there  is  the  Argyll-Robertson  pupil 
(reflex  to  light  lost,  movement  in  accommodation  still  present).  I  have  found 
in  all  my  cases  that  the  cilio-spinal  reflex  is  also  lost.  Occasionally  the  ac- 
commodative movement  is  absent.  It  is  common  for  the  j^upils  to  be  small 
(spinal  myosis),  sometimes  irregular,  and  rarely  unequal. 

The  external  muscles  of  the  eye  are  also  frequently  involved,  so  that  one 
may  have  transient  palsies  of  one  or  more  muscles,  lasting  for  a  few  days  to 
a  few  weeks  or  remaining  permanently.  Temporary  palsies  are  met  with  in 
the  early  stage,  the  permanent  paralyses  later.  One  of  the  external  recti  or 
levators  is  usually  selected.  Sometimes  the  whole  of  one  or  both  third  nerves 
is  affected,  and  occasionally  all  of  the  muscles  of  one  or  both  eyes,  external 
and  internal.     (Fig.  207.) 

In  perhaps  one  case  in  ten  or  twelve  optic  atrophy  occurs,  and  usually  as 
an  early  symptom.  It  is  a  gray  atrophy.  When  optic  atrophy  develops  the 
spinal  symptoms  are  often  retarded  or  arrested.  Blindness  may  be  gradual, 
sometimes  speedy,  total,  or  only  partial. 

Vasomotor  and  Trophic  Symptoms.  Local  sweating,  ecchymoses,  tem- 
porary loss  of  hair  in  spots  or  change  in  its  growth,  and  herpes  are  observed 
as  symptoms  of  locomotor  ataxia.  Thickening  of  the  skin  of  the  sole  with 
the  formation  of  blisters  and  indolent  ulcers  is  not  uncommon.  These  ulcers 
are  peculiar  to  tabes,  and  are  known  as  "  perforating  ulcers  "  of  the  feet. 
They  burrow  deeply  and  heal  with  difficulty.  Similar  ulcerations  about  the 
toe-nails  are  met  with.  Sometimes  there  are  trophic  changes  in  the  nails  of 
both  hands  and  feet,  but  especially  of  the  latter.  The  nails  become  thick- 
ened, brittle,  rugose,  and  may  fall  off",  growing  again  in  the  course  of  time. 
Occasionally  the  teeth  are  loosened,  fall  out,  or  decay  rapidly. 

Muscular  atrophy,  sometimes  local,  sometimes  widespread,  is  not  infre- 
quent, occasionally  no  doubt  due  to  disease  of  the  ganglion  cells  of  the  an- 
terior horns,  but  probably  more  often  due  to  neuritis.  In  the  case  here 
photographed  (Fig.  207),  to  show  double  ophthalmoplegia,  external  and  in- 


638 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


ternal,  there  were  also  paresis  and  wasting  of  the  masseters,  temporals,  and 
pterygoids  on  both  sides,  hemiatrophy  of  the  tongue,  wasting  of  right  trape- 


FlG.  207. 


>*%-^ 


Case  of  Dr.  Peterson.     Tabes  with  palsies  of  the  ocular  muscles  of  both  eyes  and  wasting  of  the 
masseter  and  pterygoid  muscles. 


Fig.  208. 


Fig.  209. 


Extensive  dystrophy  of  elbow  with  fracture 
of  ulna.    (Philadelphia  Hospital.) 


Excessive  dystrophy  of  right  knee. 
(Philadelphia  Hospital.) 


zius  and  a  number  of  muscles  in  the  forearms,  hands  and  thighs,  all  of  which 
showed  degenerative  reaction.  Dejerine  reported  eleven  out  of  106  cases  of  loco- 


DISEASES  OF  THE  SPINAL  COBD. 


639 


motor  ataxia  presenting  muscular  atrophies.     Hemiatrophy  of  the  tongue  is 
occasionally  an  early  symptom. 

Among  the  more  remarkable  trophic  phenomena  are  the  so-called  "  Char- 
cot joints."     The  knee  is  the  joint  most  frequently  aifected  (one-half  the 


Fig.  210. 

i?i^1RH 

1    '■    ^•.4^K 

1 

^k 

I 

^fgr' 

Wtai    • 

5 .  * 

Dystrophy  of  both  knees,  with  marked  retro-flexion. 

cases),  and  next  in  order  follow  the  hip-joint  (one-fifth  of  the  cases),  shoulder, 
tarsus,  elbow,  and  ankle.  The  trophic  change  may  be  atrophic  or  hyper- 
trophic.    In  the  former  case  the  cartilages  and  heads  of  the  bones  are  eroded, 

Fig.  211. 


Dystrophy  of  ankles  and  feet.    Loss  of  plantar  arch  ;  marked  flat-foot. 
(Philadelphia  Hospital.) 

and  dislocation  or  abnormal  extent  of  movement  may  be  presented.  In  the 
hypertrophic  form  the  joint  becomes  greatly  enlarged  by  the  formation  of 
hyperostoses  of  irregular  shape  on  the  heads  or  shafts  of  the  bone,  and  the 
ligaments  may  ossify.     Usually  the  onset  of  the  arthropathy  is  sudden  and 


640  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

cliaracterized  by  great  swelling,  generally  painless,  sometimes  preceded  by 
rheumatoid  pains. 

A  marked  fragility  of  the  bones  with  spontaneous  fractures  is'noticed  in 
some  cases,  usually  in  such  as  show  also  a  tendency  to  the  development  of 
arthropathies.  The  fractures  are  commonest  in  the  femur,  tibia,  and  fibula, 
radius,  and  ulna,  humerus,  and  clayicle,  though  other  bones  may  also  suffer. 

The  formation  of  bony  masses  in  muscles,  a  myositis  ossificans,  has  lately 
been  described  by  two  or  three  authors  as  sometimes  occurring  in  tabes. 

ViscEPwAL  Symptoms.  Certain  peculiar  paroxysmal  visceral  disorders  occur 
in  tabes.  They  are  termed  crises.  Gastric  and  laryngeal  crises  are  the  most 
common  forms ;  but  rectal,  intestinal,  cardiac,  bronchial,  renal,  vesical,  and 
urethral  crises  are  met  with  at  times.  In  the  gastric  crises  there  is  severe 
epigastric  pain,  sometimes  difiused  through  to  the  back  and  over  the  whole 
abdomen,  and  vomiting,  usually  incessant,  with  or  without  nausea.  The 
attack  lasts  from  a  few  hours  to  two  or  three  days,  then  ceases,  to  return  in 
some  weeks.  While  such  an  attack  is  a  typical  one,  there  are  apt  to  be  great 
variations  in  the  degree  of  pain  and  other  symptoms,  but  the  paroxysmal 
character  of  the  seizure  is  always  significant. 

In  the  laryngeal  crises  there  is  a  similar  paroxysmal  disturbance  of  func- 
tion, with  a  strong  resemblance  at  times  to  pertussis  and  laryngismus  stridu- 
lus. There  is  spasm  of  the  adductors  or  paralysis  of  the  abdvictors  of  the 
larynx,  noisy  respiration,  and  dyspnoea.  The  onset  is  sudden,  and  the  seizure 
may  last  for  a  few  minutes,  or  for  houi-s.  Just  as  paroxysms  of  pains  in  the 
legs,  arms,  or  hand  are  related  to  processes  at  various  levels  in  the  central 
nervous  system,  so  these  crises  represent  changes  going  on  in  various  vis- 
ceral centres  of  the  spinal  cord  and  bulb. 

In  rare  instances  we  observe  transient  epileptiform  and  apo]Dlectiform 
attacks  in  tabes,  resembling  very  much  those  of  general  paresis.  (See 
Chapter  XXIII.) 

Course  and  Termination.  While  usually  progressive  and  at  a  more  or 
less  rapid  rate,  there  is  great  variation  in  the  duration  of  tabes  in  limits 
from  three  to  thirty  years.  Sometimes  the  first  stage  may  last  twenty  years, 
and  the  second  stage  has  in  some  instances  been  protracted  to  fifteen  years. 
Acute  cases  lasting  less  than  a  year  have  been  recorded.  Death  is  usually 
produced  by  intercurrent  diseases,  for  there  is  nothing  in  the  nature  of  tabes 
itself  to  produce  death.  Occasionally  a  laryngeal  crisis  has  proved  fatal, 
but  the  other  crises  never.  Patients  become  bed-ridden,  remaining  so  for 
years.  Bladder  disease,  renal  disorders,  sometimes  bed-sores,  and  septi- 
csemia,  carry  them  oft'. 

Complications.  Acute  or  subacute  myelitis,  sclerosis  of  the  lateral  col- 
umns (ataxic  paraplegia),  progressive  muscular  atrophy,  disseminated  sclero- 
sis, general  paresis,  valvular  heart  disease,  and  syphilitic  disease  of  the 
bloodvessels  or  gummata  are  among  the  complications  met  with  in  locomotor 
ataxia. 

Pathology  and  Pathological  Anatomy.  Of  late  considerable  advance  has 
been  made  in  our  knowledge  of  the  pathological  conditions  underlying  tabes. 
It  is  not  so  long  ago  that  the  degeneration  of  the  posterior  columns  was 
looked  upon  as  the  chief,  if  not  the  only,  morbid  pi'ocess.  But  the  disorder 
is  now  known  to  be  a  general  disease  of  the  nervous  system,  affecting  both 
central  and  peripheral  portions,  though  mainly  limited  to  sensory  or  afferent 
structures.  While  it  is  true  that  in  the  posterior  nerve-roots  and  posterior 
columns  we  have  sensory  fibres  which  are  affected  in  tabes,  there  are  in  other 
parts  of  the  central  nervous  system  motor  ganglia  and  nerves  that  suffer  in 
this  disease  (ocular  palsies,  progressive  muscular  atrophy,  etc.).  The  ganglia 
of  the  posterior  roots  are  probably  first  acted  uj)on  by  the  morbid  process, 


DISEASES  OF  THE  SPINAL  CORD. 


641 


and  following  upon  this  we  have  degeneration  of  the  ascending  fibres  in  the 
posterior  columns.  The  first  segments  to  be  affected  are  those  of  the  lower 
dorsal  and  upper  lumbar  region,  as  a  rule  ;  but  the  point  of  origin  varies  : 
occasionally  it  is  in  the  sacral  segments  or  in  the  cervical  enlargement.     The 


Fig.  212. 


Early  stage  of  tabes.    A.  Site  of  first  degeneration  in  the  posterior  columns. 
Fig.  213. 


Second  stage  of  tabes.    Progress  of  degenerative  process  in  other  parts  of  the  posterior  columns. 

Fig.  214. 


Final  htage  of  tabes.    Degeneration  of  all  parts  of  the  posterior  columns. 

.symptoms  vary  Avith  the  point  of  origin.  Vesical  and  genital  symptoms  at 
the  inception  of  tabes  point  to  origin  in  the  sacral  segments ;  ataxia  and 
lightning  pains  in  the  legs,  with  lost  knee-jerk,  signify  a  higher  level ;  pains, 

41 


642 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


numbness,  and  ataxia  affecting  the  arms  indicate  a  beginning  in  the  cervical 
enlargement. 

The  first  part  to  be  affected  after  the  spinal  ganglia  and  posterior  roots 
become  involved  is  the  portion  of  the  posterior  column  lying  in  the  middle- 
root  zone  between  the  columns  of  Goll  and  Burdach,  but  it  gradually  ex- 
tends until  the  whole  of  the  posterior  column  is  ultimately  converted  into 
sclerotic  tissue.  (Figs.  212,  213,  214).  The  atrophy  and  grayish  color  of 
these  columns  in  a  case  of  tabes  is  easily  noted  at  autopsy  with  the  naked 

Fig.  215. 


Tabes  dorsalis.    An  early  stage,  which  involves  one  root-zone. 

eye.  When  stained  the  sclerotic  columns  become  conspicuous  for  their  deep 
color.  Lissauer's  tract  is  generally  affected,  and  sometimes  the  antero-lateral 
and  direct  cerebellar  tracts  are  more  or  less  diseased.  In  some  very  rare 
cases  there  is  degeneration  in  the  pyramidal  tracts ;  occasionally  the  gray 
matter  of  the  posterior  cornua  suffers,  and  degeneration  has  been  noted  in 
the  column  of  Clarke.     In  some,  rare  instances  the  anterior  horns  have  been 


-s*^"^ 


Fig   216. 


Tabes  dorsalis. 


A  much  later  stage  of  the  posterior  sclerosis, 
quite  uniformly  involved. 


All  01  the  posterior  columns  are 


invaded,  Avith  resulting  muscular  atrophies,  though  these  may  depend  in 
some  cases  upon  degeneration  in  the  peripheral  nerves,  which  is  not  uncom- 
mon in  advanced  tabes.  This  degenerative  atrophy  of  the  nerves  begins  in 
the  distal  ends,  travels  slowly  upward,  but  does  not  often  reach  the  lai-ger 
nerve-trunks.     Usually  it  is  the  nerves  of  the  leg  which  are  the  ones  to  suffer. 


DISEASES  OF  THE  SPINAL  COBB. 


643 


Under  the  microscope  we  find,  as  a  rule,  some  variety  in  the  histological 
characteristics  of  the  sclerosis.  There  is  more  or  less  thickening  of  the 
trabecule,  with  increase  of  nuclei ;  the  nerve-fibres  are  narrowed  or  absent, 
the  vascular  walls  thickened,  and  the  pia  and  its  septa  increased  in  thick- 
ness, either  over  the  posterior  columns  or  even  over  the  whole  cord  at  times. 
Diflflise  myelitic  changes  and  disseminated  patches  of  sclerosis  have  been 
occasionally  observed.  The  posterior  nerve-roots  are  found  altered,  some- 
times only  slightly,  often  considerably,  as  far  as  the  ganglia.  The  ganglia 
are  usually  but  slightly  eflTected,  and  the  nerve  beyond  them,  as  a  rule,  not 
implicated  in  the  process  (Figs.  217  and  218).     But  it  must  be  remembered 


Fig,  217. 


Fig.  218. 


Normal  posterior  nerve-root  and  ganglia. 


Posterior  nerve-root  and  ganglia  in  tabes. 


that  the  function  of  ganglion  cells  may  be  seriously  impaired  without  notice- 
able structural  changes,  and  the  latest  view  of  the  pathology  of  tabes  may 
be  stated  to  be  that  some  irritative  agent  acts  upon  the  spinal  ganglia  and 
their  homologues,  producing  a  lesion  which,  while  not  structurally  visible, 
suffices  to  bring  about  degeneration  in  the  sensory  fibres  of  the  cord  and 
medulla  and  in  the  peripheral  nerve-ends.  Another  view  put  forward  of 
late  also  is  that  the  cause  of  tabes  is  a  meningitis  posterior. 

Diagnosis.  Locomotor  ataxia  is  recognized  by  the  combination  of  its 
characteristic  symptoms.  Loss  of  the  knee-jerk,  the  Argyll-Robertson  pupil, 
unsteadiness  of  gait  without  loss  of  power  in  the  limbs,  lightning  pains,  a 
slow  onset,  and  a  specific  history  are  the  chief  points  to  be  relied  upon.  The 
lost  knee-jerk  is  the  most  important  of  these  symptoms,  and,  as  a  rule,  it  is 
lost  in  the  earliest  stages.  A  diagnosis  of  tabes  should  not  be  made  unless 
this  feature  is  noted,  even  though  most  of  the  other  signs  are  present.    Some- 


644  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

times  iu  the  very  earliest  period  one  knee-jerk  will  be  present  and  the  other 
lost,  which  in  itself  is  very  significant.  We  do  not  always  find  the  Argyll- 
Robertson  pupil  in  tabes,  though  it  is  one  of  the  cardinal  symptoms.  Lost 
knee-jerks  and  lost  iris- reflex  exclude  all  other  disorders  except  general 
paresis,  which  has  its  own  distinguishing  symptoms. 

Tabes  and  alcoholic  neuritis  are  apt  to  be  confounded,  but  hardly  unless 
the  latter  takes  the  form  of  pseudo-tabes.  In  pseudo-tabes  the  alcohoKc 
history,  normal  pupils,  slight  weakness  of  the  limbs,  muscular  tenderness, 
and  occasionally  altered  electrical  reactions  should  guide  one  to  a  correct 
interpretation  of  the  case. 

In  ataxic  paraplegia  and  in  other  forms  of  paraplegia  there  is  exaggera- 
tion of  the  knee-jerks  and  ankle-clonus. 

In  post-diphtheritic  paralysis  the  differential  criteria  are  the  preceding 
paralysis  of  the  palate  and  of  accommodation,  together  with  loss  of  muscular 
power  and  the  absence  of  pains. 

While  the  ataxia  of  cerebellar  neoplasms  and  that  of  tabes  sometimes 
resemble  each  other,  the  differential  diagnosis  is  generally  made  clear  by 
pains  and  anaesthesia  in  the  former  and  headache  in  the  latter.  Their  resem- 
blance consists  in  the  ataxia,  occasionally  absent  knee-jerk  in  cerebellar 
tumor,  and  optic  nerve  atrophy. 

It  is  not  unusual  for  the  pains  of  locomotor  ataxia  to  be  treated  for  rheu- 
matism, sciatica,  and  the  like,  and  the  various  crises  for  essential  diseases  of 
the  affected  organs,  and  the  physician  should  be  on  the  lookout  for  other 
symptoms,  such  as  lost  knee-jerk,  in  such  cases. 

Prognosis.  Arrest  and  improvement  of  the  disease  is  possible  iu  the  earliest 
stages,  but  a  cure  is  not  to  be  looked  for  after  the  second  stage  is  reached, 
though  even  then  amelioration  is  often  brought  about  by  careful  treatment. 
The  rule  is,  however,  that  the  disease  in  the  majority  of  cases  is  progressive, 
but  death  results  from  some  intercurrent  disorder,  almost  never  from  tabes 
itself.  The  occurrence  of  optic  nerve  atrophy  is  generally  an  indication  of 
the  arrest  of  progress  of  the  malady  in  the  spinal  cord. 

Treatment.  The  general  treatment  consists  in  a  careful  regulation  of  the 
daily  life  of  the  patient,  the  avoidance  of  mental  or  physical  fatigue,  anxiety, 
or  exposure.  When  possible  the  patient  should  give  up  any  regular  occupa- 
tion that  may  sap  his  energies.  Often  prolonged  rest  in  bed  is  useful.  Resi- 
dence in  a  warm,  dry  climate,  with  low  altitude,  where  a  quiet  life,  out  of 
doors,  may  be  enjoyed,  and  long  sea-voyages  are  often  to  be  recommended, 
but  with  due  regard  to  all  the  conditions. 

Light  and  easily  digested  food  should  be  ordered,  and  the  patient  should 
be  absolutely  abstinent  as  regards  alcohol,  and  moderately  so  as  regards 
tobacco.     Sexual  excess  is  injurious. 

Many  cases  have  been  improved  much  by  hydrotherapy  alone.  The  best 
application  of  water  is  the  Charcot  douche,  three  or  four  times  weekly. 

It  is  difficult  to  determine  whether  any  actual  benefit  is  to  be  derived  from 
electricity.  The  pains  sometimes  yield  to  the  faradic  brush  or  to  the  stabile 
galvanic  anode  placed  over  the  seat  of  pain.  A  weak  solution  of  aconitia, 
in  combination  with  a  10  per  cent,  solution  of  cocaine,  placed  upon  the 
anode,  will  sometimes  relieve  by  electric  cataphoresis  these  pains,  particu- 
larly if  the  pains  be  superficial.  Sometimes  faradization  of  the  muscles  im- 
proves the  gait  of  a  patient  for  a  time,  and  in  vesical  weakness  faradization 
has  been  of  service.  Much  benefit  is  to  be  expected  from  drugs,  though  it  is 
true  that  there  is  no  panacea  for  all  the  symptoms  of  locomotor  ataxia,  nor 
is  there  any  particular  remedy  that  can  be  looked  upon  as  in  any  respect  a 
specific. 

So  large  a  percentage  of  cases  being  due  to  syphilis,  it  is  advisable,  when 


DISEASES  OF  THE  SPINAL  CORD.  (345 

there  is  such  a  history,  to  give  a  thorough  course  of  treatment  with  mercurial 
inunctions  and  iodide  of  potash,  especially  in  the  early  stages,  though  it  must 
be  confessed  that  anti-syphilitic  treatment  rarely,  if  ever,  modifies  the  symp- 
toms in  any  respect.  In  the  later  stages  of  tabes  it  is  well  to  be  moderate  in 
the  use  of  mercury  and  the  iodide  of  potash. 

One  of  the  oldest  and  most  efficient  remedies  is  nitrate  of  silver  in  doses 
of  4-  to  I"  of  a  grain  three  times  daily.  After  long  use  of  silver  salts  a  certain 
degree  of  argyria  may  be  produced,  and  this  should  be  explained  to  the  pa- 
tient when  he  is  put  upon  the  drug.  The  discoloration  of  the  skin  from 
protracted  exhibition  of  nitrate  of  silver  is,  however,  more  than  counterbal- 
anced by  the  good  results  generally  obtained.  Next  to  silver,  arsenic  is  dis- 
tinctly of  service.  It  may  be  given  in  the  form  of  Fowler's  solution,  3  to  5 
drops  three  times  daily  in  water  after  meals,  or  in  the  shape  of  a  A^  grain 
pill  of  arseniate  of  soda,  or  -^-^  to  -^  grain  jjill  of  arsenious  acid.  An  excellent 
method  of  treatment  is  to  alternate  the  silver  and  arsenic  for  two  or  three 
months  at  a  time.  The  chloride  of  aluminum  in  2  to  4  grain  doses  has  been 
highly  commended  by  some  authorities.  Among  other  remedies  that  may 
be  looked  upon  as  usefiil  adjuncts  at  times  are  strychnine,  nux  vomica,  iron, 
quinine,  Calabar  bean,  ergot,  phosphorus,  chloride  of  gold  and  sodium,  and 
belladonna.  Strychnine  is  said  to  be  esi^ecially  useful  when  combined  with 
nitroglycerin  (gr.  ^\^). 

The  relief  of  the  pains  is  most  often  called  for  by  the  patient,  and  ease 
from  them  is  commonly  obtained  with  difficulty.  The  use  of  morphine  is 
most  reprehensible,  though  its  efficacy  is  undoubted.  Antipyrin,  antifebrin, 
and  phenacetin  have  taken  the  highest  stand  as  anodynes  in  this  disorder, 
and  their  efficiency  is  sometimes  markedly  increased  by  being  combined  with 
codeine.  Extract  of  cannabis  indica  (gr.  \  to  ?)  is  frequently  of  service. 
Massage,  ice-bags,  or  hot  applications  are  at  times  beneficial.  Frequently 
much  good  is  experienced  from  the  use  of  sinaj)isms  or  even  the  actual 
cautery.     The  value  of  electric  cataphoresis  has  already  been  alluded  to. 

Atropine  or  belladonna  is  useful  for  urinary  incontinence,  and  strychnine 
for  vesical  weakness.  Vesical  and  rectal  neuralgias  yield  to  suppositories 
containing  opium  or  codeine,  combined  with  belladonna.  In  severe  visceral 
crises  it  sometimes  becomes  necessary  to  emjDloy  morphine  hypodermically, 
which  affijrds  immediate  relief.  Nitrite  of  amyl  or  nitroglycerin  act  well 
in  laryngeal  crises. 

When  the  bladder  is  not  perfectly  emptied,  daily  catheterization  will  be- 
come necessary. 

Suspension  by  means  of  the  suspensory  spinal  apparatus,  employed  origin- 
ally for  putting  on  plaster-jackets,  was  recommended  two  or  three  years  ago 
for  locomotor  ataxia,  and  at  one  time  had  quite  a  vogue.  Undoubtedly  the 
slight  stretching  of  the  spinal  cord  produced  in  this  way  altered  at  times  the 
chronic  degenerative  process  going  on  in  the  roots  and  columns,  so  that 
symptoms  were  in  many  cases  considerably  improved  by  the  method.  Bon- 
nuzzi  ascertained  by  careftil  experiment  that  this  cord-stretching  could  be 
carried  out  much  more  efficiently  and  with  greater  safety  by  a  method  of  liis 
own  than  by  suspension.  The  method  is  briefly  this :  The  patient  lies  upon 
his  back  upon  a  couch.  The  operator  then  lifts  up  his  two  legs,  the  knees 
being  kept  extended,  and  flexes  the  thighs  as  far  as  possible  over  upon  the 
abdomen.  This  is  done  at  first  gently,  as  it  is  paiuftil,  and  but  for  a  few 
seconds,  several  times  each  week.  Gradually  the  flexion  is  increased  and 
the  duration  of  the  process  23rolonged. 


646 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


FRIEDREICH'S    ATAXIA. 


Fig.  219. 


Frieclreicli's  Disease ;  Family  Ataxia ;  Hereditary  Ataxia ;  Generic  Ataxia ; 
Friedreich's  Form  of  Locomotor  Ataxia;  Hereditary  Ataxic  Paraplegia. 
Hereditary  ataxia  would  seem  to  be  the  best  term  for  this  disease  were  it 
not  for  the  recent  description  of  another  form  of  hereditary  ataxia,  which, 
however,  the  designation  "  cerebellar  heredo-ataxia,"  suggested  by  Marie, 
will   probably  serve  to  distinguish.     The  pathology   of  the   two  forms  of 

hereditary  ataxia  would  seem  to  be  quite 
distinct,  for  in  Friedreich's  disease  the 
lesions  are  spinal,  in  the  other  variety  cere- 
bellar. Friedreich  first  described  the  form 
to  which  his  name  is  attached  in  1861.  It 
is  a  species  of  combined  sclerosis,  differing 
from  other  and  similar  systemic  degenera- 
tions of  the  cord  in  the  early  age  at  which 
it  begins  to  be  manifested,  in  its  tendency  to 
occur  in  families,  and  in  certain  additional 
characteristics  which  will  be  described  under 
symptomatology.^ 

Etiology.  The  family  character  of  the 
disease  is  one  of  its  characteristics.  Direct 
inheritance  is  rare.  Cases  are  apt  to  occur 
in  brothers  and  sisters  in  one  family,  some- 
times in  paternal  and  maternal  uncles  or 
aunts  also.  As  many  as  ten  cases  in  three 
generations  of  a  single  family  have  been 
reported.  Sometimes  the  parents  are  per- 
fectly healthy ;  often  some  degenerative 
factor  is  found  in  ancestors  or  collaterals, 
such  as  alcoholism,  chorea,  syphilis,  epilepsy, 
or  other  disorders.  Isolated  cases  are  discov- 
ered at  times.  Males  and  females  are  about 
equally  affected,  taking  all  recorded  cases 
together,  but  occasionally  in  some  particular 
family  only  the  males  suffer,  all  the  females 
escaping,  or  vice  versa. 

As  regards    age,  most   cases   are    apt  to 

develop  symptoms  of  the  disease  between  the 

ages  of  six  and  fifteen,  probably  most  fre- 

The  extremes  in  recorded  cases  have  been 

One  solitary  instance  is  given  as 


Case  of  Friedreich's  ataxia  sliowing 
attitude  and  atrophy  of  muscles  of  legs, 
(Philadelphia  Hospital.) 


quently  between  six  and  eight. 

two  years  and  twenty-four  years  of  age. 

beginning  at  the  age  of  sixty-six  years. 

Acute  infectious  diseases  are  reported  among  antecedent  exciting  factors. 

Symptomatology.  The  earliest  and  the  cardinal  symptom  is  ataxia,  a 
gradually  developing  inco-ordination  at  first  most  noticeable  in  the  lower, 
later  in  the  upper  extremities.  It  affects  the  gait,  and  in  standing  the  feet 
must  be  kept  wide  apart.  As  in  locomotor  ataxia,  closing  the  eyes  increases 
the  swaying,  though  in  exceptional  instances  this  is  not  the  case.  Fre- 
quently a  tendency  to  fall  easily  and  to  stumble  in  walking  is  first  observed. 
Later  on  a  jerky  inco-ordination  in  the  arms  is  noticed.  There  are  usually 
no  pains  in  the  extremities  or  other  sensory  disturbances,  but  sometimes 
rheumatoid  pains  are  "complained  of     The  knee-jerks  are  always  absent  in 


1  See  Brain,  1890,  article  by  Ladame,  for  full  bibliography. 


DISEASES  OF  THE  SPINAL  CORD.  647 

typical  cases  very  early  in  the  disease.  As  time  goes  on  the  neck  muscles 
particijDate  to  a  greater  or  less  degree  in  the  ataxic  movements,  and  a  sort  of 
jerky  tremor  is  manifested.  The  tongue  may  also  be  included,  and  the 
speech  takes  on  a  peculiar  character  in  the  course  of  a  few  years- — a  ten- 
dency to  elision  and  hesitation  in  the  enunciation  of  sentences.  It  is  not 
unlike  the  scanning  or  staccato  utterance  of  multiple  sclerosis.  Nystagmus, 
either  vertical  or  lateral,  and  developed,  as  a  rule,  only  upon  movement  of  the 
eyes  upward  or  laterally,  is  present  in  most  cases.  It  is  seldom  noticed  when 
the  eyes  are  at  rest.  As  a  rule,  the  pupils  react  normally  to  light.  There 
is  never  optic-nerve  atrophy.  There  are  never  trophic  changes  in  the  skin,  or 
joints,  never  trouble  with  the  vesical  and  rectal  sphincters.  There  is  often 
vertigo.  In  the  later  stages  there  may  be  paraplegia,  contractures  (talipes 
equinus  or  equino-varus),  lateral  spinal  curvature,  and  some  muscular  wast- 
ing. The  progress  of  the  malady  is  exceedingly  slow  and  gradual,  as  a  rule, 
and  may  remain  at  a  standstill  for  years.  Death  may  occur  at  the  end  of 
ten  or  twelve  years  or  not  for  thirty  years.  The  usual  cause  of  death  is 
some  intercurrent  disease  not  especially  related  to  the  chronic  disorder. 

In  isolated  cases  atypical  symptoms  have  been  at  times  observed,  such  as 
diplopia,  lost  pupillary  reflexes,  frequent  i^ulse-rate,  vasomotor  disturbances, 
headache,  ansesthesia,  difiicult  micturition,  diminished  electrical  contractil- 
ity, impotence,  glycosuria,  and  imbecility. 

There  are  never  visceral  crises  or  mental  disturbances. 

The  chief  peculiarities  in  typical  cases  may  then  be  summarized  as  fol- 
lows: 

1.  Ataxic  gait  and  jerky  inco-orclination  of  the  upper  extremities. 

2.  Slow  and  jerky  articulation. 

3.  Absent  knee-jerks. 

4.  Nystagmus. 

5.  Scoliosis  and  talipes  ecpiino-varus. 

6.  Occurrence  in  several  members  of  the  same  family. 

7.  Inception  before  the  age  of  puberty. 

8.  No  sensory  disturbances,  no  pupillary  disorders,  no  mental  disorder. 
Pathology  and  Pathological  Anatomy.     The  essential  lesions  are  in  the 

spinal  cord — sclerosis  of  the  posterior  columns  and  of  the  pyramidal  tracts — 
in  fact,  a  combined  sclerosis,  such  as  is  also  noted  in  ataxic  paraplegia.  The 
posterior  columns  are  usually  more  affected  than  the  lateral  and  anterior. 
As  in  tabes,  the  posterior  nerve-roots  are  apt  to  be  involved  in  the  degenera- 
tive process.  Sometimes  the  adjacent  direct  cerebellar  tract  is  included  in 
the  lateral  sclerosis.  There  have  been  some  variations  in  the  pathological 
findings  in  the  many  autopsies  that  have  been  made,  but  those  just  given  are 
the  chief  features  in  all.  The  process  may  not  be  equally  intense  in  all  parts 
of  the  cord.  Atrophy  of  the  posterior  vesicular  columns  has  been  obsers^ed. 
Occasionally  slight  changes  in  the  ganglion  cells  of  the  anterior  horns  have 
been  seen.  The  pia  over  the  posterior  columns  is  at  times  thickened.  Thick- 
ening and  induration  of  the  pons  and  medulla,  with  atrophic  changes  in  the 
cells  of  the  post-pyramidal  nucleus  and  in  the  restiforra  bodies,  have  been  re- 
ported. It  has  been  also  stated  that  the  cord  is  at  times  congenitally  im- 
perfect. Two  central  canals  have  been  noted.  There  are  no  changes  in  the 
brain  and  rarely  in  the  peripheral  nerves. 

It  has  been  suggested,  for  various  reasons,  that  the  disorder  is  a  manifes- 
tation of  a  sort  of  arrest  of  development,  so  that  the  nerve  tissues  involved 
have  a  lower  vitality  than  other  structures,  and  thus  tend  to  degeneration 
early  in  life.  It  has  also  been  supposed  that  the  true  pathology  is  a  ten- 
dency to  a  proliferation  of  the  interstitial  neuroglia  by  which  the  nen^ous  ele- 
ments are  forced  to  succumb. 


648  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Diagnosis.  In  the  first  place  it  is  necessary  to  distinguish  cerebellar 
heredo-ataxia  from  Friedreich's  form  of  hereditary  ataxia.  The  former, 
due  to  atrophy  of  the  cerebellum,  is  a  peculiar  and  rare  syndrome  whose 
characteristics  may  be  drawn  from  a  study  of  the  cases  recorded  by  Fraser, 
Nonne,  Sanger  Brown  and  Klippel,  and  Durante.  I  give  the  contrasting 
and  corresponding  symptoms  of  the  two  disorders  in  the  following  parallel ; 


Friedreich's  Disease. 

Cerebellar  Heredo-alaxia. 

1. 

Ataxia. 

1. 

Ataxia. 

2. 

Disordered  speech. 

2. 

Disordered  speech. 

3. 

Absent  knee-jerks. 

3. 

Normal  or  exaggerated  knee-jerks. 

4. 

Nystagmus. 

4. 

Nystagmus. 

5. 

Normal  pupils. 

5. 

Argyll-Robertson  pupils. 

6. 

No  ocular  symptoms. 

6. 

Limitation  of  the  field  of  vision,  dyschroma- 
topia,  optic-nerve  atrophy  often. 

7. 

Scoliosis  and  club-foot. 

7. 

No  scoliosis  or  club-foot. 

8. 

Heredity. 

8. 

Heredity. 

9. 

Inception  before  the  age  of  puberty. 

9, 

Inception  after  the  age  of  twenty. 

From  locomotor  ataxia,  the  early  age  of  onset,  nystagmus,  defect  in 
articulation,  and  absence  of  jDupillary  symj)toms  ought  to  render  the  differ- 
entiation of  Friedreich's  disease  easy. 

The  exaggerated  knee-jerks,  age  of  onset,  and  the  like  suflaciently  dis- 
tinguishes ataxic  paraplegia,  although  the  pathological  changes  in  the  two 
diseases  are  very  similar. 

In  disseminated  sclerosis  we  have  the  similar  symptoms,  nystagmus,  dis- 
turbance of  speech,  and  inco-ordination  of  muscles,  but  the  reflexes  are  ex- 
aggerated, the  progress  of  the  disease  is  more  rapid,  and  it  is  isolated,  not 
hereditary.     Besides,  the  utterance  is  quite  different  in  the  two  maladies. 

In  cerebellar  tumor  there  is  optic  neuritis,  headache,  vertigo,  vomiting, 
though  in  other  respects  there  may  at  times  be  considerable  similarity  of 
symptoms. 

Prognosis.  The  disease  is  progressive  and  incurable,  but  continues  often 
for  many  years  without  very  distressing  symptoms.  Death  usually  occurs 
from  intercurrent  disorders. 

Treatment.  Little  or  nothing  can  be  done  in  so  unfavorable  a  complaint. 
Arsenic  and  nitrate  of  silver  may  be  tried.  Electricity  may  be  helpful  at 
times,  and  injections  of  phosphate  of  soda  may  ameliorate  occasionally  some 
of  the  symptoms. 


COMBINED    SCLEROSIS. 

Ataxic  Paraplegia ;  Progressive  Spastic  Ataxia ;  Combined  Lateral  and 
Posterior  Sclerosis. 

In  this  disease  we  have  a  combination  of  lateral  sclerosis  (spastic  paraplegia) 
and  posterior  sclerosis  (ataxia),  to  which  the  name  ataxic  paraplegia  is 
therefore  properly  applied.  The  symptoms  accordingly  partake  more  or  less 
of  the  nature  of  locomotor  ataxia  and  of  primary  lateral  sclerosis,  sometimes 
more  akin  to  one  than  the  other,  but  always  affording  a  sufficiently  clear 
clinical  picture  to  distinguish  this  syndrome  from  either  of  the  others.  There 
are  occasional  irregular  forms  such  as  one  described  by  Putnam  and  Dana 
as  a  combined  sclerosis  with  terminal  softening. 

Etiology.  In  one-tenth  of  the  cases  there  is  a  neuropathic  hereditary  taint. 
Syphilis  is  very  rare  as  a  causative  factor.  It  is  more  common  in  males  than 
in  females.  It  is  a  disease  of  adult  life ;  overexertion,  exposure,  traumatism 
to  the  spine,  and  sexual' excess  have  been  described  as  antecedents  in  the 
history  of  this  disorder. 


DISEASES  OF  THE  SPINAL  CORD. 


649 


Fig.  220. 


Symptomatology.  The  malady  is  slow  iu  onset,  though  occasionally  a 
few  months  only  instead  of  a  few  years  are  required  for  the  manifestation 
of  the  typical  symptoms.  Either  ataxia  or  spastic  rigidity  of  the  lower  ex- 
tremities may  appear  first.  A  certain  amount 
of  paresis  will  be  found  on  examination  of 
the  legs.  There  is  a  sense  of  fatigue  after 
even  a  short  walk,  and  the  unsteadiness 
becomes  more  or  less  marked  on  walking 
with  the  eyes  closed  or  in  the  dark.  The 
Romberg  symptom,  or  "  tabetic  swaying,"  is 
present.  There  is  stiffness  of  the  legs,  so  that 
the  gait  seldom  resembles  the  high,  stepping 
movement  of  tabes.  There  may  be  dull  pain 
or  numbness  in  the  lower  extremities,  but 
almost  never  the  lightning  pains  of  locomotor 
ataxia.  On  the  other  hand,  dull  pain  in  the 
back  or  sacrum  is  common,  and  is  frequently 
an  early  symj)tom.  The  girdle  sensation  is 
very  exceptional.  There  is  no  anaesthesia  of 
the  extremities  or  trunk.  The  chief  differ- 
ence from  tabes  lies  in  the  exaggeration  of 
the  knee-jerks  and  the  usual  presence  of 
ankle-clonus.  The  knee-jerk  is  generally  so 
great  as  to  be  obtained  by  striking  the  top  of. 
the  patella  or  the  belly  of  the  quadriceps  ex- 
tensor. Often  the  arms  are  involved,  and  in 
such  cases  weakness,  inco-ordination,  and  ex- 
aggerated wrist  and  elbow-jerks  are  elicited. 
There  is  no  atrophy  of  muscles  anywhere. 

The  sphincters  of  the  bladder  and  rectum 
are  not  always  affected,  but  frequently  there 
is  difficult  micturition.  Sexual  power  is  often 
impaired  at  an  early  period. 

We  do  not  usually  find  the  Argyll-Rob- 
ertson pupil  in  this  malady,  but  occasionally  the  iris  reflex  is  lost  as  in  tabes. 
Atrophy  of  the  optic  nerve  is  extremely  rare,  and  the  ocular  muscles  do  not 
suffer.     The  mental  state  is  normal. 

With  the  progress  of  the  disorder,  the  muscular  paresis  and  rigidity  be- 
come more  marked,  and  the  inco-ordination  rather  less  noticeable,  so  that  the 
condition  is  very  similar  to  that  of  spastic  paraplegia.  The  patient  may 
become  bedridden  after  a  time,  but  the  progress  of  the  disease  extends  over 
a  period  of  j^ears  usually.  The  above-described  symptoms  are  those  of  a  typ- 
ical case,  but  slight  variations,  giving  a  nearer  resemblance  to  tabes,  some- 
times occur.     Visceral  crises  are  never  observed. 

Pathology  and  Pathological  Anatomy.  The  actual  cause  of  the  setting 
up  of  the  degenerative  process  is  unknown.  The  fact  that  the  posterior  and 
lateral  columns  both  are  involved  explains  the  peculiar  combination  of  symp- 
toms, some  belonging  to  tabes  and  some  to  primary  lateral  sclerosis. 

The  condition  of  the  posterior  columns  differs  slightly  from  that  in  tabes, 
in  that  the  lumbar  and  dorsal  portions  of  the  cord  may  suffer  equally,  or  the 
dorsal  even  more  than  the  lumbar ;  and  the  intensity  of  the  sclerosis  is  not 
apt  to  be  so  great  in  the  root-zone  of  the  postero-external  column  in  ataxic 
paraplegia. 

As  to  the  condition  of  the  lateral  columns,  while  the  pyramidal  tracts  are 
the  parts  chiefly  affected,  the  sclerotic  process  is  often  difilised  into  the  mixed 


Attitude  in  a  case  of  combined  sclerosis. 
(Philadelphia  Hospital.) 


650 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


zones  of  the  lateral  columns,  the  lateral  limiting  layers,  and  even  the  direct 
cerebellar  tracts.  The  direct  anterior  tracts  are  more  or  less  diseased  in 
nearly  all  cases. 

There  is  no  morbid  change  in  the  gray  matter  or  membranes  of  the  cord. 

Diagnosis.  There  should  be  no  difficulty  in  recognizing  the  nature  of  the 
malady  when  fully  developed.  We  must  remember  that  at  first  there  is 
ataxia,  and  that  the  spastic  condition  develops  later  on  in  its  course.    Hence 


Fig.  221. 


Fig.  222. 


Combined  sclerosis.    Mid-dorsal  region.  Combined  sclerosis.    Same  case  as  preceding 

and  from  a  lower  level  in  the  cord  (about  D 11  o 
12),  where  the  degeneration  is  more  extensive  in 
both  sets  of  columns. 

in  the  incipient  stage  a  possibility  of  its  being  tabes  is  to  be  borne  in  mind. 
The  exaggeration  instead  of  abolition  of  the  knee-jerk  will  exclude  this. 
The  inco-ordination  present  at  some  period  of  the  disorder  should  eliminate 
primary  lateral  sclerosis. 

If  we  recall  some  of  the  chief  symptoms  of  Friedreich's  ataxia,  such  as 
hereditary  or  family  character,  onset  in  early  youth,  loss  of  knee-jerk,  nys- 
tagmus, disordered  speech,  scoliosis,  and  clula-foot,  we  can  scarcely  confase 
this  disorder  with  the  one  under  consideration. 

In  cerebellar  heredo-ataxia  the  distinctive  symptoms  are  nystagmus,  Argyll- 
Robertson  pupils,  limitation  of  the  field  of  vision,  occasional  optic  atrophy, 
dyschromatopsia,  heredity,  and  disordered  speech. 

In  tumor  of  the  middle  lobe  of  the  cerebellum  there  is  sometimes  a  consid- 
erable gross  resemblance  to  ataxic  paraj)legia,  but  headaches,  vertigo,  vomit- 
ing, and  optic  neuritis  will  serve  us  in  the  diflferential  diagnosis  here. 

Some  cases  of  myelitis,  diffiise  or  local,  and  chronic,  may  simulate  closely 
ataxic  paraplegia  and  render  the  diagnosis  very  difficult.  In  myelitis  the 
course  of  the  disease  is  more  rapid  as  a  rule,  and  there  is  a  regressive  instead 
of  a  progressive  tendency. 

Prognosis.  The  chronic  course,  running  over  a  period  of  years,  with  occa- 
sionally arrest  of  the  disorder  for  a  time,  is  to  be  remembered.  Recovery 
never  takes  place.  Death,  as  a  result  of  intercurrent  aflTections,  or  from  sep- 
ticsemia  from  bed-sores,  or  from  renal  disease  due  to  overdistention  of  the 
bladder,  is  the  usual  termination. 

Treatment.  Warm  baths  and  residence  in  a  warm  climate  are  indicated 
for  the  relief  of  the  spastic  symptoms.  Where  there  is  a  specific  history  the 
iodides  and  mercurial  inunctions  should  be  used.  Electricity  is  of  no  ser- 
vice. Strychnine  or  nux  vomica  should  not  be  employed.  The  bromides  are 
occasionally  of  service  to  alleviate  trembling  and  twitching,  especially  at 
night.     Arsenious  acid  fnay  be  given  as  in  spastic  paraplegia. 


DISEASES  OF  THE  SPINAL  CORD.  651 


LESIONS  OF  THE  CONUS  MEDULLARIS. 

The  conus  medullaris,  or,  as  it  is  sometimes  called,  the  conus  termiualis,  is 
the  lowest  portion  of  the  spinal  cord,  lying  below  the  lumbar  enlargement. 
It  is  club-shaped.  From  it  passes  forth  the  long  narrow  prolongation 
known  as  the  filum  terminale. 

The  conus  medullaris  is  probably  the  true  spinal  centre  for  the  vesical  and 
anal  sphincters.  At  least,  that  seems  to  be  the  fact  from  the  results  of 
isolated  lesion  of  this  particular  part  of  the  cord.  Such  lesions  are  extremely 
rare,  for,  as  a  rule,  the  cauda  or  a  part  of  the  lumbar  enlargement  is  apt  to 
be  implicated  in  any  lesion  affecting  the  conus.  Disease  of  the  conus  alone 
would  therefore  involve  only  the  fimctions  of  the  bladder  and  rectum. 
There  would  be  no  disturbance  of  sensation  and  no  motor  disability. 

Some  of  the  cases  described  as  pure  conus  lesions  have  not  been  such  alto- 
gether. Thus,  a  case  of  Lachmann's,  frequently  referred  to  in  literature  as 
,  a  conus  lesion,  is  described  in  the  Arch,  fiir  Psych.,  vol.  xiii.  p.  50,  under 
the  title  of  "  Glioma  in  the  Upper  Part  of  Filum  Terminale  with  Isolated 
Compression  of  the  Nerves  of  the  Bladder"  (Gliom  im  obersten  theil  des 
Filum  terminale  mit  isolirte  Compression  der  Blasennerven).  The  case  was 
one  aged  forty-six  years,  with  difficult  urination  and  constipation  of  two  years' 
duration.  Upon  examination  there  were  found  retention  of  urine,  constipa- 
tion, exaggerated  knee-jerks,  occasional  fibrillary  twitchings  in  the  calf 
muscles,  and  lumbar  pain.  At  the  autopsy  the  dura  around  the  cauda  was 
distended.  The  conus  was  merged  into  a  tumor  6.5  c.cm.  long.  The  tumor 
did  not  include  the  nerves  of  the  cauda  and  did  not  extend  to  the  extreme 
end  of  the  filum  terminale.  There  were  no  changes  in  the  lumbar  or  dorsal 
portions  of  the  spinal  cord. 

A  case  reported  by  Oppenheim  {Arch,  fur  Psych.,  vol.  xx.  p.  298),  under 
the  title,  "  On  a  Traumatic  Lesion  Limited  to  the  Conus  Terminalis  of  the 
Spinal  Cord "  ( Ueber  eine  sich  auf  den  Conus  Terminalis  des  Ruckenmarhs 
beschrankende  traumatische  Erkrankung),  is  interesting.  It  was  as  follows  :  A 
man,  aged  twenty-four  years,  fell  from  a  height,  striking  upon  the  sacrum. 
He  was  unconscious  for  a  short  time.  For  a  brief  space  there  was  a  dead  feel- 
ing and  weakness  in  the  limbs  and  retention  of  urine ;  then  incontinence  of 
urine  and  feces,  which  persisted.  There  was  lack  of  power  of  erection  and 
soitie  loss  of  sensation  about  the  anus.  Upon  examination  there  were  found 
tenderness  and  gibbus  over  the  first  and  second  lumbar  vertebrae.  There  was 
no  paralysis  and  no  atrophy.  The  knee-jerks  were  active.  There  was  ankle- 
clonus.  Paralysis  of  the  bladder  and  rectum  was  complete.  There  was 
anaesthesia  about  the  anus,  over  the  nates  slightly,  in  the  perineo-scrotal  region, 
on  the  penis,  and  a  narrow  band  on  the  posterior  pai't  of  the  inner  surface  of 
the  thigh.  The  anaesthesia  was  to  all  kinds  of  sensation,  especially  for  pain. 
It  was  limited  above  by  a  line  drawn  across  the  middle  of  the  sacrum,  and 
externally  by  the  depression  between  the  tuber  ischii  and  trochanter  major. 
The  patient  died  three  and  one-half  months  later  from  cystitis  and  pyelo- 
nephritis. The  conus  medullaris  was  put  in  celloidin  and  cut  from  below 
upward.  In  the  lowest  part  the  whole  of  the  posterior  portion  was  de- 
stroyed. The  anterior  horns  and  anterior  horn  cells  and  pyramidal  tracts 
were  only  partially  injured.  These  changes  became  less  marked  in  the  sacral 
portion  of  the  cord,  and  in  the  lowest  lumbar  portion  there  was  only  an 
ascending  degeneration. 

It  is  seen  then  that  this  case  of  Oppenheim's  is  also  not  a  pure  conus  lesion, 
although  his  title  would  indicate  it.  His  pathological  description,  however, 
shows  the  involvement  of  other  parts  than  the  conus,  and  the  clinical  syn- 


652 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


drome  presented  evidence  of  disturbance  in   the  cauda  or  in  the  sacral 
cord. 

While  the  evidence  is  not  at  all  conclusive,  we  may  safely  assume  for  the 
present  the  truth  of  the  statements  made  above,  that  in  the  conns  medullaris 
lie  the  centres  for  the  bladder  and  rectum,  and  that  isolated  lesions  here  will 
cause  no  disturbance  of  sensation  or  motion. 


LESIONS  OF  THE  CAUDA  EQUINA. 

The  spinal  cord  terminates  in  the  spinal  canal  at  the  ujDper  level  of  the 
second  lumbar  vertebra.  The  lumbar  enlargement  of  the  cord  is  situated 
above  this  point.  From  this  lumbar  enlargement  spring  the  lumbar,  sacral, 
and  coccygeal  nerves  and  filum  terminale  which  enter  into  the  formation  of 
the  cauda  equina,  as  shown  in  Fig.  223.     The  spinal  canal  extends  some  nine 


Fig.  223. 


Fig.  224. 


Lumbar  enlargement  and  conus  with 
umbar  and  sacral  nerves  which  form 
the  Cauda  equina, 


Nerves  forming  cauda  equina  shown  heavily 
shaded .  Point  of  termination  of  cord  at  second 
lumbar  vertebra  shown. 


or  ten  inches  beyond  the  lower  end  of  the  cord,  and  this  space  is  filled  by  the 
long  nerve-roots  which  constitute  the  cauda  equina.  Fig.  224  gives  an  ade- 
quate idea  of  the  termination  of  the  cord  at  the  inferior  level  of  the  first 


DISEASES  OF  THE  SPINAL  CORD.  653 

lumbar  vertebra  and  of  the  occupation  of  the  rest  of  the  space  iu  the  spinal 
canal  by  the  nerves  springing  from  the  lumbar  intumescence  of  the  cord. 

The  Cauda  equina  tlius  contains  most  of  the  nerves  which  have  to  do  with 
the  motor,  sensory,  trophic,  and  reflex  functions  of  the  lower  extremities, 
bladder,  rectum,  and  genital  organs.  These  nerves  represent  the  fimctions  of 
the  segments  from  which  they  spring,  and  any  lesion  of  them  affects  the 
above-named  functions  in  the  same  manner  as  similar  lesions  in  the  spinal 
centres  of  the  corresponding  nerves. 

It  is,  therefore,  not  always  easy  to  dififerentiate  cauda  lesions  from  spinal 
cord  lesions.  A  study  of  the  aneesthetic  areas  helps  us  very  little  in  this  re- 
spect, since,  for  instance,  lesions  affecting  the  sacral  nerve  roots  produce  the 
same  areas  as  do  lesions  of  the  sacral  part  of  the  cord,  together  Avith  paral- 
ysis of  the  sphincters  of  the  bladder  and  rectum.  A  lack  of  symmetry  on 
the  two  sides  in  the  distribution  of  the  paralyses  and  of  the  anaesthesias 
would  be  strongly  presumptive  of  a  cauda  rather  than  of  a  cord  lesion.  An 
exceedingly  slow  and  irregular  development  of  the  symptoms  would  also  be 
suggestive  of  a  cauda  lesion.  The  fact  is  that  the  cauda  and  the  lower  part 
of  the  cord  are  often  involved  together  in  the  pathological  process.  We  owe 
a  great  deal  to  Thorburn,  Starr,  and  others  who  have  helped  to  elucidate  the 
clinical,  diagnostic,  and  pathological  features  of  such  lesions. 

It  has  been  demonstrated  that  pressure  on  the  cauda  equina  afiects  to  a 
greater  degree  the  nerves  in  the  middle  part  of  the  cauda  than  those  near  the 
surface  (Thorburn).  The  lower  nerve-roots  of  the  cauda  are  nearer  the 
middle  line  than  the  nerves  which  pass  out  above  them ;  and  when  pressure 
is  brought  to  bear  upon  the  cauda  the  nerves  which  pass  out  at  the  lower 
levels  are  apt  to  suffer  more  seriously  than  those  emerging  above  them.  So, 
too,  in  lesions,  such  as  hemorrhage  or  compression  from  fracture-dislocation, 
when  improvement  may  be  expected  to  take  place,  the  upper  roots  tend 
to  show  signs  of  betterment  soonest,  and  may  indeed  recover  completely, 
while  the  lower  ones  remain  as  before.  Pressure  upon  the  nerves  of  the 
cauda  is  often  sufficient  to  produce  widespread  paralysis  when  sensation  is 
but  slightly  affected  (Starr).  This  is  often  of  value  in  the  differential  diag- 
nosis, since  lesions  of  the- same  magnitude  in  the  lumbar  enlargement  of  the 
cord  would  produce  only  a  moderate  amount  of  paralysis  depending  upon 
the  segment  or  segments  involved.  (See  section  upon  the  Structure  and  Func- 
tions of  the  Spinal  Cord.) 

In  traumatic  conditions  the  external  evidence  of  fracture  or  dislocation 
below  the  first  lumbar  vertebra,  affecting  the  lumbar  or  sacral  portions  of 
the  spinal  column,  is  an  important  indication  of  the  involvement  of  the 
cauda  equina. 

Pain  and  tenderness  in  the  same  regions,  especially  the  sacral,  have  often 
been  noted  iu  cases  of  cauda  lesion.     This  is  particularly  true  of  neoplasms. 

In  cauda  lesions  the  sciatic  and  pudic  nerves,  and  sometimes  the  anterior 
crural  and  obturator,  are  prone  to  suffer  with  especial  frequency.  Whether 
the  degenerative  reaction  in  the  muscles  supplied  by  the  affected  nerves  will 
be  present  depends  naturally  upon  the  amount  of  damage  done  them,  which 
is  extremely  variable. 

As  to  the  reflexes,  the  knee-jerks  will  be  absent  if  the  nerves  to  the  anterior 
thigh  muscles  are  affected.  In  no  case  of  purely  cauda  lesion  will  they  be 
exaggerated.  The  plantar  reflexes  are  usually  absent.  The  extent  of  the 
lesion  in  the  cauda  equina  will  determine  to  what  degree  the  sphincters  are 
disturbed.  Disorder  of  the  mechanism  governing  the  sphincters  of  the  blad- 
der and  rectum  will  depend  upon  whether  their  particular  nerves  are  in- 
volved and  to  what  degree.  Urinary  retention  with  overflow  incontinence 
is  not  very  frequent,  and  when  it  does  exist  may  be  recovered  ft'om  as  pressure 


654  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

diminishes.  The  presence  of  complete  paralysis  of  the  bladder  and  rectum 
is  rather  suggestive  of  coincident  lesion  of  the  conus  medullaris. 

Bed-sores  and  sometimes  perforating  ulcers  have  been  noted  in  a  consider- 
able proportion  of  cases. 

In  addition  to  the  necessity  of  excluding  cord  lesions,  it  is  necessary  to  avoid 
confusion  with  peripheral  nerve  lesions,  such  as  multiple  neuritis  and  disorders 
of  the  lumbar  and  sacral  plexuses. 

Ordinary  multiple  neuritis  should  present  no  difficulty  in  the  way  of  dif- 
ferentiation, but  a  bilateral  lumbo-sacral  neuritis  may  offer  obstacles  to  diag- 
nosis for  some  time,  at  least  until  absolutely  characteristic  symptoms  have 
appeared. 

In  other  lumbo-sacral  plexus  lesions,  which  are  almost  always  entirely  uni- 
lateral, a  bilateral  manifestation  of  symptoms  should  favor  a  diagnosis  of 
Cauda  disorder,  though  in  some  very  rare  instances  an  involvement  of  the 
Cauda  upon  one  side  might  for  a  time  give  rise  to  confusion. 

Occasionally  a  lesion  of  the  cauda  (tumor)  may  for  a  time  simulate  loco- 
motor ataxia  by  presenting  some  of  the  symptoms  common  to  both,  viz. : 
loss  of  knee-jerks,  disorder  of  the  bladder  sphincter,  sharp  pains  radiating 
down  the  legs,  and  peculiarity  of  gait.  But  there  will  be  no  ataxia,  and  pu- 
pillary symptoms  will  be  wanting,  while  the  supervention  of  atrophies  and 
anaesthetic  areas  will  in  the  course  of  time  demonstrate  the  presence  of  a 
Cauda  lesion. 

The  most  common  of  all  pathological  processes  affecting  the  cauda  equina 
is  fracture-dislocation  of  the  lumbar  spine,  which  either  comiDresses  or  crushes 
the  nerve-roots,  or  both  ;  moderate  dislocation  of  the  vertebrae  may  cause  ht- 
tle  damage  because  of  the  large  size  of  this  portion  of  the  spinal  canal  and 
the  relatively  small  part  of  it  occupied  by  the  bundle  of  nerve-roots.  The 
symptoms  will  vary  with  the  extent  and  degree  of  the  injury. 

Hemorrhage  is  another,  though  infrequent,  lesion  of  the  cauda.  Caries  of 
the  lumbar  vertebrae  may  induce  compression  of  the  cauda. 

Rather  more  common  than  these  are  neoplasms.  Among  the  tumors  which 
have  been  described  as  developing  in  this  part  of  the  vertebral  canal  and 
affecting  the  cauda  equina  are  sarcoma,  fib ro-sar coma,  meningocele  in  spina 
bifida,  gumma,  cavernous  angioma,  and  multij^le  neuromata. 

The  chief  characteristics  of  tumor  comj)ression  of  the  cauda  equina  are 
slow  and  progressive  development  of  the  atrophic  paralyses,  reflex  disorders, 
and  anaesthesias  peculiar  to  the  region  ;  intense  and  increasing  sacral  pain  of 
a  radiating  character,  and  tenderness  often  very  marked  in  degree  on  the 
sacrum.  Sometimes  the  growth  of  the  neoplasm  may  be  temporarily  ar- 
rested, and  more  rarely  undergo  retrogression. 

From  a  study  of  the  above  facts  in  connection  with  the  section  on  Struc- 
ture and  Functions  of  the  Spinal  Cord  in  another  part  of  this  chapter  the  chief 
points  in  the  diagnosis  of  cauda  lesions  should  be  clear.  A  glance  at  the 
following  tabulation  of  a  few  of  the  noteworthy  cases  in  literature  may  also 
prove  useful : 


DISEASES  OF  THE  SPINAL  CORD. 


655 


Author. 


Thorbum, 


Thorbum, 


Reference. 


Nature  of 
lesion. 


Surgery  of  Dislocation 


Motor  symp- 
toms. 


Thorburn, 


Thorbum, 


Westphal, 


Starr  and 
Lloyd, 


Starr  and 
McBurney, 


Herter, 


Spinal  Cord 


Surgery  of 
Spinal  Cord 


Surgery  of 
Spinal  Cord 


Shaw  and 
Bush, 


1st  lumbar 
vertebra. 


Spina 
bifida. 


Fibro-sar- 
coma  of 
Cauda. 


Surgery  of  Dislocation 
Spinal  Cord  2d  lumbar 
vertebra. 


Char.  Ann. 
1.  421. 


Am.  Journ. 
Med.  Sci., 
civ.  p.  15. 


Am.  Journ. 
Med.  Sci , 
civ.  p.  15. 


Paralysis  of  all 

muscles  below 
knee;  weakness 

knee  flexors 
and  adductors, 
abductors,  and 

extensors  of 
thigh  ;  reaction 

degeneration. 

Atrophy  and 

paresis  of  legs 

below  knee ; 

pseudo-tabic 

gait;  occasional 

fibrillary 

twitchings 

and  choreiform 

movements. 

Wasting  and 

paresis  of 
lower  limbs. 


Paresis  lower 
extremities  ; 
paralysis  at 
ankle  and  foot 
atrophy  and 
degenerative 
reaction. 


Area  of  anesthesia.    1  gy^^ptoms .     Reflexes. 


Complete  anaesthesia  of  Retention 
back  of  thighs  and       of  urine 
lower  part  of  buttocks,  and  incon- 
of  outer  sides  of  legs  tinence  of 
and  of  the  feet;  also       feces. 
of  perineum,   penis, 
and  scrotum. 


Loss  sense  of  position      Difficult 
in  right  leg,  anses-      urination, 
thesia  over  buttocks,     sometimes 
backs  of  thighs,  backs     inconti- 
of  legs,  and  whole  of  i    nence  of 
feet,  also  inner  side  feces, 

thighs  and  legs  ;  and 
perineum,  scrotum, 
and  penis. 

AuEesthesia  same  dis- 
tribution as  last,  save 
that  inner  sides  of  feet 
escaped.    Sacral  pain. 


Gumma 
with  hem- 
orrhagic 
exudate. 

Fracture 

lumbar 

vertebrae. 


Fracture 

lumbar 

vertebrae. 


New  York  Old  hemor- 
Med.  Journ.:  rhage  and 
Aug.  22,     areas  of  in- 
1891.       flammatory 
material 
in  Cauda 
and  involv 
ing  Yi,  inch 
of  lower 
tip  of  cord 

Brit.  Med.  Old  hemor- 
Journ.,  vol.,  rhage  op- 


xi.  No.  41. 


posite  4th 
and  5th 
lumbar 
spines. 


Anaesthesia  over  lower, 
gluteal  regions,  down 
backs  of  thighs  to  soles 
of  feet  and  over  front 
of  legs  and  dorsum  of, 
feet:  genitals  includ-i 
ed. 


Difficult 
micturi- 
tion ;  con- 
stipation. 


Knee-jerks 

and  plantar 

reflexes 

absent. 


Knee-jerks 
and  plantar 
reflex  ab- 
sent ;   cre- 
masteric, 
abdominal, 
and  epi- 
gastric 
present. 

Knee-jerks 

active. 
plantar  and 
cremasteric 
exagger- 
ated. 

Knee-jerks 
and  plantar 
reflexes 
absent ; 
cremasteric 
and  gluteus 
exagger- 
ated. 


None. 


Anaesthesia  of  genitals,  'Paralysis  of 
perineum,  anus,  and  sphincters, 
buttocks. 


Atrophic  paral-  Saddle-shaped  anaes- 
ysisof  peronei,  thetic  area,  but  ex- 
ant,  and  post.  1  tending  down  right 
tibial  group,  leg  behind  in  a  nar- 
and  glutei  of  row  strip  to  sole  of 
right  leg.         foot. 

Atrophic  paral-  Almost  complete  loss 

ysisofall      |  of  sensation  over 
muscles  of  both    whole  of  both  legs, 
lower  extremi- 
ties. 

Atrophic  paral-  Ansesthesia  over  but- 
ysisof  both  legs   locks,  perineum,  geni- 

below  knees ;  '  tals,  and  extending 
thighs  could  be   slightly  down  backs 
moved.  of  thighs  ;  anaesthesia 

also  over  backs  of  both 
legs  from  half-way 
below  knees  down 
over  heels  and  soles. 


Atrophic  paral-  Anaesthesia  of  anus, 
ysisofham-      perineum,  buttocks, 
string,  pero-      back,  and  inner  sides 
neal,  calf,  and  ;  of  thighs,  popliteal 
tibial  muscles,    spaces,  calves,  lower 
parts,   front  of  legs, 
'  outer  side  left  leg,  en 
I  tire  feet  except  inner 
'  surfaces,  also  of  ure 
thra  and  rectum. 


Paralysis  of 
sphincters 


Paralysis  of 
sphincters 


Paralysis  of 
sphincters. 


Sphincters 
paralyzed . 


Lost  knee- 
jerks. 


Right  knee- 
jerk  normal 
left  active  ; 
plantar 
absent ; 
cremasteric 
present. 


Illustrated  cases  might  be  multiplied,  but  the  above  selected  at  random 
will  serve  to  emphasize  some  of  the  features  of  cauda  lesions  considered. 


656  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

Treatment.  Almost  all  of  these  cases  fall  as  regards  treatment  within  the 
province  of  the  surgeon.  There  are  few  cases  in  which  operations  to  relieve 
pressure  from  fracture  or  dislocation,  or  both,  or  to  remove  neoplasms,  are  not 
justifiable,  and  from  which  improvement,  or  rarely  recovery,  by  surgical  pro- 
cedure may  not  be  hoped  for.  There  have  already  been  a  sufficient  number 
of  operations  undertaken  for  this  purpose  to  demonstrate  the  truth  of  this 
statement. 

The  cause  having  been  removed,  the  general  treatment  should  be  conducted 
on  the  same  principles  as  guide  us  in  the  management  of  sensory  disturb- 
ances, atrophic  paralysis,  and  sphincter  disorders  from  lesions  elsewhere. 
The  use  of  the  faradic  brush  for  ansesthesias,  and  of  both  faradism  and  gal- 
vanism for  the  wasted  and  paralyzed  muscles,  is  indicated ;  massage,  active 
and  passive  movements,  and  hydriatric  applications  are  of  service.  General 
tonics,  such  as  arsenic,  iron,  and  strychnine,  should  be  employed. 


CHAPTER  XXI. 


BULBAR  PALSY. 


By  FKEDERICK  PETEESON,  M.D. 


Bulbar  Palsy  is  an  associated  paralysis  and  wasting  of  muscles  of  the 
lips,  tongue,  fauces,  and  pharynx,  due  to  disease  in  the  "  bulb,"  or  medulla 
oblongata,  of  the  nuclei  of  nerves  supplying  these  parts. 

Usually  the  process  is  a  chronic  degenerative  one,  corresponding  to  that  in 
the  ganglion  cells  of  the  anterior  cornua  of  the  spinal  cord.  There  are  cases, 
however,  in  which  the  onset  is  acute,  either  apo23lectiform  in  character 
(softening)  or  inflammatory.  The  symptoms  are  closely  simulated  at  times 
by  bilateral  cerebral  softening,  and  cases  very  like  bulbar  palsy  have  been 
reported  where  the  lesion  existed  in  but  one  of  the  hemispheres  (pseudo- 
bulbar paralysis). 

The  nerves  affected  by  the  disease  are  some  of  the  facial  fibres  (orbicularis 
oris),  the  hypoglossal  (tongue),  spinal  accessory  (larynx  and  palate),  glosso- 
pharyngeal, and  vagus  (pharynx). 


CHRONIC  BULBAR  PALSY. 

Etiology.     The  disease  in  most  cases  manifests  itself  after  the  age  of  forty 
years,  though  cases  have  been  reported  at  a  much  earlier  period  of  life,  even 


Fig.  225. 


MEDULLA 


Schematic  representation  of  bulbar  nuclei  involved  in  bulbar  palsy. 

in  childhood.  It  is  more  frequent  in  men  than  in  women.  Some  direct  or 
indirect  neurotic  heredity  is  sometimes  to  be  traced,  and  a  family  predis- 
position has  been  noted  in  cases  occurring  in  early  life.      Mental  strain, 

42 


658  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

exposure,  overuse  of  muscles  (observed  by  Stein  in  a  clarionet  player, 
and  by  the  writer  in  a  cornet  player),  lead,  perhaps  syphilis,  are  among 
probable  causes.  Elsewhere  is  mentioned  its  development  as  a  part  of  a 
progressive  muscular  atrophy.  Gowers  relates  a  case  developing  as  a  sequel 
to  dij)htheria. 

Symptomatology.  The  disease  is  very  slow  in  its  onset,  and  usually  the 
first  indication  of  any  trouble  is  a  weakness  of  the  tongue,  rendering  the 
pronunciation  of  lingual  and  linguo-palatine  consonants,  cl,  I,  r,  n,  t,  difficult. 
The  articulation  of  these  letters  at  first  becomes  indistinct  only  after  fatigue 
of  the  muscles,  but  later  on  is  noticeable  at  all  times.  Occasionally  some 
pain  in  the  back  of  the  head  has  been  complained  of  antecedent  to  the 
change  in  si:)eech.  Following  closely  upon  the  weakness  of  the  tongue,  the 
lips  begin  to  lose  power,  and  the  letters  o,  u,  j),  b,  and  m  become  difficult  to 
enunciate  distinctly.  The  patient  cannot  whistle.  Coincident  with  this,  or 
more  often  following  this,  there  is  some  trouble  in  swallowing.  The  patient 
begins  to  drool.  The  palate  grows  weak,  increasing  the  difficulty  of  speech, 
giving  the  voice  a  nasal  sound,  and  allowing  liquids  to  regurgitate  through 
the  nares  in  attempting  to  swallow. 

The  tongue  can  no  longer  be  thrust  forward,  and  becomes  more  or  less 
atrophied  and  rugose.  The  mouth  remains  open.  Other  muscles  about  the 
mouth  besides  the  orbicularis  oris  may  sufier.  As  a  rule,,  the  zygomatici 
escape,  and,  by  contracture,  deepen  the  naso-labial  folds.  It  becomes  impos- 
sible to  understand  any  words  the  patient  attempts  to  utter.  The  muscles  of 
the  vocal  cords  are  the  next  to  suffer.  Swallowing  becomes  more  and  more 
difficult.  Solids  cannot  be  taken  at  all,  and  are  apt  to  get  into  the  larynx. 
Liquids  run  out  of  the  mouth  and  nose.  Hence,  semi-solids  are  best  taken. 
The  face  of  the  patient  takes  on  a  look  of  great  distress  that  is  very  charac- 
teristic. Sensibility  is  nowhere  lost,  though  the  pharyngeal  reflex  disappears. 
As  in  the  tongue,  atrophy  may  be  noted  in  the  lips,  and  an  electrical  reaction 
of  degeneration  may  be  at  times  found.  Sometimes  there  is  a  marked  gross 
tremor  (not  fine  as  in  general  paresis)  in  attempting  to  speak.  Occasionally 
a  markedly  increased  jaw-jerk,  or  even  jaw-clonus,  is  observed.  The  mind 
is  not  affected,  but  the  patient  may  be  very  emotional.  Frequency  of  the 
pulse  has  been  observed  in  some  cases,  especially  in  the  later  stages. 

The  disease  is  found  associated  with  progressive  muscular  atrophy  and 
amyotrophic  lateral  sclerosis,  and  even  lateral  sclerosis,  in  their  later  stages, 
and  occasionally  it  is  noted  in  combination  with  ophthalmoplegia. 

Course  of  the  Disease.  The  malady  is  gradually  progressive,  though  an 
arrest  of  its  progress  for  weeks  or  months  may  take  place.  It  usually  lasts 
for  from  two  to  four  years.  Patients  are  apt  to  emaciate  from  lack  of  suffi- 
cient nourishment,  and  inanition  is  a  common  cause  of  death.  Pneumonia 
is  often  set  up  by  particles  of  food  slipping  into  the  air-passages  (Sehhiek 
pneumonie). 

Pathology  and  Morbid  Anatomy.  As  in  other  degenerations  of  the  ner- 
vous system,  the  actual  cause  of  this  pai'ticular  manifestation  of  disease  is 
unknown.  It  is  probable  that  some  toxic  condition  of  the  blood  has  an 
elective  affinity  for  these  particular  groups  of  cells,  which  are  functionally 
associated,  and  which  have,  therefore,  a  similar  constitution  and  vulnera- 
bility. The  morbid  process  is  essentially  the  same  as  that  affecting  homolo- 
gous structures  elsewhere  (as  in  progressive  muscular  atrophy). 

To  the  naked  eye  the  medulla  appears  to  be  normal,  but  upon  microscopical 
examination  characteristic  changes  are  found  in  the  nuclei  of  the  nerves 
mentioned  and  in  the  fibres  passing  off  from  them  within  the  medulla.  The 
nerve-cells  are  shrunken  and  lose  their  processes,  and  granule-corpuscles, 
together  with  other  degenerative  elements,  ax'e  found  in  the  interstitial  tissue. 


BULBAR  PALSY.  659 

Sometimes  the  vascular  walls  are  thickened  and  the  connective  tissue  in- 
creased. While  such  nuclear  changes  are  observed  in  a  typical  case,  there 
are  many  variations  from  this  typical  picture  in  the  degree  of  degeneration 
and  character  of  changes.  It  has  been  suggested,  indeed,  that  there  are 
parenchymatous  and  interstitial  forms  of  bulbar  palsy.  The  most  marked 
alterations  are  noted  in  the  nuclei  of  the  hypoglossal,  glosso-pharyngeal, 
spinal  accessory,  and  vagus  nerves.  Besides  these  nuclei,  some  of  the  cells 
of  the  facial  nerve  and  those  of  the  nucleus  ambiguus  may  be  affected,  rarely 
the  nucleus  of  the  fifth  nerve.  Degeneration  is  often  to  be  seen  in  the  ante- 
rior pyramids.  When  bulbar  paralysis  is  associated  with  any  of  the  spinal- 
cord  diseases  already  mentioned,  or  with  ophthalmoplegia,  we  discover  in 
addition  atrophic  processes  in  the  cells  of  the  cord  and  in  the  oculomotor 
nuclei.  Degeneration  of  fibres  in  the  raphe  in  the  loop  of  the  facial  nerve, 
and  in  the  posterior  longitudinal  fibres,  has  been  noted.  The  involvement 
of  the  orbicularis  oris  is  not  yet  clearly  understood,  though  it  is  believed  that 
orbicularis  fibres  may  descend  to  or  even  originate  in  the  hypoglossal  nucleus. 
The  close  functional  relation  of  the  tongue  and  lip  movements  would  suppose 
some  close  central  anatomical  relation.  Degeneration  of  the  anterior  pyra- 
mids in  the  pons  and  crura  has  also  been  observed.  The  motor  nerve-trunks 
degenerate  and  are  gray  and  softened.  The  nerve-endings  in  the  muscles  are 
degenerated.  As  far  as  the  muscles  are  concerned,  there  is  found  in  a  typical 
atrophic  case  the  same  pathological  changes  as  in  muscles  in  a  progressive 
muscular  atrophy  of  the  Aran-Duchenne  type.  The  fibres  become  narrowed 
and  granular  or  fatty,  and  ultimately  disappear  from  the  sarcolemma  sheaths. 
The  interstitial  tissue  increases,  the  nuclei  of  the  sheaths  are  multiplied,  and 
there  may  be  fatty  infiltration  and  red-pigment  deposits  between  them. 

Duchenne  described  two  forms  of  bulbar  palsy,  a  paralytic  and  an  atro- 
j)hic.  In  the  former  class  the  wasting  in  the  lips  and  tongue  is  not  noticeable 
and  the  jaw-jerk  is  increased,  so  that  sometimes  even  a  jaw-clonus  may  be 
obtained,  and  in  such  cases  there  is  slight  or  no  degeneration  in  the  nuclei, 
but  marked  changes  in  the  supra- nuclear  tracts  leading  to  the  cortex.  In 
the  atrophic  variety  we  have  the  marked  degeneration  in  the  nuclei  and 
infra-nuclear  fibres  leading  to  the  muscles. 

Diagnosis.  Chronic  bulbar  palsy  is  to  be  distinguished  from  the  acute 
form  (polioencephalitis  inferior,  hemorrhage,  softening)  and  from  bulbar 
tumors,  multiple  sclerosis,  and  pseudo-bulbar  paralysis.  From  the  acute 
variety  the  slow  and  gradual  onset  is  sufficient  to  differentiate  this  form.  It 
is  different,  however,  with  bulbar  tumors,  which  also  run  a  chronic  course, 
but  these  almost  always  present  unilateral  symptoms,  whereas  in  bulbar  palsy 
the  manifestations  are  always  bilateral.  Then,  too,  with  tumor  we  have 
headache  and  sometimes  convulsion.  Multiple  sclerosis,  while  it  may  simu- 
late by  involvement  of  the  medulla  some  of  the  symptoms  of  bulbar  paralysis, 
is  also  apt  to  be  unsymmetrical  in  its  distribution  and  to  present  other  signs 
sufficiently  marked  to  establish  the  correct  diagnosis. 

Pseudo-bulbar  paralysis  has  been  caused  by  sclerosis  and  by  acute  lesions 
(hemorrhage,  thrombosis)  affecting  the  two  hemispheres.  The  lesion  in  such 
cases  tends  to  be  first  on  one  side  and  then  on  the  other,  and  here,  too,  other 
symptoms  (hemiplegia,  diplegia,  and  the  like)  aid  in  the  differentiation. 

Prognosis.  The  disease  is  serious  in  the  extreme,  and  almost  invariably 
leads  to  death.  It  is  possible  that  in  some  excessively  rare  cases  the  progress 
of  the  malady  may  be  arrested  wholly  or  for  a  long  period. 

Treatment.  Although  little  can  be  anticipated  from  any  means  of  treat- 
ment at  present  known  to  us,  efforts  should  be  made  to  alleviate  some  of 
the  symptoms,  and  some  hope  may  be  entertained  in  any  case  of  a  possible 
arrest  of  the  progress  of  the  disorder.     As  to  general  measures,  the  patient 


660  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

should  avoid  overexertion  of  any  kind,  be  well-fed,  and  receive  massage 
and  electricity.  The  last  does  not,  offer  much  encouragement ;  but  cases 
do  occasionally  reveal  improvement  in  the  use  of  some  of  the  muscles  after 
its  employment.  As  the  muscles  respond  to  both  galvanism  and  faradism, 
it  is  well  to  make  use  of  both  currents  in  moderation  two  or  three  times 
weekly,  fifteen-minute  seances,  the  currents  being  applied  with  a  proper  elec- 
trode to  the  lips,  tongue,  and  pharynx.  There  is  a  reflex  centre  for  swallow- 
ing immediately  over  the  pomum  Adami,  which  is  easily  excited  by  the 
cathode  employed  with  an  interrupting  handle,  the  anode  being  placed  at 
any  indifferent  spot,  preferably  the  back  of  the  neck.  This  reflex  degluti- 
tion should  not  be  repeated  so  often  as  to  cause  great  fatigue. 

As  to  drugs,  various  nerve  tonics  may  be  exhibited.  Hypodermic  injec- 
tions of  strychnine  (gr.  gig-)  are  useful.  Arsenic,  phosphorus,  quinine,  and 
nitrate  of  silver  may  be  given  with  some  little  benefit.  For  the  drooling  of 
saliva  atropine  (gr.  y^-Q  to  -g-'^)  may  be  administered,  either  by  mouth  or  hypo- 
dermically,  twice  daily.  Stimulant  doses  of  morphine  (gr.  -^^  to  ■^)  sub- 
cutaneously  have  occasionally  good  effect. 

The  care  of  the  nutrition  of  the  patient,  which  is  so  apt  to  suffer,  is 
important.  The  food  must  be  given  in  a  pulpy  or  semi-solid  state,  and  when 
swallowing  becomes  so  difficult  as  to  become  dangerous,  the  soft-rubber  nasal 
or  stomach-tube  with  funnel  must  be  made  use  of  and  the  patient  given  twice 
daily  a  liquid  mixture  of  milk,  raw  eggs,  whiskey  or  brandy  if  indicated, 
and  meat  juice.  Peptonized  foods  per  rectum  may  be  employed  instead  of 
the  stomach  feeding,  but  is  not  as  efficient. 


ACUTE  BULBAR  PALSY. 

It  would  perhaps  be  well,  as  has  been  suggested,  to  use  the  term  "  acute 
bulbar  palsy  "  only  for  such  cases  as  are  due  to  an  acute  inflammatory  change 
in  the  bulbar  nuclei — polioencephahtis  inferior  acuta  in  contradistinction  to 
polioencephalitis  inferior  chronica — but  clinically  this  active  inflammation  is 
generally  difficult  to  separate  from  other  forms  of  bulbar  paralysis  charac- 
terized by  sudden  onset  (the  apoplectiform  variety).  The  chief  distinction 
is  in  the  symmetrical  bilateral  character  of  the  symptoms  ;  in  the  apoplecti- 
form cases  it  is  the  rule  to  discover  irregularity  of  distribution  of  the  palsies, 
as  well  as  a  wider  range  of  symptoms,  such  as  weakness  and  j)arsesthesi0e  of 
the  extremities.  Thrombosis  of  a  vertebral  artery,  rarely  embolism,  is  the 
most  frequent  cause.  The  chief  difficulty  in  diagnosis  of  the  apoplectiform 
cases  hes  in  the  close  resemblance  to  pseudo-bulbar  paralysis ;  but  a  history 
of  two  distinct  cerebral  attacks,  one  on  each  side,  should  be  looked  for. 

These  cases  are  gravest  at  their  onset,  when  a  fatal  result  commonly  occurs 
within  a  short  time.  The  acute  stage  safely  passed,  there  is  amelioration  of 
some  of  the  symptoms,  but  degenerations  take  place  to  a  certain  degree  at 
times,  and  the  case  comes  to  resemble  the  chronic  form.  Occasionally  great 
improvement,  and  even  recovery,  takes  j)lace  in  apoplectiform  cases.  The 
prognosis  is  thus  much  better  than  in  the  chronic  form. 

As  regards  treatment,  the  apoplectiform  variety  should  be  cared  for  on  the 
general  principles  laid  down  for  acute  softening  in  other  parts  of  the  brain ; 
and  the  inflammatory  group  should  be  treated  as  are  other  cerebral  inflam- 
mations. In  the  chronic  conditions  we  employ  much  the  same  methods  as 
were  discussed  above  in  the  treatment  of  the  chronic  degenerative  type  of 
bulbar  paralysis. 


CHAPTER   XXII. 
MULTIPLE  CEREBRO-SPINAL  SCLEROSIS. 

By  FREDERICK  PETERSON,  M.D. 

Multiple  sclerosis  is  one  of  the  chronic  degenerative  nervous  diseases 
in  which  the  sclerotic  process,  instead  of  being  limited  to  certain  systems  in 
the  central  nervous  structures,  is  disseminated  irregularly,  in  small  patches 
or  plaques,  throughout  the  brain  or  spinal  cord,  and  which  is  characterized 
by  paralysis,  spastic  rigidity,  tremor,  peculiar  disturbance  of  speech,  nystag- 
mus, and  other  symptoms,  varying  considerably  according  to  the  location  of 
the  sclerotic  patches.  The  disease  is  more  common  than  lateral  or  amyo- 
trophic sclerosis.  The  pathological  anatomy  of  the  disease  is  thoroughly 
understood,  although  the  actual  cause  of  the  sclerotic  changes  is  as  myste- 
rious as  in  the  other  chronic  degenerative  disorders  of  the  central  nervous 
system.  Three  different  groups,  owing  to  the  variability  of  the  symptoms, 
have  been  made,  and  these  are  cerebral,  spinal,  and  cerebro-spinal.  The 
perfect  type  of  multiple  sclerosis  is  that  in  which  the  islets  of  the  sclerosis 
are  found  both  in  the  brain  and  sjDinal  cord.  Sometimes  these  types  merge 
into  one  another ;  thus,  a  case  of  my  own,  which  for  three  or  four  years  was 
a  perfectly  tyj^ical  one  of  lateral  sclerosis,  gradually  became  a  typical  cere- 
bro-spinal disseminated  sclerosis.  Owing  to  the  protean  nature  of  the 
symptoms,  depending,  as  they  do,  upon  the  localization  of  the  patches  in 
various  parts  of  the  central  nervous  system,  mistakes  in  diagnosis  are  quite 
frequent,  and  other  disorders  are  sometimes  mistaken  for  multiple  sclerosis. 

Etiology.  Both  sexes  are  equally  liable  to  this  disease.  As  regards  age, 
most  cases  are  found  in  the  early  half  of  life,  but  the  disorder  may  be  ob- 
served at  any  age  from  childhood  to  senility.  Hereditary  influences  play 
but  a  small  part,  though  we  may  frequently  trace  an  inherited  neuropathic 
constitution. 

The  exciting  causes  are  often  difiicult  to  discover,  and  perhaps,  in  the 
majority  of  cases,  no  exciting  cause  will  be  found.  The  disease  has  been 
ascribed  to  exposure,  overwork,  mental  strain,  traumatic  lesion  of  the  cen- 
tral ner  vous  system,  and  to  acute,  infectious  diseases,  such  as  typhoid  fever, 
diphtheria,  smallpox,  measles,  and  erysipelas.  In  some  cases  it  has  been 
believed  to  have  developed  after  some  acute  or  subacute  inflammation  in  the 
central  nervous  system,  such  as  myelitis.  Syphilis  seems  to  have  little  or  no 
part  in  its  etiology. 

Symptomatology  and  Course.  Owing  to  the  wide  difilxsion  of  the  patches 
of  sclerosis  throughout  the  central  nervous  system,  we  are  certain  to  have 
islets  somewhere  in  the  motor  tract  in  almost  every  case,  and  consequently 
we  have  some  loss  of  power  in  one  or  more  limbs,  sometimes  in  all  of  the 
extremities.     This  amounts,  usually,  to  a  paresis,  and  not  a  paralysis. 

Another  very  characteristic  motor  symptom  is  tremor  of  wide  excursion, 
characterized  by  its  development  on  intended  movements  only,  and  there- 
fore called  "  intention  tremor."  It  is  not  present  when  the  parts  are  at 
rest,  although  occasionally,  when  it  exists  in  the  neck  muscles,  the  head  may 


662  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

show  a  marked  tremor  whenever  the  patient  is  erect  or  sitting  up.  In  the 
legs  there  is  seldom  any  particular  tremor,  although  ataxia  may  be  present, 
but  usually  we  have  a  spastic  paraplegia,  so  that  the  patient's  gait  is  spastic 
and  paretic. 

Nystagmus  is  so  common  as  to  constitute  one  of  the  cardinal  symptoms, 
and  should  be  looked  for  in  all  cases.  Usually  this  nystagmus  is  developed 
only  on  movement  of  the  eyes.  Nystagmus  when  the  eyes  are  at  rest  is 
rather  uncommon.  It  is  generally  a  vertical  nystagmus,  or  lateral,  more  sel- 
dom rotatory.  Occasionally  there  are  paralyses  of  cranial  nerves.  There 
is  a  peculiar  disturbance  of  speech  in  most  cases,  the  syllables  of  words  being 
articulated  separately,  and  sometimes  in  a  peculiar  accentuated  manner, 
which  has  given  rise  to  the  term,  staccato  utterance.  The  words  "  syllabic," 
or  "scanning,"  are  also  used  to  qualify  the  articulation.  At  times  there  are 
attacks  of  vertigo  or  epileptiform  or  apoplectiform  seizures.  Sensory  symp- 
toms are  occasionally  present.  It  is  not  uncommon  to  note  some  slight  dul- 
ness  of  the  mind  as  the  result  of  the  disease,  usually  accompanied  by  a  mor- 
bid j)lacidity  or  complacency,  quite  out  of  proportion  to  the  seriousness  of 
the  malady. 

These  are  the  chief  features,  and  most  of  them  are  present  in  a  typical 
case  of  multiple  sclerosis.  It  may  be  well  to  enumerate  again  briefly  these 
cardinal  symptoms : 

1.  A  muscular  weakness,  with  rigidity,  taking  a  hemiplegic,  paraplegic, 
or  monoplegic  form,  sometimes  with  cranial  nerve  paralysis. 

2.  "  Intention  tremor." 

3.  Exaggerated  knee-jerks,  wrist-jerks,  with  ankle-clonus,  possibly  jaw- 
jerk. 

4.  Nystagmus. 

5.  Various  symptoms  of  nervous  disturbances,  like  vertigo,  headache,  epi- 
leptiform and  apoplectiform  attacks,  and  mental  dulness. 

6.  Disorder  of  speech. 

These  symptoms  may  gradually  appear  coincidently,  or  any  one  of  them 
may  precede  the  others,  depending  altogether  upon  the  great  variability 
in  the  mode  of  onset,  and  in  the  localization  of  the  first  patches  of  sclerosis. 
As  a  rule,  the  weakness  and  rigidity  in  the  limbs  appear  before  other 
symptoms.  The  jerky  "intention  tremor"  is  supposed  to  be  due  to  resist- 
ance to  conduction  in  nerve-fibres  traversing  the  sclerosed  patch.  Occasion- 
ally this  same  sort  of  tremor  is  found  in  some  cases  of  tumor  of  the  brain, 
interfering  with  conduction  in  the  motor  path.  Some  authorities,  however, 
believe,  that  it  is  necessary  that  the  islets  of  disease  should  exist  in  some 
particular  position,  as  in  the  pons,  for  instance,  in  order  to  afiect  the  co-ordi- 
nation of  the  muscles.  We  find  cases,  at  times,  which  simulate  very  closely 
tabes,  owing  to  the  existence  of  a  patch  of  sclerosis  in  the  posterior  columns. 
Sometimes  the  spastic  condition  of  the  legs  is  such  that  flexor  contracture 
may  take  place,  and  the  legs  be  drawn  up  permanently,  but  it  is  more  com- 
mon to  have  an  extensor  spasm.  Muscular  wasting  is  very  uncommon,  but 
it  may  occur  from  the  sclerotic  process  affecting  the  gray  matter  of  the  ante- 
rior horns  in  some  particular  segment.  The  atrophy  would  then  be  local 
and  irregular,  depending  upon  the  particular  segment  in  which  the  lesion 
occurred.  Sensibility  varies  to  a  great  extent,  according  to  the  localization 
of  the  lesion.  There  may  be  hemianesthesia  from  invasion  of  the  sensory  path 
in  the  brain  by  a  patch  of  sclerosis,  or  the  anaesthesia  may  be  a  small  patch  on 
one  limb.  When  the  disease  has  invaded  the  cord  very  generally  there  is 
apt  to  be  considerable  loss  of  sensibility  in  the  legs.  Paraesthesias  are  more 
common ;  feelings  of  numbness  or  prickling  and  tingling  in  the  hands  and 
feet ;  dull  aching  pains  in  the  limbs,  and  in  the  back  sharp  shooting  pains ; 


MULTIPLE  CEREBROSPINAL  SCLEROSIS.  663 

the  girdle  pain  may  occasionally  be  present  also.  Among  the  eye  symptoms, 
in  addition  to  nystagmus,  we  have  other  disturbances,  such  as  impairment  of 
sight  in  one  or  both  eyes,  or  contraction  of  the  field  of  vision,  due  to  sclero- 
tic processes  occurring  in  the  optic  nerve  of  the  chiasm.  Sometimes  com- 
plete blindness  occurs  in  one  eye  ;  after  a  time  atrophy  of  the  optic  nerves  takes 
place,  and  can  be  observed  with  an  ophthalmoscope.  The  Argyll-Robertson 
pupil  is  very  rarely  found  in  multiple  sclerosis.  External  palsies  of  the  eye 
are  not  uncommon,  the  lesions  affecting  the  external  recti,  the  converging 
muscles,  and  the  superior  rectus  sometimes,  but  very  rarely  a  single  whole 
nerve,  like  the  third ;  occasionally  transient  diplopia  is  met  with,  as  in  tabes. 
Among  the  other  cranial  nerves  which  may  suffer  from  the  disease  are  the 
seventh  and  fifth  and  hypoglossal.  In  some  very  rare  cases  there  have  been 
trophic  disturbances,  such  as  local  oedema,  changes  in  the  growth  of  the  hair 
and  nails,  arthritic  troubles,  and  herpes. 

Atypical  Forms  of  Multiple  Sclerosis.  Sometimes  the  sclerotic 
patches  are  so  few  and  so  uniquely  placed  that  they  give  rise  to  very  unu- 
sual forms  of  multiple  sclerosis.  Occasionally,  for  instance,  the  lateral  col- 
umns of  the  cord  may  be  first  affected  for  a  year  or  two,  making  a  condi- 
tion simulating  that  of  a  primary  lateral  sclerosis.  Sometimes  a  single 
island  of  sclerosis  in  the  brain  may  give  rise  to  a  mono-  or  hemiiDlegia ; 
for  example  in  a  case  under  my  observation  there  is  a  monoplegia  of  the 
right  arm,  with  typical  rigidity  and  tremor,  exaggerated  reflexes,  and  so 
on,  which  have  existed  for  several  years,  yet  other  symptoms  have  not  devel- 
oped to  the  present  time.  Distinctively  spinal  and  cerebral  forms  of 
multiple  sclerosis  have  been  described.  The  condition  known  as  "difiuse 
sclerosis "  is  one  in  which  the  connective-tissue  elements  are  increased  in 
large  portions  of  the  brain  or  cord,  and  not  in  small  patches,  as  in  the  dis- 
seminated form  which  we  have  been  considering.  The  difilise  sclerosis  may 
involve  any  part  of  the  cerebrum  or  cerebellum ;  may  involve  any  portion 
of  the  white  substance  or  the  cortex,  or  a  part  or  whole  of  the  hemisphere, 
or  both  hemispheres.  Sometimes  this  is  associated  with  a  diminution  in  the 
size  of  the  parts  affected,  so  that  an  atrophic  sclerosis  is  spoken  of.  This 
sclerotic  process  is  quite  common  in  the  brains  of  cases  which  have  suffered 
from  infantile  cerebral  palsy,  and,  undoubtedly,  in  most  of  these  cases,  the 
condition  is  due  to  antecedent  meningeal  hemorrhage,  but  embolism,  throm- 

FlG.  226. 


Multiple  sclerosis.    Section  through  crus.    Unstained  portions  show  distribution  of  sclerotic  tissue, 

Weigert  stain. 

bosis,  possibly  acute  encephahtis,  may  give  rise  to  the  same  condition.  It  is 
sometimes  found  as  a  result  of  congenital  syphilis,  and  a  difliise  sclerosis  has 
been  observed  after  long  indulgence  in  alcohol.     In  many  cases  of  idiocy 


664 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


diffuse  sclerosis  has  been  found.  Miliary  sclerosis  is  a  term  that  has  been 
applied  to  minute  patches  of  degeneration  scattered  throughout  the  nervous 
system,  and  almost  microscopic  in  character. 

Pathology.  Multiple  sclerosis  of  the  brain  and  spinal  cord  is  one  of  the  most 
striking  pathological  conditions  to  be  observed  in  the  central  nervous  system. 
On  cutting  into  the  parts,  the  grayish  patches  are  visible  to  the  naked  eye 

Fig.  227. 


Multiple  sclerosis.    Section  at  mid-pontile  region  in  same  case  as  Fig.  226.    Weigert  stain. 

in  striking  contrast  to  the  tissues  around  them.  They  vary  in  size,  from  a 
line,  or  less,  to  an  inch  in  diameter.  Their  consistence  is  firmer  than  that  of 
the  rest  of  the  brain.  It  is  impossible  to  understand  what  is  the  actual 
cause  of  the  formation  of  these  nodules  of  sclerotic  tissue.  It  is  strongly 
suggestive  of  the  presence  of  some  irritant  or  toxine  in  the  blood,  which 
stimulates  the  overgrowth  of  connective  tissue  about  the  smaller  vessels. 
Under  the  microscope,  we  find  the  islets  to  be  composed  of  fibrous  tissue, 

Fig.  228. 


Multiple  sclerosis.    Section  at  level  of  sixth  and  seventh  nerves.    Weigert  stain. 


which,  gradually  encroaching  upon  the  nerve  substance  about  them,  cause 
wasting  of  the  white  substance  of  the  fibres,  though  often  the  axis-cylinders 
can  be  observed  penetrating  the  sclerotic  patches.  The  bloodvessels  in  con- 
nection with  these  areas  are  thickened,  as  a  rule,  and  there  is  nearly  always 
a  particular  increase  of  connective  tissue  nearest  to  the  vessels.  While  the 
system  degenerations  of  the  spinal  coi'd  are  quite  different  from  the  dissem- 
inated variety  of  sclerosis,  they  are  not  infrequently  found  associated  to- 
gether in  the  same  subject,  and  it  is  possible  that  they  have,  as  their  basis,  a 
similar  pathology.     More  than  one  observer  has  noted  a  resemblance  be- 


MULTIPLE  CEREBROSPINAL  SCLEROSIS. 


665 


tween  a  difflise  cerebro-spinal  syphilis  aud  a  disseminated  sclerosis,  as  regards 
the  character  and  distribution  of  the  process,  and  this  is  also  suggestive  of 
an  analogy  in  etiology. 

Fig.  229. 


Multiple  sclerosis.    Section  at  upper  level  of  motor  decussation.    Pals's  method. 

Fig.  230. 


Multiple  sclerosis.    Section  of  medulla  at  level  of  teuth  and  twelfth  nerves.    Pals's  method. 

Fig.  231. 


Multiple  sclerosis.    Section  at  level  of  seventh  cervical  segment.    VVeigert  stain. 

Course  and  Duration.  As  a  rule,  the  disease  is  intermittently  progressive, 
although  sometimes  the  course  of  the  disorder  is  quite  gradual  and  uniform 
throughout.  Remissions  or  arrest  of  progress  may  occur  and  last  for  long 
periods.  The  disease  itself  may  go  on  for  five  to  fifteen  years,  although  five 
or  six  years  is  placed  as  the  average  duration.     In  cases  in  which  the 


QQQ  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

medulla  is  involved  early,  death  may  occur  very  soon.  Usually  patients  die 
from  weakness  and  exhaustion,  due  to  the  long  continuance  of  a  gradually 
increasing  disease  of  the  central  nervous  system,  or  from  intercurrent  dis- 
eases. 

Diagnosis.  The  diagnosis  in  the  typical  cases  is  easy  from  the  character- 
istic symptoms  of  tremor,  weakness  of  the  extremities,  slow  development, 
vertiginous  attacks,  nystagmus,  spastic  rigidity,  peculiar  speech,  and  exagger- 
ated reflexes.  There  should  be  no  difiiculty  in  making  a  diagnosis  between 
this  disorder  and  paralysis  agitans.  In  this  latter  disease  the  tremor  occurs 
only  during  rest,  is  chiefly  confined  to  the  hands  and  fingers,  and  has  an 
almost  perfect  rhythmic  regularity  of  five  per  second.  Occasionally  there 
may  be  difficulty  between  cases  of  general  paralysis  of  the  insane  and  cases 
of  disseminated  sclerosis.  In  the  former  disease  there  may  be  an  "  intention 
tremor,"  very  similar  to  that  of  the  latter,  and,  while  the  differences  in 
speech  are  marked  to  those  familiar  with  the  two  types  of  speech  developed, 
the  practitioner  who  sees  but  few  of  these  cases  may  at  times  be  confused  by 
their  great  resemblance.  It  must  be  remembered  that  the  speech  in  sclero- 
sis is  of  a  stacatto-like  character,  the  syllables  being  separated,  while  in 
general  paralysis  the  speech  is  drawling  and  indistinct,  very  much  like  that 
of  a  drunken  person.  Any  marked  mental  change  would,  of  course,  be  in 
favor  of  general  paralysis.  The  real  difficulty  in  diagnosis  is  between  the 
atypical  forms  of  insular  sclerosis  and  disorders  like  Friedreich's  ataxia, 
locomotor  ataxia,  bulbar  palsy,  chronic  meningitis,  and  hysteria.  These 
fine  distinctions  can  be  made  only  after  careftil  study  of  the  whole  condition 
and  of  the  points  mentioned  under  the  headings  referring  to  these  other 
diseases. 

Prognosis.  The  prognosis  is,  of  course,  grave  as  regards  the  curability  of 
the  disorder,  but  some  hope  of  a  possibility  of  improvement  or  of  a  remis- 
sion may  be  held  out.  The  improvement  sometimes  is  quite  remarkable, 
and,  hence,  the  prognosis  cannot  be  as  absolutely  bad  as  in  the  systemic 
sclerotic  processes  which  go  on  in  the  spinal  cord.  Where  the  medulla  or 
the  nerves  arising  from  it  seem  to  be  affected  the  prognosis  is  much  more 
serious. 

Treatment.  There  is  very  little,  in  a  therapeutic  way,  which  can  be  done 
for  this  disorder.  We  should  employ  nerve  tonics,  such  as  arsenic,  quinine, 
and  nitrate  of  silver ;  iodide  of  potassium  and  mercury  should  also  be  used 
with  some  hope  of  improving  the  condition.  Arsenic  has  been  recommended 
to  be  employed  hypodermically.  Solanine  has  also  been  recommended  for 
diminishing  the  tremor,  but  probably  the  benefit  derived  would  be  more  than 
counterbalanced  by  the  bad  effects  of  this  powerful  drug.  Certain  hygienic 
measures  are  of  service,  and  hydrotherapy  and  electricity  may  at  times  be 
used.  Doubtless  as  much  good  can  be  derived  from  hydrotherapy  as  from 
any  ordinary  general  form  of  treatment.  The  life  should  be  regular  in  every 
respect,  and  the  patient  should  be  kept  as  quiet  as  possible. 

Note.  The  microphotographs  illustrating  Dr.  Peterson's  chapters  were 
taken  by  Dr.  Leaming  from  sections  belonging  to  Drs.  Van  Gieson  and 
Peterson. 


CHAPTER   XXIII. 

PARETIC  DEMENTIA. 

By  F.  X.  DEKCUM,  M.D. 

The  disease  we  are  about  to  consider  is  variously  known  as  paretic  de- 
mentia, general  paralysis  of  the  insane,  paralytic  dementia,  paresis,  and  as 
progressive  general  paralysis. 

In  a  work  upon  diseases  of  the  nervous  system,  an  affection  presenting 
such  profound  pathological  changes  as  paretic  dementia  deserves  detailed 
consideration.  It  differs  widely  from  the  ordinary  psychoses  in  the  degree 
in  which  such  changes  can  be  demonstrated.  The  pathological  process  is 
widespread,  involving  both  brain  and  cord  and  even  the  peripheral  nerves. 
It  is  accentuated  in  the  brain,  but  in  all  cases  distinct  spinal  lesions  are 
present,  and  in  not  a  few  these  antedate  the  cerebral  disorder.  Changes  in 
the  peripheral  nerves  suggesting  those  seen  in  neurotabes  have  also  been 
found  by  a  number  of  observers,  e.  g.,  Dejerine,  Bevan  Lewis,  and  Campbell. 

The  affection  is  important  because  of  its  serious  and  progressive  character. 
It  is  a  disease  in  which  a  gradual  change  ensues  in  all  of  the  mental  and 
physical  powers,  a  change  which  is  degenerative  in  nature,  and  the  recogni- 
tion of  which  at  an  early  period  is  of  the  utmost  importance,  not  only  to  the 
patient,  but  to  his  friends  and  relatives. 

Etiology.  Certain  factors  outweigh  all  others  in  the  etiology  of  paretic 
dementia.  These  are  for  the  most  part  directly  exciting  causes.  There  are, 
however,  secondary  and  extraneous  elements  which  increase  the  liability  or 
tendency  to  the  disease,  and  it  is  therefore  convenient  to  divide  the  various 
causes  into  predisposing  and  exciting. 

Predisposing  Causes.  Among  the  predisposing  causes  are  heredity, 
time  of  life,  sex,  race,  occupation,  social  position,  and  the  unmarried  state. 

The  family  history  of  paretics  is  of  some  significance,  because  of  its 
occasional  neuropathic  character.  However,  the  importance  of  heredity 
has  been  somewhat  exaggerated.  Indeed,  Mickle's"  studies  justify  the  con- 
clusion that  in  the  whole  group  of  mental  diseases  taken  together  heredity 
is  relatively  more  frequent  than  it  is  in  paresis  taken  separately.  Even 
in  cases  where  heredity  can  be  traced,  it  is  not  insanity  or  paresis  that  is 
transmitted,  but  rather  a  general  tendency  to  organic  and  functional  nervous 
disease,  apoplexy,  epilepsy,  paralysis,  etc.  With  this  view  the  larger  number 
of  writers  are  in  accord.  Krafft-Ebing  maintains  that  the  predisposition  to 
paretic  dementia  is  usually  acquired  and  not  hereditary.  One  curious  fact, 
however,  should  be  stated,  and  that  is  that  an  hereditary  element  can  be 
more  frequently  traced  among  female  paretics  than  among  males.  As  allied 
to  heredity.  Regis  points  out  that  consanguinity  constitutes  a  predisposition 
to  paresis,  as  it  does  to  other  nervous  affections. 

Paretic  dementia  is  most  frequently  met  with  between  the  ages  of  thirty 
and  fifty-five  years.    It  is  quite  rare  before  twenty-five.    It  is  very  infrequent 

1  Mickle  on  "  General  Paralysis  of  the  Insane,"  1886. 


668  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

after  sixty.  Taking  it  all  and  all,  the  period  between  thirty-five  and  forty 
seems  to  be  the  one  in  which  the  greatest  liability  to  the  disease  obtains. 
This  period  was  formerly  regarded  as  being  from  forty  to  fifty,  but  there  can 
be  no  doubt  that  the  larger  number  of  cases  reported  within  recent  years 
occur  before  forty.  In  general  terms  the  age  at  which  paresis  occurs,  thirty 
to  fifty-five,  corresponds  to  the  most  active  period  of  life,  a  period  in  which 
the  greatest  strains  have  to  be  borne  and  in  which  the  greatest  wear  and  tear 
takes  place.  Exceptionally,  however,  it  occurs  much  earlier  ;  thus  cases  of 
eighteen  and  sixteen  years  have  been  reported.  Wigglesworth^  has  placed 
on  record  two  cases  aged  fifteen,  a  boy  and  a  girl.  He  also  collected  five 
additional  cases  in  which  the  ages  ranged  from  twelve  to  sixteen.  All  of 
these  cases  assumed  a  type  of  primary  progressive  dementia.  In  only  one 
case  (Clouston's)  were  delusions  of  grandeur  present.  The  greater  number 
were  girls.  Bristowe'^  reports  the  case  of  a  boy,  aged  thirteen  years,  and 
Toulouse'  cases  of  eleven  and  twelve  years.* 

Experience  has  abundantly  demonstrated  that  paretic  dementia  occurs 
much  more  frequently  among  men  than  among  Avomen  ;  and  this,  when  we 
consider  the  special  exciting  causes,  is  not  surprising.  The  relative  propor- 
tion of  the  sexes  afiected  by  the  disease  varies  as  to  country,  social  position, 
and  as  to  rural  and  city  life.  We  should  expect,  therefore,  the  proportion 
to  vary  considerably.  In  Germany,  for  instance,  the  average  is  somewhere 
between  eight  to  one  and  four  to  one.  In  France  the  proportion  of  women 
is  distinctly  higher,  but  still  variable,  while  in  our  own  country  the  propor- 
tion in  the  New  England  asylums  is  about  four  males  to  one  female,  in  the 
New  York  asylums  (exclusive  of  the  city  of  New  York),  about  nine  to  one, 
and  in  some  of  the  Western  asylums,  such  as  those  of  Michigan,  thirteen  to 
one  (Stearns). ^ 

Paresis  occurs  very  infreqently  among  women  of  the  upper  class,  and,  in 
keeping  with  this  fact,  we  find  almost  without  exception  that  in  public 
asylums  the  proportion  of  female  paretics  to  male  paretics  is  much  greater 
than  in  private  asylums. 

In  rural  populations,  again,  we  not  only,  find  the  total  number  of  cases  of 
paresis  less,  but  also  a  comparatively  slight  disproportion  between  the  sexes. 
For  rural  populations  in  France,  Regis  states  that  it  is  only  one  and  a  half 
times  more  common  in  men  than  in  women.  In  our  own  country,  according 
to  Stearns,  taking  the  States  of  Maine  and  Vermont,  which  contain  no  large 
towns,  we  find  the  proportion  of  female  paretics  one  to  three.  In  cities, 
paresis  is  not  only  relatively  frequent,  but  the  disproportion  between  the 
sexes  is  much  increased.  Especially  is  this  true  of  the  higher  classes  of 
society.  According  to  Regis,  for  instance,  it  is  thirteen  times  more  frequent 
among  men  of  the  upper  class  than  among  women  of  the  same  class.  Among 
the  laboring  population  of  large  cities,  however,  this  disproportion  again 
falls,  being  only  three  times  more  common  in  men  than  in  women.  These 
facts  are  exactly  in  keeping  with  what  we  know  of  the  principal  exciting 
causes  of  the  disease.  Men,  on  the  average,  undergo  far  greater  mental 
strains  in  the  early  or  middle  period  of  life  than  women.  As  we  would 
naturally  expect,  where  this  strain  is  most  disproportionate,  e.  g.,  in  the 
upper  social  class,  men  suffer  much  more  frequently,  while  in  the  lower 
strata  of  society,  where  the  strains  of  life  are  more  equalized,  the  proportion 

1  Wigglesworth  :  British  Med.  Journ..l893,  i.  635. 

-  Bristovve:  British  Med.  Journ.,  1874.  i.  1125. 

3  Toulouse  :  Gaz.  des  HGpitaux,  1893,  Ixvi.  909. 

■*  Whenever  such  exceedingly  precocious  paresis  is  met  ivith  we  should  always  be  suspicious  of 
some  such  potent  factor  as  hereditfyy  syphilis.  In  both  of  Wigglesworth's  cases,  and  also  in  that  of 
Brisiowe,  there  was  a  history  of  injury  to  the  head. 

'•>  Stearns :  Mental  Diseases,  Philadelphia,  1893. 


PARETIC  DEMENTIA.  669 

of  women  affected  rises.  "We  have  also  reason  to  think  that  it  is  more  com- 
mon in  those  women  who  have  entered  into  competition  with  the  male  sex 
in  occupations  ordinarily  carried  on  by  the  latter.  This  supposition  is  borne 
out  by  the  fact  that  paresis  is  distinctly  on  the  increase  among  women.  The 
menopause  cannot  be  regarded  as  a  predisposing  factor  of  great  importance, 
though  it  must  be  admitted  that  cases  not  infrequently  occur  at  that  time. 
Out  of  forty-one  female  cases  recorded  by  Westphal/  eight  are  ascribed  to 
the  climacteric,  a  rather  unusual  number.  Gestation  exercises  little  or  no 
influence.  Krafil-Ebing,  however,  states  that  paresis  sometimes  follows  re- 
peated and  severe  labors. 

Paresis  is  far  more  common  in  AVestern  Europe  and  America  than  else- 
where, although  this  statement  is  open  to  a  number  of  qualifications.  For 
instance,  while  paresis  is  very  frequent  in  England,  it  is  so  rare  in  Ireland 
as  to  be  almost  unknown.  While  rather  frequent  in  Germany,  it  is  almost 
unknown  in  Scandinavia,  inhabited  by  a  kindred  race.  It  would  appear 
that,  under  certain  circumstances,  when  the  Anglo-Saxon,  or,  in  a  larger 
sense,  the  Teutonic  race,  are  stimulated  to  unusual  exertion,  paresis  occurs 
among  them.  The  studies  which  have  been  made  in  our  own  country  in 
reference  to  this  point,  by  Spitzka  and  by  Stearns,  are  in  conformity  with 
this  view.  Spitzka,  for  instance,  found  that  in  a  pauper  insane  asylum  in 
New  York  City  the  Anglo-Saxons  headed  the  list  in  numbers.  Next  fol- 
lowed in  order  Celts,  Germans,  and  negroes.  These  facts  are  largely  in 
keeping  with  the  characteristics  of  the  races,  those  of  Anglo-Saxon  blood 
being,  for  the  most  part,  engaged  in  feverish  business  activities  and  burdened 
with  great  and  exhausting  responsibilities.  The  phlegmatic  character  of  the 
German  and  the  indifference  of  the  Celt  explain  their  secondary  positions. 
It  is,  however,  somewhat  difficult  to  account  for  the  relative  infrequency  of 
paresis  among  Hebrews,  as  they  are,  for  the  most  part,  a  race  exceedingly 
active  both  in  business  and  professional  life.  Regarding  negroes,  Berkley  ^ 
found  that  of  seventy-four  patients,  five,  or  6.7  per  cent.,  suffered  from 
paresis,  a  much  larger  proportion  than  he  found  among  the  white  patients, 
three  hundred  and  thirty  of  whom  presented  only  three  paretics,  or  less  than 
one  per  cent. 

Exciting  Causes.  Among  the  exciting  causes  of  paretic  dementia,  one 
stands  out  prominently  above  all  others.  It  consists  of  those  great  strains  of 
the  nervous  system  implied  by  overwork,  overexertion,  intense  and  pro- 
longed worry,  terrible  disappointments,  serious  and  apparently  hopeless  re- 
verses of  fortune — in  short,  all  causes  that  tax  the  intellectual  and  emotional 
faculties  to  the  uttermost.  In  this  list  we  shovild  also  include  such  profoundly 
disturbing  causes  as  fright  and  excessive  nervous  shock.  Often  a  number  of 
causes  of  overstrain  are  present.  Not  infrequently  do  we  find  that  a  man 
engaged  in  an  active  and  exhausting  business  which  taxes  his  energies  ex- 
cessively does  not  develop  paresis  unless  to  this  already  great  strain  there  be 
added  some  profound  emotional  disturbance,  as  a  sudden  and  depressing 
grief  or  domestic  trouble.  In  a  small  number  of  cases  physical  overexer- 
tion is  to  be  regarded  as  a  cause.  Sometimes  there  is  a  combination  of  both 
psychical  and  physical  overstrain.  In  keeping  with  the  above  facts  we 
find  that  the  number  of  cases  of  paresis  occurring  among  business  men  and 
among  those  who  live  in  the  intense  excitment  of  political  strife  is  relatively 
high ;  Avhilst  those  who  lead  the  more  quiet  lives  of  farmers,  stock-raisers, 
and  the  like  furnish  a  comparatively  small  number.  These  facts  are  also  in 
keeping  with  the  many  predisposing  causes  which  we  have  already  consid- 

1  Westphal :  Charite  Annalen,  1893,  x.  719. 

2  Berkley  :  Johns  Hopkins  Hosp.  Bulletin,  No.  34,  October,  1893. 


670  NERVOUS  DISEASES  AND  THEIR  TREATMENT 

erecl,  such  as  the  frequency  of  j)aresis  in  the  most  active  periods  of  life, 
namely,  from  thirty-five  to  fifty,  and  also  its  greater  frequency  among  the 
male  sex,  especially  in  the  middle  and  upper  classes. 

The  majority  of  writers  have  laid  great  stress  upon  alcoholism  as  a  factor. 
Proof  is,  however,  lacking  that  alcohol  of  itself  brings  about  paretic  demen- 
tia. On  the  contrary,  the  symptoms  of  alcoholic  dementia  difier  in  im- 
portant points  from  those  of  paresis.  Evidently  the  abuse  of  alcohol  can 
only  be  regarded  as  a  factor  secondary  in  importance.  However,  that  it 
acts  as  a  powerflil  adjuvant  in  the  causation  of  paresis,  when  the  factors  of 
intellectual  and  emotional  overstrain  exist,  there  can  be  no  doubt.  Cer- 
tainly no  danger  is  greater  than  a  resort  to  stimulants  by  persons  passing 
through  such  strains.  A  mere  physiological  hypersemia  of  the  brain  under 
the  use  of  alcohol  may  become  pathological  and  determine  the  onset  of 
paresis.  Considered  from  this  standpoint,  the  dangerous  nature  of  alcohol 
under  such  circumstances  can  readily  be  understood.  On  the  other  hand, 
we  are  liable  to  err  regarding  the  extent  to  which  paresis  can  be  attributed 
to  alcohol.  The  vast  majority  of  paretics,  by  very  reason  of  their  disease, 
commit  excesses  of  all  kinds  in  the  prodromal  and  early  stages,  and  under 
these  circumstances  the  abuse  of  alcohol  is  not  so  much  a  cause  as  an  effect 
and  symptom. 

The  same  statements  are  also  true  of  the  sexual  excess  which  patients  pre- 
sent and  which  various  writers  enumerate  among  the  causes  of  paresis.  We 
find,  from  Mickle's^  studies  of  the  reports  of  the  commissioners  in  lunacy 
(England),  that  out  of  four  thousand  two  hundred  and  eighty-four  cases,  the 
disease  was  ascribed  to  sexual  excess  in  one  hundred  and  nine,  i.  e.,  only  2.5 
per  cent.  The  importance  of  sexual  excess  as  a  factor  is  open  to  still  farther 
question.  In  the  first  place,  the  age  at  which  paretic  dementia  is  prone  to 
occur  is  not  the  age  of  sexual  excess.  The  period  of  sexual  excess  ranges 
from  early  youth  up  to  thirty  years  of  age.  Rarely  is  it  found  at  other  times. 
Paresis  occurs  much  later — at  a  time  when  both  men  and  women  are  sobered 
by  the  severe  realities  of  life.  Doubtless  in  the  majority  of  cases  sexual  ex- 
cess is  to  be  looked  upon  as  an  effect  of  the  disease  and  not  as  a  cause. 

A  very  important  factor  in  the  causation  of  paretic  dementia  is  trauma  of 
the  head.  Among  the  four  thousand  two  hundred  and  eighty-four  cases 
collected  by  Mickle,  as  many  as  two  hundred  and  eighty  were  ascribed  to  acci- 
dent or  injury.  Concussion  of  the  brain  seems  to  lessen  its  power  of  resist- 
ance, perhaps  affects  directly  the  vasomotor  control  of  its  larger  vessels,  and 
thus  predisposes  it  more  readily  to  attacks  of  congestion.  As  a  rule,  the  de- 
velopment of  paresis  after  a  severe  blow  upon  the  head  is  gradual,  many 
months  or  even  years  intervening,  although  the  interval  is  in  rare  cases 
much  shorter.  Sometimes  the  interval  is  so  long  that  the  trauma  is  often 
looked  upon  as  a  predisposing  rather  than  as  a  directly  exciting  cause. 

Sunstroke,  or  prolonged  exposure  to  great  furnace  heat,  is  also  an  im- 
portant factor.  In  ninety-seven  of  the  cases  collected  by  Mickle,  sunstroke 
was  assigned  as  the  cause.  It  is  very  probable  that  sunstroke  acts  very 
much  as  does  concussion  of  the  brain,  namely,  by  predisposing  the  organ  to 
hypersemia  and  by  lessening  its  power  of  resistance. 

Syphilis  as  a  cause  of  paresis  has  been  much  discussed.  Undoubted^  it 
is  a  powerful  factor.  According  to  Graf,  as  many  as  40  per  cent,  of  paretics 
are  victims  of  syphilis,  and  Mendel  gives  the  percentage  as  75.  According 
to  Rieger,  quoted  by  Kraffl-Ebing,  the  subjects  of  syphilis  are  from  sixteen 
to  seventeen  times  more  liable  to  paretic  dementia  than  others  not  so  affected. 
According  Regis,'  syphilis  exists  in  seventy  to  ninety  cases  in  every  one  hun- 

1  Loc.  cit.  2  Manual  of  Mental  Medicine,  1894,  transl.  by  Bannister. 


PARETIC  DEMENTIA.  671 

dred  in  general  paralysis.  Hougberg^  found  syphilis  in  75.7  per  cent ;  Ban- 
nister ^  in  89  per  cent.  Whether  syphilis  is  an  active  factor  in  the  produc- 
tion of  paresis  or  is  only  a  predisposing  cause  has  been  much  disputed.  Several 
possibilities  suggest  themselves.  It  is  possible,  first,  that  paresis  is  the  out- 
come of  the  late  action  of  the  toxine  of  syphilis,  a  parallel  instance  of  such 
supposed  action  being  furnished  by  locomotor  ataxia.  This  parallelism  is 
enhanced  by  the  fact  that  an  ataxia  comparable  to  ordinary  locomotor 
ataxia  now  and  then  precedes  the  development  of  paresis  (paretic  dementia 
of  the  ascending  type).  It  is  possible,  secondly,  that  a  nei'vous  system  pro- 
foundly exhausted  by  the  infection  of  syphilis  breaks  down  more  readily 
under  the  intellectual  and  emotional  strains  which  play  so  important  a  part 
as  exciting  causes  of  paresis.  It  is  further  significant  that,  for  the  most  part, 
paresis  in  syphilitic  subjects  is  a  late  development.  In  Hougberg's^  cases, 
eighty-one  in  number,  the  onset  occurred  in  from  five  to  nineteen  years  after 
infection. 

When  in  a  syphilitic  subject  true  gummatous  infiltration  of  the  cortex  oc- 
curs, i.  e.,  of  the  membranes  and  of  the  vessels,  the  case  is  not  one  of  paresis, 
but  of  syphilitic  dementia.  (See  Chapter  XXIV.)  A  possible  and  a  seri- 
ous error  in  regard  to  syphilis  should  here  be  pointed  out,  and  that  is,  that, 
due  to  the  sexual  excesses  and  concomitant  exposure  to  specific  infection  in 
the  earlier  stages,  the  patient  may  acquire  syphilis  siihsequently  to  the  actual 
onset  of  the  disease.  In  such  a  case,  of  course,  syphilis  could  not  be  regarded 
as  the  causal  factor.* 

Among  other  causes  to  which  paresis  is  rarely  attributed  are  lead-poison- 
ing and  the  excessive  use  of  tobacco.  Inasmuch,  however,  as  the  symptoms  of 
lead  encephalopathy  differ  from  those  of  classical  paretic  dementia,  it  is  prob- 
able that  the  place  which  it  occupies  in  etiology  is  that  of  a  predisposing 
rather  than  a  directly  exciting  cause.  The  same  remarks  apply,  in  all  proba- 
bility, to  tobacco,  attention  to  which  as  a  cause  of  paresis  was  especially  called 
by  Guislain. 

Paresis  is  rarely  if  ever  to  be  attributed  to  acute  illness,  such  as  fevers, 
pneumonia,  and  other  severe  diseases.  The  latter  are  much  more  prone  to 
cause  other  forms  of  mental  derangement.  Occasionally  paretic  dementia  is 
met  with  subsequent  to  various  insanities.  It  cannot,  however,  be  regarded 
as  standing  in  any  relation  to  these  insanities.  In  a  case  presenting  such  a 
history,  the  paresis  must  be  regarded  as  an  affection  de  novo.  The  same 
statement  is  true  of  the  relation  of  other  nervous  disorders  to  this  disease. 
Paresis  is  never  met  with,  for  instance,  as  the  outcome  of  neurasthenia  or 
hysteria. 

Symptoms  and  Course.  Both  the  symptoms  and  the  course  of  the  disease 
are  extremely  variable.  Throughout  the  clinical  picture,  however,  there  is 
discernible  a  progressive  mental  and  physical  enfeeblement.  As  might  be 
expected  in  a  disease  the  changes  of  which  are  widespread  and  difiiise, 
there  are  present  various  psychic  anomalies,  many  of  which  are  common  to 
other  psychoses,  and  also  various  physical  anomalies,  many  of  which  are  com- 
mon to  other  degenerative  nervous  diseases.  Further,  these  symptoms,  both 
mental  and  physical,  are  as  a  rule,  at  first  so  slight  as  frequently  to  escape  recog- 
nition. Gradually,  however,  they  become  more  and  more  pronounced  until 
with  time  they  are  evident  even  to  the  lay  observer.     When  once  established 

1  Hougberg:  Neurolog.  Centralbl.,  1894,  p.  279. 

2  Bannister  :  American  Journal  of  Insanity,  1893-4,  p.  477.  3  lqc.  cit. 

*  The  relation  wbich  the  two  sexes  bear  to  paretic  dementia  as  caused  by  syphilis  appears  to  be 
difTerent.  Thus,  in  148  cases  of  paresis  in  women  recorded  by  Westphal  (loc.  cit.)  syphilitic  infec- 
tion was  probable  in  48,  a  much  smaller  proportion  than  is  usually  found  among  men.  In  this  con- 
nection a  curious  personal  observation  made  by  Morel-Lavallee  is  interesting.  Of  five  men  infected 
from  the  same  source  three  developed  general  paralysis  ;  two  died  of  cerebral  syphilis ;  while  the 
woman  remained  perfectly  well,  married,  and  had  two  sound  children. 


672  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  degenerative  changes,  save  with  one  or  two  possible  temporary  interrup- 
tions, steadily  deepen  until  they  finally  become  incompatible  with  life. 

Because  of  the  very  gradual  and  ]Drogressive  character  of  the  disease,  it 
is  separable  into  a  series  of  stages  or  periods.  We  recognize  at  once  the 
fact  that  there  is  in  every  case  an  initial  period  which  distinctly  antedates 
the  fully  develo]3ed  disease,  and  to  this  the  name  of  the  "prodromal  stage" 
has  been  given. 

The  disease  begins  in  a  manner  so  extremely  gradual  that  it  is  rarely  if 
ever  possible  to  fix  more  than  approximately  the  time  of  its  inception,  and 
similarly  the  various  stages  pass  for  the  most  part  insensibly  one  into  the 
other.  It  is  important  at  the  outset  to  recognize  that  this  separation  into 
stages  is  largely  artificial,  and,  keeping  in  mind  the  flirther  fact,  already 
alluded  to,  that  both  the  symptoms  and  the  course  of  the  disease  are  ex- 
tremely variable,  it  is  not  surprising  to  learn  that  medical  Avriters  frequently 
diflfer  as  to  the  number  and  arrangement  of  these  stages.  However,  this  is 
true  rather  of  the  fully  developed  disease  than  of  the  prodromal  period.  The 
existence  of  the  latter  is,  as  a  matter  of  course,  recognized  by  all  writers.  To 
this  prodromal  or  initial  period,  as  it  is  better  termed,  we  will  now  give  our 
attention. 

Initial  Period.  In  the  majority  of  cases  we  are  unfortunately  dependent 
upon  relatives  and  friends  for  an  account  of  the  earliest  symptoms.  How- 
ever, the  facts  that  are  obtained,  though  often  fragmentary,  are  of  the  greatest 
value.  They  are  for  the  most  part  sufficient  to  indicate  that  various  changes, 
both  mental  and  physical,  have  taken  place  in  the  individual.  In  a  general 
way,  for  instance,  it  has  been  noted  that  the  patient  has  not  been  well  for 
some  time  past.  Often  the  friends  maintain  that  the  patient's  appearance 
and  manner  have  changed,  that  he  no  longer  attends  to  his  business  as  care- 
ftiUy,  or  no  longer  does  his  work  as  well  as  formerly.  Often  he  looks  badly. 
His  face  may  be  unusually  pale,  or,  on  the  other  hand,  may  exhibit  an  unac- 
customed flush.  He  may  look  tired,  often  sleepy.  Frequently  his  face  seems 
to  lack  expression.  Physically  he  may  seem  weak.  His  attitude,  his  move- 
ments, his  walk  may  suggest  a  general  loss  of  tone  and  vigor.  Not  infre- 
quently he  complains  of  a  sense  of  fulness,  pressure,  or  constriction  about 
the  head.  Sometimes  there  are  rheumatoid  pains  referred  to  the  legs,  to  the 
arms,  or  to  the  back  of  the  neck  or  trunk.  Occasionally  these  pains  are 
neuralgic  in  character,  and  indeed  at  times  lightning-like  pains  resembling 
those  found  in  the  early  stages  of  locomotor  ataxia  are  present.  Often  the 
patient  complains  of  headaches.  Sometimes  the  latter  occur  in  paroxysms 
of  great  severity.  The  pain,  instead  of  being  difflise,  may  be  referred  to  some 
special  region,  as  the  occiput  or  the  brow.  Occasionally  the  headache  simu- 
lates an  attack  of  migraine,  the  pain  being  felt  with  great  intensity  not  only 
in  the  supra-orbital  and  adjacent  regions,  but  especially  in  the  eyeball  of  the 
aflfected  side.  Sometimes  cases  are  met  with  in  which  this  pain  is  so  severe 
as  to  suggest,  for  the  time  being,  an  acute  attack  of  glaucoma.  Frequently 
ringing  in  the  ears,  sparks  before  the  eyes,  and  muscae  volitantes  are  com- 
plained of.  Attacks  of  giddiness  and  vertigo  may  also  occur,  and  sometimes 
the  patient  complains  of  a  dazed  or  stunned  feeling  in  the  head. 

Mentally  the  patient  presents  symptoms  which  at  first  suggest,  and  indeed 
are  sometimes  remarkably  like,  those  of  neurasthenia.  He  cannot  do  his 
work  Avithout  making  an  imusual  effort.  Work,  especially  mental  work,  soon 
becomes  distasteful  and  even  painful.  Inability  to  fix  the  attention  for  any 
length  of  time  upon  an  ordinary  affair  of  business  or  other  everyday  matter, 
also,  becomes  evident.  In  conversation  it  frequently  becomes  necessary  to  re- 
peat to  him  the  simplest  statement  a  number  of  times.  There  is  distinct  feeble- 
ness both  in  the  ability  to  apprehend  and  in  the  ability  to  remember.    Unusual 


PARETIC  DEMENTIA.  673 

forgetfulness  is  especially  observed  about  the  smaller  details  of  life.  A  previ- 
ously precise  and  methodical  man  forgets  to  wind  his  watch,  to  mail  his  let- 
ters, or,  in  dressing,  forgets  some  article  of  attire,  such  as  a  collar  or  a  cravat. 
It  is  further  significant  that  recent  events  are  soon  forgotten  even  when  the  lat- 
ter are  of  a  character  as  ordinarily  to  impress  themselves  upon  the  patient,  e.  g., 
the  death  of  a  friend  or  a  business  transaction  conducted  only  a  few  days  before. 
It  is  also  in  keeping  with  these  facts  that  the  patient  often  repeats  the  same 
statement  or  tells  the  same  story  a  number  of  times  in  succession,  being  him- 
self unconscious  of  the  repetition.  Such  facts  as  these  are  of  course  of  sig- 
nificance only  if  they  be  in  striking  contrast  with  the  former  peculiarities  of 
the  individual. 

In  numerous  ways  the  patient  may  reveal  other  changes.  For  instance, 
his  sensibilities,  both  intellectual  and  emotional,  become  blunted.  Things 
which  formerly  interested  him  greatly,  appeal  to  him  less  forcibly  or  perhaps 
not  at  all.  An  intellectual  man  devoted  to  some  ethical  or  aesthetic  pur- 
suit loses  all  interest  in  the  latter  and  may  become  entirely  indifierent  to 
it.  Similarly  his  sense  of  obligation  to  his  family,  although  formerly  re- 
garded in  the  most  exalted  light,  is  much  lessened.  The  news  of  the  sudden 
illness  of  a  beloved  child  is  heard  with  indifference ;  the  caresses  of  wife  and 
children  no  longer  meet  with  their  former  response.  His  daily  vocation,  no 
matter  how  pressing,  appeals  to  him  in  a  much  lessened  degree,  and  at  the 
same  time  he  betrays  numerous  errors  of  judgment  about  the  commonest 
affairs  of  life.  His  business  capacity  becomes  much  impaired.  Errors  and 
confusion  begin  to  appear  in  his  accounts.  Engagements  are  neglected  and 
business  transactions  badly  conducted. 

Hand-in-hand  with  the  general  blunting  of  the  emotions  and  of  the  in- 
tellectual powers,  the  grosser  animal  qualities  rise  to  the  surface.  A  man 
formerly  temperate  in  both  eating  and  drinking  now  eats  and  drinks  exces- 
sively, showing  evident  satisfaction,  in  this,  to  him,  unwonted  and  coarse  grati- 
fication. Soon  he  becomes  indifferent  to  his  personal  attire,  often  appearing 
in  the  presence  of  his  family  or  strangers  with  his  clothing  improperly  ad- 
justed, and  in  other  ways  manifests  a  distinct  loss  of  the  sense  of  the  pro- 
prieties. Often,  indeed,  he  makes  careless  and  indecent  exposures  of  his 
person.  His  speech,  too,  loses  its  former  nicety  and  refinement  and  often  be- 
comes coarse  and  vulgar.  Often  he  is  obscene,  and  sometimes  he  attempts 
liberties  with  the  female  servants  of  his  household  or  with  other  persons  of 
the  opposite  sex  in  whose  company  he  may  happen  to  be. 

Gradually  the  signs  of  the  threatening  dementia  become  more  and  more 
pronounced.  The  occasional  lapses  of  memory  soon  increase  to  serious  gaps, 
and  the  attendant  dazed  and  confused  condition  of  mind,  together  with  the 
feebleness  of  the  will,  render  the  patient  less  capable  than  ever  of  conducting 
his  affairs.  It  is  not  surprising  that  every  now  and  then  disaster  and  bank- 
ruptcy should  under  these  circumstances  occur,  or  that  errors  of  accounts  and 
neglect  of  obligations  should  make  his  affairs  the  subject  of  litigation. 

There  is  also  a  change  in  character  and  disposition,  which  may  be  so  marked 
as  to  be  almost  like  a  complete  change  in  personality.  Sometimes  he  is  apa- 
thetic, abstracted,  and  dull.  More  frequently  he  is  restless,  irritable,  and  ex- 
citable. He  becomes  angry  at  slight  causes,  but  falls  utterly  to  react  in  a 
normal  manner  to  events  of  real  consequence.  Thus  S^^itzka  cites  the  case 
of  a  patient  who  threw  a  knife  at  his  servant  because  she  took  his  plate  aAvay 
before  he  had,  as  he  alleged,  finished  dining,  and  who  heard  unmoved  a  few 
hours  later  of  the  collapse  of  a  large  business  undertaking  which  involved 
a  loss  to  him  of  over  a  hundred  thousand  dollars. 

In  addition,  the  patient  is  excessively  egotistical,  and  this  feeling  is  often 
accompanied  by  a  fictitious  sense  of  physical  well-being  and  power.     He 

43 


674  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

talks  extravagantly  about  himself  and  his  affairs.  He  plans  great  enter- 
prises, undertakes  great  projects,  and  generally  succeeds  in  making  absurd 
and  useless  expenditures.  Thus  a  physician  bought  a  large  number  of  bird 
cages,  a  laboring  man  ordered  an  enormous  quantity  of  flowers,  while  a  third 
patient,  a  woman,  purchased  a  great  number  of  miscellaneous  and  incon- 
gruous articles  without  assignable  object. 

Together  with  this  intellectual  deterioration  there  is  also  a  distinct  impair- 
ment of  the  moral  nature.  The  patient  may  tell  silly  and  absurd  lies  without 
object  or  j)ur230se.  He  is  prone  to  commit  theft,  often  stealing  things  for 
which  he  can  have  no  possible  use ;  indeed,  theft  is  every  now  and  then  the 
first  overt  act  by  which  general  attention  is  drawn  to  the  patient's  condition. 
At  times  this  thieving  and  lying  has  its  origin  in  loss  of  memory  and  absent- 
mindedness.  At  other  times  it  is  plainly  the  outcome  of  a  blunting  or  per- 
version of  the  moral  faculty,  as,  for  example,  when  theft  is  perpetrated  by 
means  of  a  forgery. 

Various  sleep  disturbances,  as  a  rule,  also  make  their  appearance.  The 
patient  may  suffer  from  more  or  less  marked  insomnia,  and  sleep,  when  it 
does  occur,  may  be  disturbed  by  disagreeable  dreams.  On  the  other  hand, 
during  the  day  more  or  less  somnolence  may  be  present.  The  patient  is  apt 
to  fall  asleep  at  unusual  times  and  places ;  for  example,  at  his  office  and  at 
hours  usually  devoted  to  active  business.  The  somnolence  is  especially 
noted  after  eating,  when  it  may  be  almost  impossible  for  the  patient  to  keep 
awake. 

The  tendency  to  excess  in  drinking,  already  noted,  gradually  becomes 
more  marked.  Sexual  excess  also  becomes  more  pronounced.  The  previous 
indifference  to  exposure  of  the  person  now  gives  place  to  active  erotic  excite- 
ment, the  patient  making  no  effort  to  conceal  his  condition,  and  often  com- 
mitting almost  incredible  excesses,  as,  for  instance,  in  a  case  cited  by 
Mickle,  in  which  the  patient,  in  the  space  of  one  week,  "  engaged,  it  is  said, 
in  about  fifty  acts  of  marital  coitus  with  full  seminal  ejaculation  on  each 
occasion."  Sometimes  the  erotism  is  so  great  as  to  lead  to  the  commission  of 
violent  acts,  as  in  the  case  of  a  patient  who  attempted  to  rape  his  own 
daughter.  In  some  cases,  however,  it  should  be  stated,  early  loss  of  both 
sexual  desire  and  power  occurs. 

In  his  movements  the  patient  reveals  that  he  is  awkward.  His  gait  is 
often  sluggish  and  unsteady.  Mechanics,  formerly  skilful  in  certain  move- 
ments, lose  their  dexterity.  There  is  generally,  also,  more  or  less  marked  awk- 
wardness and  hesitation  in  speech  ;  sometimes  there  are  attacks  of  transient 
aphasia.  More  or  less  myosis,  inequality  of  the  pupils  or  other  motor  symp- 
toms referable  to  the  eyes,  fibrillary  tremors  of  the  tongue,  irregularly  recur- 
ring twitchings  of  the  facial  muscles,  or  fine  tremors  of  the  hands,  may  also 
be  present.  Tremor  is  also  apt  to  be  revealed  by  the  handwriting.  The 
handwriting,  in  addition  to  being  somewhat  tremulous  and  jerky,  may  also 
reveal  occasional  errors,  such  as  the  elision  of  letters,  syllables,  or  words, 
or  unwonted  errors  in  grammar.  These  peculiarities  are,  however,  much 
more  noticeable  in  the  ftilly  established  disease.  Indeed,  it  not  infrequently 
happens  that  the  motor  symptoms  as  a  whole  are  very  insignificant  in  the 
prodromal  period. 

Among  the  various  physical  symptoms,  the  patient  may  also  present 
anomalies  of  the  knee-jerks.  These  a4-e  usually  exaggerated,  though  some- 
times much  diminished  and  even  lost.  When  this  is  the  case  spinal 
symptoms,  such  as  are  found  in  locomotor  ataxia,  are  generally  present,  and 
have  for  some  time  preceded  the  cerebral  symptoms.  In  other  words,  dimi- 
nution or  loss  of  knee-jerks  is  apt  to  be  present  in  the  so-called  ascending 
form  of  the  disease.     When,  on  the  other  hand,  the  knee-jerks  are  exag- 


PARETIC  DEMENTIA.  675 

gerated,  spastic  symptoms  in  the  legs  may  be  j)resent.  It  is  important, 
however,  to  bear  in  mind  that  in  many  cases  of  paresis,  in  the  initial  period, 
the  knee-jerks  are  not  j)erceptibly  changed.  The  condition  of  the  cutaneous 
reflexes  is  also  very  variable.  In  about  50  per  cent,  of  the  cases  these  reflexes 
appear  to  be  normal.  However,  they  are  often  lost,  and  especially  is  this 
true  of  the  cremasteric  reflex.  With  the  latter  there  is  sometimes  found 
associated  a  beginning  atrophy  of  the  testicle.  In  a  very  small  number  of 
cases  the  cvitaneous  reflexes  are  found  exaggerated. 

At  any  time  during  this  initial  period  the  patient  may  suffer  from  attacks 
closely  resembling  apoplexy  or  ordinary  epilepsy.  They  are  not,  however, 
by  any  means  always  present.  When  such  seizures  do  occur  in  this  period 
they  are  more  apt  to  be  apoplectiform  than  ej)ileptiform.  After  a  few  pre- 
monitory symptoms,  such  as  increased  restlessness,  excitement,  and  sleepless- 
ness, and  perhaps  flushings  of  the  head,  the  patient  suffers  from  a  loss  of  con- 
sciousness, the  attack  being  accompanied  by  a  sudden  though  temjDorary  loss 
of  power  over  one-half  of  the  body.  Sometimes  the  resulting  hemiplegia  is 
somewhat  persistent.  Occasionally  marked  weakness  of  both  sides  of  the 
body  results,  though  usually  this  symptom  is  more  pronounced  on  one  side 
than  upon  the  other.  Less  frequently  the  seizures,  instead  of  being  apoplec- 
tiform, are  like  those  of  epilepsy,  the  patient  having  a  convulsive  attack, 
generally  accompanied  by  a  more  or  less  marked  loss  of  consciousness.  To  a 
detailed  consideration  of  these  convulsive  seizures  we  will  presently  return. 
Suffice  it  here  to  say  that  after  such  an  attack  the  various  symptoms  of  the 
disease  become  accentuated.  Occasionally  the  initial  period  terminates  ab- 
ruptly in  an  apoplectiform  or  epileptiform  seizure,  the  patient  passing  at 
once  into  the  fully  develojoed  stage  of  the  disease.  We  must  remember, 
however,  that  sudden  seizures  are  by  no  means  present  in  all  cases,  and  that, 
under  these  circumstances,  the  transition  from  the  initial  period  to  the  devel- 
oped disease  is  so  gradual  that  we  are  unable  to  determine  when  they  merge 
one  into  the  other. 

The  duration  of  the  initial  period,  as  a  rule,  is  from  one  to  three  years, 
though  it  is  sometimes  much  longer.  Cases  in  which  the  initial  period  is 
very  short — e.  g.,  several  weeks — are  exceedingly  rare  and  are  really  open 
to  question.  The  difficulty  of  fixing  the  duration  of  this  period  is  increased 
by  the  fact  that  the  progress  of  the  disease  is  not  always  steady  and  uninter- 
rupted. Temporary  recession  of  both  physical  and  mental  symptoms  now 
and  then  occurs,  and  under  favorable  conditions  such  a  recession  may  extend 
not  only  over  several  days  and  weeks,  but  over  much  longer  time.  To  this 
fact  is  doubtless  due  the  extraordinarily  long  duration  of  the  initial  period 
observed  in  some  cases.  In  addition,  the  course  of  the  initial  period  is  often 
irregular ;  while  certain  symptoms,  such  as  tremor  or  ataxia,  may  recede, 
others,  such  as  loss  of  memory  and  blunting  of  the  moral  faculties,  may 
steadily  advance.  At  other  times  the  reverse  obtains,  mental  symptoms 
receding  and  physical  symptoms  persisting. 

The  reader  must  not  conclude  from  the  above  description  of  the  initial 
period  that  all  of  the  symptoms  detailed  occur  in  every  case  or  that  they 
even  occur  with  an  equal  degree  of  severity.  Some  of  the  symptoms  may 
be  suppressed,  while  others  may  be  unusually  prominent.  However,  no  mat- 
ter how  or  when  occurring  they  are  always  indicative  of  the  essential  feature 
of  the  disease ;  namely,  persistent  and  unmistakable  loss  of  psychic  and 
physical  powers. 

It  is  important  to  state  that  the  symptoms  often  vary  considerably  during 
the  day.  The  patient  who  in  the  afternoon  or  evening  presents  inore  or  less 
marked  anomalies  of  judgment,  of  memory,  of  will  power,  or  of  movement, 
e.  g.,  ataxia  and  tremor,  or,  whose  face  has  been  flushed,  who  has  been  dull. 


676  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

heavy  and  sleepy,  may  the  next  morning  be  comparatively  himself.  Often 
during  these  early  morning  remissions,  as  they  may  be  called,  the  patient 
vaguely  and  sometimes  vividly  realizes  his  unfortunate  condition  ;  but  as  the 
day  advances  the  flush,  the  somnolence,  the  thick  and  hesitating  speech,  the 
tremor  of  the  lips,  the  forgetfulness,  again  reassert  themselves. 

Frequently,  as  the  initial  period  progresses,  the  patient  becomes  hypochon- 
driacal and  melancholic.  He  becomes  filled  with  vague  forebodings  and 
ill-defined  fears.  This  mental  state  may  come  on  spontaneously,  but  some- 
times it  is  the  direct  result  of  the  partial  recognition  by  the  patient  of  his 
condition.  Mental  depression  is  of  such  frequent  occurrence  that  Mendel 
has  erected  it  into  a  separate  stage  of  the  disease.^  He  regards  it  as  a  second 
period,  or  as  the  first  stage  of  the  established  affection. 

The  fact  upon  which  we  have  already  dwelt,  namely,  that  the  symptoms 
are  extremely  variable,  is  noticeable  not  only  in  the  initial  period,  but 
especially  in  the  fully  developed  disease.  This  has  led  to  difierences  not  so 
much  in  the  description  of  the  symptoms  as  in  the  division  of  the  disease  into 
stages.  We  have  just  alluded  to  the  fact  that  in  some  cases  the  hypochon- 
driacal symptoms  in  the  latter  part  of  the  initial  period  are  so  marked  as  to 
have  led  Mendel  to  erect  out  of  these  symptoms  the  first  stage  of  the  fiiUy 
developed  disease.  For  practical  purposes,  however,  since  this  condition 
of  hypochondriasis  is  sometimes  absent,  it  is  best  to  consider  it  as  a  part 
of  the  initial  period.  The  arrangement  adopted  by  Krafit-Ebing  appears 
to  be  the  most  natural,  inasmuch  as  it  is  in  accord  with  our  general  experi- 
ence. 

The  initial  period  eventuates  in  three  diflferent  ways :  first,  and  most  com- 
monly, in  a  condition  in  which  the  symptoms  of  dementia  already  noted  in 
the  initial  period  have  become  more  pronounced,  but  to  which  there  is  now 
added  an  expansive  or  a  maniacal  mental  state  ;  secondly,  and  less  frequently, 
in  a  condition  in  which,  as  before,  the  symptoms  of  dementia  are  more  pro- 
nounced, but  to  which  there  is  now  added  a  depressive,  hypochondriacal^  or 
melancholic  mental  state ;  and,  thirdly,  and  least  frequent  of  all,  a  condition 
in  which  there  is  simply  a  steady  increase  in  the  symptoms  of  the  dementia 
without  the  addition  of  any  expansive  or  depressive  mental  phenomena,  the 
disease  resembling  in  its  course  a  simple  progressive  dementia. 

The  period  of  the  fully  developed  disease  may  be  divided  into  a  number  of 
stages.  Inasmuch  as  the  disease  is  slowly,  and  for  the  most  part,  steadily 
progressive,  the  transition  of  these  various  so-called  stages  into  each  other  is 
usually  very  gradual,  and  the  separation  of  the  disease  into  stages  is  really 
artificial.  However,  for  practical  purposes  it  is  convenient.  Roughly 
speaking,  the  period  of  the  established  disease  in  the  expansive  and  depres- 
sive forms  consists  of  first,  a  stage  in  which  the  expansive  or  depressive  mental 
state  is  at  its  fullest  development ;  secondly,  a  stage  in  which  the  dementia 
has  increased  to  such  an  extent  that  well-marked  delusions  no  longer  exist, 
and  in  which  at  most  mere  traces  of  the  former  expansive  or  depressive  men- 
tal state  are  found  ;  and,  thirdly,  of  a  stage  in  which  the  dementia  has  become 
so  pronounced  that  psychic  life  is  almost  extinct.  It  will  serve  our  purpose 
best  to  consider  the  special  symptoms  of  the  various  forms  of  paretic  dementia 
separately.     We  will,  therefore,  turn  our  attention  first  to  the  expansive  form. 

First  Stage  of  the  Established  Disease. 

Symptoms  of  the  Expansive  Form.  As  just  stated,  this  stage  most  frequently 
begins  gradually,  so  that  it  is  impossible  to  say  when  the  initial  period  has 
ended  and  the  first  stage  of  the  disease  begun.  We  must  remember,  how- 
ever, that  at  times  it  is  ushered  in  suddenly  by  an  apoplectiform  attack. 

1  Die  progressive  Paralyse  der  Irren,  Berlin,  1880. 


PABETIG  DEMENTIA.  677 

We  notice  at  once  that  many  of  the  symptoms  presented  in  the  initial 
period  are  now  more  marked  than  before.  Mental  failure,  for  instance,  is  more 
evident ;  memory,  especially  for  recent  events,  is  feebler  than  before,  and  this 
is  likewise  true  of  attention,  judgment,  and  will  power.  Especially  notice- 
able, also,  is  the  increase  in  the  loss  of  the  power  on  the  part  of  the  patient 
of  appreciating  the  actual  circumstances  in  which  he  is  placed  or  to  recog- 
nize properly  his  own  relations  to  his  business  or  to  the  people  about  him. 
These  evidences  of  progressive  dementia  are  not,  however,  the  most  striking 
features  of  this  stage.  New  symptoms  are  now  added,  and  they  are  so 
common  as  to  be  characteristic.  The  tendency  to  boastfuluess  and  occa- 
sional exaggeration,  noted,  perhaps,  in  the  initial  period,  now  becomes  very 
marked. 

Delusions  most  extravagant  in  character  make  their  appearance.  The 
patient  believes  himself  to  be  a  person  of  great  importance,  to  be  possessed 
of  extraordinary  physical  strength,  or,  what  is  most  common,  he  believes 
himself  to  be  the  possessor  of  enormous  wealth.  If  the  patient  be  a  woman, 
she  is  endowed  with  great  personal  beauty,  is  blessed  with  an  extraordinary 
number  of  children,  or  is  favored  by  more  than  the  usual  number  of  lovers 
and  husbands.  A  characteristic  of  these  delusions  of  grandeur,  as  they  are 
termed,  is  that  they  are  imperfectly  systematized,  that  they  are  often  feebly 
held,  and  that  they  are  always  grossly  improbable.  They  are,  further,  ex- 
tremely variable.  The  patient  who  tells  us  to-day  that  his  wealth  was  the 
result  of  some  great  invention,  to-morrow  tells  us  that  he  received  it  as  a 
bequest,  or  he  makes  no  effort  to  account  for  it  at  all.  The  patient  who 
to-day  asserts  that  he  is  v»"orth  two  hundred  thousand  dollars,  may  to-morrow 
assert  that  he  is  worth  several  billions,  or  the  next  day  but  a  fraction  of  this 
amount.  In  like  manner  does  the  substance  of  the  delusions  change.  To- 
day he  is  a  king  or  emperor,  to-morrow  a  great  physician,  a  great  judge,  or 
the  richest  man  in  the  world.  Some  of  the  delusions,  however,  may  be  more 
persistent  than  others  and  slightly  more  systematized.  This  is  particularly 
true  of  the  delusions  of  wealth.  Many  of  these  expansive  ideas  have  no 
connection  at  all  with  each  other,  and  they  all  betray  great  inherent  weak- 
ness.    The  following  case  will  serve  as  an  illustration : 

R.  J.  B.,  admitted  to  the  Philadelphia  Hospital  February  10, 1895  ;  white, 
aged  fifty-one  years,  salesman. 

Family  history  negative  as  to  mental  and  nervous  diseases. 

Personal  history :  Patient  had  a  severe  blow  on  the  back  of  the  head  in 
1876,  which  left  him  with  a  headache  for  several  years.  Has  also  been  a 
steady  drinker,  frequently  committing  excesses.  In  1887,  after  a  drinking 
bout,  his  friends  say  that  he  "  acted  crazy  "  for  a  week  or  ten  days. 

Has  for  some  time  past  been  indifferent  to  the  wants  of  his  family.  Within 
five  months  developed  wild  schemes  and  delusions  as. to  money-getting,  wealth, 
etc.  Pawned  anything  he  could  find  at  home ;  talked  extravagantly,  said 
he  stopped  runaway  horses,  etc.  Gave  checks ;  signed  his  mother's  name  to 
checks  on  the  Centennial  Bank,  where  some  years  ago  he  had  an  account. 
Claimed  to  have  inherited  vast  estates.  Abandoned  his  religious  belief  and 
joined  the  new  order  of  the  "  Third  Christians." 

At  the  time  of  admission  the  patient  was  asked  the  following  question  : 
What  is  your  business?  He  replied:  "I  am  a  manufacturer  of  the  first 
character  of  ladies'  shoes,  having  been  in  the  business  for  twenty-five  years. 
Our  firm  is  a  queer  combination,  me  a  Friend,  two  Jews,  and  a  Dutch  Roman 
Catholic,  so  we  never  discuss  religion.  Our  firm  does  a  business  of  over 
$600,000  a  year,  the  profits  being  28  to  30  per  cent.  We  make  nothing  but 
the  very  best  class  of  shoes,  silk  linings,  and  many  have  either  gold  or  silver 
buttons."     Says  that  he  has  not  accumulated  much  from  business,  as  he  has 


678  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

had  to  have  his  hand  in  his  pocket  continually  to  keep  his  brother's  head 
above  water.  "  I  have,  however,  been  fortunate  in  having  been  '  left '  $6,000,- 
000  in  the  following  way  :  In  January,  1877,  while  strolling  through  the 
Park,  I  caught  the  runaway  horses  of  a  gentleman,  and,  no  doubt,  saved  his 
life.  He  took  my  name  and  address,  and  said  sometime  I  would  hear  from 
him.  Four  months  ago  he  died,  leaving  me  $3,000,000,  and  there  was  a 
codicil  which  said  that  if  not  satisfied  I  should  ask  for  more,  and  so  I  asked 
for  $3,000,000  more.  I  also  own  two  charitable  hospitals — one  for  children 
and  one  for  adults — which  I  have  endowed  for  $1,000,000  each;"  and  thus, 
in  a  quiet,  self-satisfied  manner,  he  speaks  of  his  great  wealth  and  the  number 
of  relatives  he  intends  to  assist  financially.  He  states  further  that  he  "  was 
Governor  of  this  State ;  in  1873,  Mayor ;  at  the  present  time  he  is  United 
States  Senator,  and  has  been  recently  nominated  for  Select  Council."  Says 
that  he  has  "always  had  the  biggest  majority  of  any  one  in  this  city,"  and 
has  "a  large  following,"  and  thinks  he  ought  to  take  the  position  of  Coun- 
cilman to  halt  two  men  who  are  robbing  the  city.  Prefers  not  to  give  the 
names  of  the  two  men  at  present.  He  "  is  defending  one  in  a  suit,  and  while 
defending  him  as  a  lawyer  he  will  do  as  little  to  help  him  as  possible."  In 
another  minute  he  tells  us  that  he  graduated  in  medicine  at  Harvard,  in 
Berlin,  and  at  Paris ;  that  he  has  practised  medicine  for  eighteen  years. 
Since  sixteen  years  of  age  "  has  been  an  elegant  singer  and  player." 

In  appearance  he  is  sleepy  looking,  nervous  in  action,  and  yet  calm  in 
mind.  Hardly  recognizes  his  surroundings,  calls  the  hospital  the  "Hughes 
Academy,"  but  really  does  not  know.  His  whole  demeanor  during  his  men- 
tal examination  was  that  of  a  man  who  believed  exactly  what  he  said. 

February  12,  1895.  His  "delusions  of  grandeur"  are,  if  possible,  growing 
greater,  but  he  is  gradually  adapting  himself  to  the  discipline  of  the  hospital ; 
sleeping  and  eating  well. 

February  15th.  At  5.45  last  evening  was  determined  to  leave  the  hospital, 
caught  up  a  chair  and  struck  the  window  with  it,  breaking  a  pane  of  glass. 
When  the  attendant  endeavored  to  quiet  him  he  attacked  the  latter  with  the 
chair.     Was,  however,  finally  quieted. 

March  5.  After  the  outbreak  above  mentioned  the  patient  was  transferred 
to  Ward  5  (acute  ward),  and  placed  in  bed.  He  has  been  perfectly  tracta- 
ble since,  and  has  in  every  way  submitted  to  the  discipline  of  the  ward.  After 
one  week  in  bed  he  was  again  permitted  to  be  up  and  took  his  place  in  the 
ward  day-room.  His  delusions  have  grown  in  vastuess,  so  that  now  he  esti- 
mates his  wealth  at  $150,000,000,  $50,000,000  of  which  he  made  "  in  as  many 
minutes."  He  is  still  not  cognizant  of  his  surroundings.  Shows  no  discontent 
with  his  detention. 

Somatic  condition :  Face,  exj^ressionless,  pale.  Eyes,  partial  ptosis,  pupils 
small,  unequal — the  right  larger  ;  reaction  to  light  imperfect ;  accommoda- 
tion normal.  Tongue,  slightly  tremulous.  Knee-jerk,  slightly  exaggerated. 
No  ankle-clonus.  Cremasteric  reflex  feeble.  Heart,  vessels,  lungs,  and 
abdominal  viscera  negative. 

In  keeping  with  the  expansive  mental  condition,  the  bearing  and  expres- 
sion of  the  patient  indicate  satisfaction  and  contentment.  Often  great  pleas- 
ure and  happiness  are  depicted  on  his  countenance.  The  expression,  how- 
ever, may  be  modified,  as  we  shall  presently  see,  by  such  factors  as  the  partial 
efiacement  of  the  normal  wrinkles  and  folds  of  the  skin,  slight  facial  in- 
equality, tremor,  and  twitching. 

It  not  infrequently  occurs  that  in  this  foi'm  marked  delusions  are  absent, 
the  expansive  state  being  merely  indicated  by  the  patient's  manner  and  ex- 
pression, and  by  his  oft-repeated  statement  that  he  is  feeling  very  well  and 


PARETIC  DEMENTIA.  679 

that  he  was  never  better  in  his  life.  In  other  words,  an  exaggerated  sense 
of  physical  well  being  is  at  times  the  only  indication  of  the  expansive  con- 
dition. 

Occasionally  during  the  expansive  stage,  the  exaltation  increases  to  such 
an  extent  that  the  patient  may  for  short  periods  be  in  a  condition  closely 
simulating  ordinary  mania.  There  is  marked  excitement  and  restlessness. 
Sometimes  the  patient  is  destructive,  and  his  language  foul  and  conduct  inde- 
cent. Such  a  maniacal  condition  is  usually  brief,  though  sometimes  it  is 
prolonged.  It  is  important  also  to  state  that  occasionally  a  sudden  maniacal 
outbreak  seems  to  replace  the  apoplectiform  or  epileptiform  seizures  seen  in 
other  cases.  These  maniacal  outbreaks  are  in  such  instances  followed,  like 
the  seizures,  by  a  marked  increase  of  the  dementia.  It  is  further  a  note- 
worthy fact  that  cases  of  paretic  dementia  presenting  marked  excitement  or 
maniacal  attacks  run  a  comparatively  rajDid  course. 

Sometimes  the  mania  is  i-eplaced  by  an  intense  motor  excitement,  the  so- 
called  "  silent  excitement "  (Mickle),  in  which  the  patient  is  continually 
moving  his  limbs,  pulling  restlessly  at  his  bed-clothing,  or  pushing  at  the 
objects  about  him,  and  at  the  same  time  resisting  interference  from  his  atten- 
dant, even  when  this  is  necessary  for  his  immediate  wants.  Hours  may  be 
spent  in  this  restless  moving,  pulling,  pushing,  shoving  to  and  fro. 

Little  by  little,  as  the  case  progresses  and  the  dementia  becomes  more 
marked,  the  delusions  of  grandeur  become  gradually  less  clear  and  less 
coherent  until  finally  they  are  rej^resented  merely  by  fragmentary  ideas. 
The  patient  then  passes  into  the  next  stage  of  the  disease,  that  of  simple 
dementia. 

Symptoms  of  the  Depre-mve  Form.  Instead  of  the  expansive  mental  state 
supervening  upon  the  initial  period,  the  patient  passes  in  tliis  form  into  a 
state  of  marked  mental  depression.  Delusions  of  both  physical  and  spiritual 
ills  make  their  appearance.  Sometimes  hypochondriasis,  at  other  times 
melancholia  is  most  pronounced.  Occasionally  hypochondriacal  ideas  are  the 
direct  outcome  of  the  mental  depression  observed  at  the  close  of  the  initial 
period.  The  patient  then  has  delusions  of  some  hopeless  physical  disease; 
he  may  believe,  for  instance,  that  his  blood  has  become  congealed ;  that  his 
viscera  have  undergone  decay ;  that  his  bones  are  broken  in  many  places ; 
that  he  has  lost  his  arms  or  lost  his  legs ;  that  he  cannot  eat,  because  he  has 
no  longer  a  mouth,  or  that  his  bowels  have  become  hopelessly  obstructed. 
Sometimes  these  ideas  are  replaced  by  delusions  of  "  belittlement "  (Mickle), 
in  which  the  patient  believes  himself  to  have  wasted  away,  grown  smaller, 
become  dwarfed,  etc.  In  other  cases,  again,  the  patient  suffers  from  ideas  of 
impending  evil,  delusions  of  persecution,  of  poisoning,  or  that  he  can  no 
longer  be  "  saved "  (that  is,  in  a  spiritual  sense).  Just  as  the  delusions 
of  grandeur  are  extremely  shifting  and  poorly  systematized,  so  it  is  with 
these  ideas  of  spiritual  and  physical  ills.  Further,  in  the  larger  number 
of  cases  of  the  depressive  form,  hypochondriacal  and  melancholic  ideas  are 
intermingled,  though  it  is  usually  the  case  that  one  or  the  other  group  of 
delusions  is  uppermost.  As  in  true  melancholia,  suicidal  attemjDts  may  be 
made,  but  these  for  obvious  reasons  are  infrequent  and  rarely  successful. 

It  is  important  to  add  that  hallucinations  are  more  marked  in  the  depres- 
sive than  in  the  expansive  form.  The  patient  hears  voices,  and  may  base 
his  delusions  of  persecution  upon  this  symptom.  Hallucinations  of  taste 
and  smell  are  also  pi'eseut,  and  may  in  turn  serve  as  the  basis  of  delusions  of 
poisoning.  Finally,  the  depressive  form  of  paretic  dementia  appears  to  be 
somewhat  more  frequent  among  women  than  among  men. 

In  its  course  this  form  is  progressive,  like  the  expansive  form,  though,  as  a 
rule,  much  more  slowly.     Like  the  expansive  form,  again,  it  may  be  inter- 


680  NERVOUS  DISEASES  ANB  THEIR  TREATMENT. 

rupted  now  and  then  by  epileptiform  or  apoplectiform  seizures,  or  it  may 
pass  gradually  into  the  second  stage  of  the  established  disease,  namely,  that 
in  which  the  depressive  delusions  are  forgotten,  and  nothing  but  simple  de- 
mentia remains. 

Rarely,  the  expansive  and  the  depressive  mental  states  alternate  with  each 
other,  either  by  sudden  transitions,  or  separated  by  an  interval  in  which  no 
delusions  are  present.  This  fact  has  given  rise  to  the  expression  of  "  the 
circular  form  "  of  paresis.  Several  such  alternations  may  take  place  in  the 
course  of  the  disease.  The  condition  is,  however,  easily  differentiated  from 
ordinary  "  circular  insanity  "  by  the  accompanying  dementia,  which  is  always 
more  or  less  marked  and  progressive.  The  mere  occurrence  of  a  form  of 
paresis  in  which  expansive  and  depressive  mental  states  alternate  is  evi- 
dence that  the  distinction  between  the  various  forms  we  have  described  can- 
not be  considered  as  absolute.  Indeed,  to  go  further,  it  is  by  no  means  an 
uncommon  experience  to  find,  in  the  expansive  form,  traces  of  depressive  de- 
lusions or  even  short  periods  in  which  mental  depression,  distress  or  fear  is 
uppermost. 

As  in  the  maniacal  or  expansive  form,  attacks  of  intense  motor  excite- 
ment, the  "  silent  excitement  "  already  mentioned,  may  occur.  Again,  it 
sometimes  happens  that  just  as  in  the  expansive  form  there  is  present  merely 
a  feeling  of  heightened  physical  well  being,  without  well-marked  delusions, 
so  in  the  depressive  form  there  may  be  present  merely  a  vague  feeling  of  de- 
pression and  of  illness.  In  rare  cases  again,  the  symptoms  resemble  those 
of  a  stuporous  melancholia  or  a  simple  stuporous  insanity.  According  to 
Mickle,  the  physical  signs  are  in  such  instances  at  first  absent  or  slight,  though 
later,  and  generally  after  a  remission,  the  physical  signs  may  slowly  increase, 

Symptoms  of  the  Simple  or  Uncomplicated  Form.  Here  both  the  expansive 
and  the  depressive  mental  states  are  wanting,  and  the  disease  resembles  in 
its  course  a  simple  progressive  dementia.  Gradual  loss  of  memory  and  of  the 
other  mental  faculties  becomes  more  and  more  marked.  It  can  readily  be 
understood  that  there  is  a  time  when  the  mental  condition  of  all  cases  of 
paresis  is  the  same.  For  instance,  a  case  of  the  expansive  form  which  has 
progressed  so  far  that  well-marked  delusions  have  been  effaced  is  in  a  condi- 
tion indistinguishable  from  that  of  the  simple  or  uncomplicated  form.  The 
latter  occurs  beyond  a  doubt  more  frequently  among  women.  Indeed,  paresis 
is,  almost  as  a  rule,  milder  in  women  than  in  men,  and  the  dementia  is  apt 
to  be  of  a  quiet  type.^  The  simple  form,  further,  differs  from  the  other 
forms  by  frequently  ajDpearing  at  a  relatively  early  age.  It  is  often  exces- 
sively gradual  in  its  onset,  and  its  covirse  so  smooth  that  for  a  long  time  it 
may  remain  unrecognized. 

General  Symptoms  Common  to  or  More  or  Less  Liable  to  he  Present  in  All 
Forms  of  the  Established  Disease.  When  divesting  the  expansive  and  de- 
pressive forms  of  their  special  features,  an  underlying  basis  of  clinical  facts 
is  revealed  which  is  practically  common  to  all  forms.  We  have  already 
noted  how  with  the  appearance  of  the  fully  developed  disease  mental  failure 
becomes  more  pronounced.  Memory,  judgment,  and  will-poAver  are  feebler 
than  before.  All  of  the  psychic  anomalies  observed  in  the  prodromal  period 
become  exaggerated.  So,  too,  the  various  physical  symptoms,  traces  of 
which  were  seen  in  the  prodromal  period,  become  more  pronounced.  If  we 
test  the  strength  of  the  muscles  we  find  that  muscular  power  is  now  decid- 
edly diminished.  It  is  true  that  sometimes  decided  loss  of  strength  does  not 
appear  unless  the  test  by  the  dynamometer  be  repeated  at  short  intervals  ; 
rapidly  induced  fatigue  is  then  noted.     Tremor  may  also  be  present,  espe- 

•  Mickle,  loc.  cit.;  Elkins,  Lancet,  1894,  p.  1495. 


PARETIC  DEMENTIA.  681 

cially  when  the  patient  makes  a  voluntary  effort.  Generally  the  movements 
are  jerky  and  spasmodic.  Motor  disturbances  are,  as  a  rule,  most  marked 
in  the  face.  Irregularly  recurring  twitches  of  the  facial  muscles,  twitching 
or  tremulousness  of  the  lips  or  of  the  muscles  about  the  eyes  and  fore- 
head, are  striking  symptoms.  The  various  folds  about  the  face  are  less 
evident  than  in  health.  Especially  is  this  the  case  with  the  naso-labial 
fold  and  the  lines  about  the  forehead.  In  addition  the  face  may  seem 
slightly  puffed  or  tumid,  that  is,  fuller  than  normal ;  the  features  may  seem 
flabby  and  coarse.  Sometimes  one  half  of  the  face  distinctly  droops  or  is 
more  frequently  disturbed  by  sj)asms  and  tremors  than  its  fellow,  so  that 
the  two  sides  appear  to  have  a  different  expression.  When  asked  to  show 
the  tongue,  the  patient  may  j^rotrude  it  by  jerky  and  irregular  move- 
ments. 

Myosis,  which  may  have  been  noted  in  the  prodromal  period,  is  now  as  a 
rule  marked ;  or,  there  may  be  present  unequal  dilatation  of  the  pupils. 
Reaction  of  the  pupils  to  light  is  either  sluggish  or  is  altogether  lost.  Some- 
times other  difficulties,  such  as  diplopia,  partial  ptosis,  and  other  conditions 
pointing  to  affections  of  the  ocular  nerves  are  met  with. 

As  may  be  inferred  from  what  has  been  said  in  the  account  of  the  pro- 
dromal period,  the  gait  is  very  variable.  The  latter  may  still  present  only  a 
slight  departure  from  the  normal.  On  the  other  hand,  it  may  be  somewhat 
ataxic  or  spastic ;  sometimes,  indeed,  it  partakes  of  both  of  these  features,  and 
in  such  cases  the  elements  of  an  ataxic  paraplegia  are  present.  At  other 
times  it  is  atypical.  In  those  cases  in  which  the  spinal  symptoms  are  pro- 
nounced or  in  which  they  precede^  the  cerebral  symptoms,  abnormalities  of 
gait  are  more  evident.  Uncertainty  of  movement  may  also  be  noted  in  the 
hands,  especially  when  the  patient  attempts  to  button  his  clothes  or  to  pick 
up  an  object.  The  knee-jerks  and  other  tendon  reactions  may  reveal  a  con- 
dition similar  to  that  met  with  in  the  prodromal  period ;  they  may  be  exag- 
gerated, normal,  diminished,  or  lost.  It  can  very  readily  be  understood  that 
the  knee-jerks  in  paresis  are  a  very  variable  factor  ;  that  if  spastic  symptoms 
predominate  they  are  increased,  and  that  if  ataxic  symptoms  are  in  excess 
they  are  diminished  or  lost. 

The  awkwardness,  thickness,  and  hesitation  in  speech,  present  perhaps  in 
the  initial  period,  is  in  this  stage  apt  to  be  pronounced.  It  is  noted  when  the 
patient  attempts  to  speak  that  the  twitching  of  the  lips  and  of  the  facial 
muscles  becomes  more  marked.  The  patient  stammers,  stutters,  and  pro- 
nounces the  words  imperfectly,  often  slurring  certain  syllables.''  Sometimes 
syllables  are  omitted  altogether,  or  there  are  almost  constant  breaks  or  halts 
between  syllables  and  words.  Various  factors  contribute  a  share  in  the 
production  of  these  phenomena.  Some  of  the  symptoms  indicate  defec- 
tive action  of  the  cortical  centres,  the  third  left  frontal  and  other  convolu- 
tions. There  may  be  more  or  less  verbal  amnesia,  and  the  speech  may  be 
constantly  arrested  by  the  inability  of  the  patient  to  recall  or  frame  the  neces- 
sary words.  Frequently  also  the  wrong  word  is  used.  The  tremulousness 
and  ataxic  movements  of  the  various  organs  concerned  in  articulation — the 
tongue,  lips,  and  palate — account  in  part  for  the  imperfect  enunciation. 
As  might  be  expected,  this  is  especially  noticeable  in  words  containing 
dentals  and  labials.  The  syllable  containing  them  may  be  slurred  alto- 
gether, or  various  of  the  labials  or  dentals  may  be  substituted  for  each  other, 
as  for  instance,  a  b  for  a  |),  a  (i  for  a  t.     Generally  the  speech  of  paresis  is 

1  The  spinal  symptoms  may  simulate  locomotor  ataxia,  lateral  sclerosis,  combined  sclerosis  and 
rarely  amyotrophic  lateral  sclerosis. 

2  Sometimes  bulbar  symptoms  are  precocious  as  well  as  pronounced,  and  then  give  rise  to  the  so- 
called  "  bulbar  form." 


682  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

slow,  though,  when  marked  exaltation  and  excitement  exists,  the  words  may 
follow  each  other  with  great  rapidity. 

In  studying  the  speech  j)henomena  of  this  stage  we  should  remember  that 
though  the  psychic  and  other  symptoms  may  be  pronounced,  the  speech  de- 
fect may  still  be  comparatively  slight.  As  a  rule,  however,  defects  of  articu- 
lation can  be  elicited  by  asking  the  patient  to  pronounce  words  which  require 
nicety  of  adjustment  of  the  tongue  and  lips,  for  example,  "  truly  rural," 
"  Popocatapetl,"  and  the  like. 

In  keeping  with  these  facts  the  handwriting  is  also  decidedly  changed ;  it 
is  shaky  and  irregular,  and  the  patient  makes  in  addition  the  grossest  errors 
of  spelling  and  of  grammar.  Elision  of  letters,  of  syllables,  or  of  words, 
occurs  with  frequency,  while  the  paper  is  often  smeared  and  blotted.  The 
writing,  when  it  can  be  interpreted  at  all,  deals  disconnectedly  with  the  de- 
lusions of  the  patient.  Sentences  are  incomplete,  words  run  together,  and 
dates  and  signatures  are  omitted. 

Sensory  symptoms  are  not,  as  a  rule,  pronounced  in  this  stage  of  the  dis- 
ease. However,  now  and  then,  there  is  distinct  blunting  of  the  cutaneous  sensi- 
bility ;  and  this  goes  hand-in-hand  with  the  diminution  or  loss  of  the  cutaneous 
reflexes  observecl  in  so  many  cases.  Actual  anaesthesia  appears  to  be  rare. 
Various  disturbances  of  the  special  senses  may  also  be  noted ;  for  example, 
diminution  of  visual  power,  color-blindness,  amaurosis,  or,  on  the  other  hand, 
visual  hyperaesthesia.  Similar  conditions  may  be  noted  as  regards  the  senses 
of  hearing  and  smell.  Hallucinations  of  vision  and  of  hearing,  as  has  already 
been  pointed  out,  are  not  infrequent,  especially  in  the  dej)ressive  form  of  the 
disease. 

Second  Stage  of  the  Established  Disease.  Little  by  little,  the  vari- 
ous physical  and  mental  symptoms  of  the  preceding  stage  become  more  and 
more  pronounced.  Conversation  becomes  more  and  more  difficult,  owing  not 
only  to  the  anomalies  of  speech,  but  also  to  the  steadily  increasing  dementia. 
Many  of  the  previous  speech  symptoms  are  accentuated.  The  words  follow 
each  other  slowly  and  are  badly  put  together.  The  speech  is  drawling, 
halting,  and  stumbling,  and  at  the  same  time  the  quality  of  the  voice  becomes 
changed.  It  may  become  hoarse,  lower  in  pitch,  and  may  sound  hollow  and 
rough,  or  perhaps  indistinct  and  weak.  Less  frequently  the  pitch  is  raised. 
Often  the  voice  is  monotonous,  all  of  the  words  being  equally  intoned.  These 
symptoms  are  doubtless  due  to  weakness  and  irregularity  of  action  of  the 
muscles  of  the  larynx.  Sometimes,  and  especially  after  convulsive  and  apo- 
plectiform attacks,  aphasic  symptoms,  more  or  less  pronounced,  make  their 
appearance,  and  these  may  not  be  confined  to  mere  motor  aphasia,  but  may 
also  include  word-deafness.     (See  page  437.) 

Gradually  the  delusions  of  grandeur  or  of  belittlement  and  depression 
vanish,  and  only  on  occasion  do  they  recur,  and  then  in  a  fragmentary  man- 
ner. Finally  they  are  altogether  lost.  In  numerous  ways  the  patient  shows 
that  his  appreciation  of  his  surroundings  is  more  imperfect  than  before.  In 
every  respect  there  has  been  an  increased  diminution  in  his  sensibilities.  If 
he  walks  at  all  he  stumbles  and  staggers  from  weakness  and  ataxia.  Occa- 
sionally his  steps  are  short,  and  he  moves  as  though  his  limbs  were  more  or 
less  rigid.  Movements  of  his  arms  are  ataxic  and  jerky.  The  truncal  mus- 
cles are  weak  and  their  action  is  irregular.  The  patient,  as  he  sits  in  his 
chair,  lolls  forward,  or  frequently  to  one  side.  He  now  fails  to  evacuate  the 
bladder  or  the  bowel  at  will,  and  he  frequently  becomes  extremely  filthy. 
The  expression  of  his  face  is  now  one  of  marked  dementia.  The  various 
folds  and  wrinkles  of  the.  skin  are  more  or  less  effaced.  The  features  are 
coarse  and  flabby,  and  the  expression  is  vacuous  and  indifferent.  Occasion- 
ally tremors  and  spasmodic  twitchings  distort  the  features,  but  they  seem  to 


PARETIC  DEMENTIA.  683 

correspond  to  no  emotion  of  the  patient.  The  two  sides  of  the  face  are  some- 
times unequal,  but  decided  facial  palsy  does  not  exist.  Occasionally,  also, 
there  is  automatic  grinding  of  the  teeth — a  true  masticatory  spasm.  The 
pupils,  as  in  the  previous  stage,  respond  feebly  or  not  at  all  to  light.  They 
may  still  be  small  and  contracted,  though  not  infrequently  they  are  in  this 
stage  dilated,  as  a  rule  unequally.  If  asked  to  protrude  the  tongue,  the 
patient  frequently  fails  to  comply.  At  other  times,  it  is  protruded  partially 
and  with  jerky  movements.  The  patient's  habits  and  manner  of  eating  be- 
come more  gross  than  ever,  and  inasmuch  as  the  fauces  and  pharynx  are 
blunted,  he  is  sometimes  in  danger  of  choking.  Digestion  is  not  much  dis- 
turbed, though  sometimes  diarrhoea  is  present. 

Bed-sores  are  aj)t  to  form,  also  boils,  carbuncles,  blebs,  herpes  zoster,  or  the 
peculiar  hemorrhagic  formation  known  as  hematoma  auris.  At  various  times 
during  this  j)eriod,  apoplectiform  or  epileptiform  seizures,  resembling  those 
occurring  in  the  preceding  or  even  the  prodromal  period,  may  be  observed. 
In  fact,  their  recurrence  at  this  stage  is  rather  frequent.  These  attacks  are, 
as  before,  not  followed  by  any  permanent  loss  of  power,  but  for  a  number  of 
hours  following  such  a  seizure  there  may  be  a  more  or  less  marked  paresis  of 
one  side,  or  perhaps  a  temporary  aphasia.  Jerkings  and  twitchings  confined 
to  one  or  more  limbs  may  be  observed  for  some  time  after  such  a  seizure. 
Sometimes  the  attacks  terminate  fatally. 

Third  Stage  of  the  Established  Disease.  Finally  the  patient 
becomes  hopelessly  bed-ridden.  Voluntary  movements  are  either  not  at- 
tempted, or  attempted  without  evident  purpose.  They  are  more  irregular, 
more  shaky,  more  ataxic  than  before.  Locomotion,  if  it  be  at  all  pos- 
sible, is  attended  with  the  utmost  difficulty.  The  legs,  especially  in  the  non- 
ataxic  form,  are  now  markedly  rigid,  and  in  many  cases  severe  contractures 
of  both  arms  and  legs  make  their  appearance.  The  legs  become  flexed  over 
the  abdomen,  adducted  or  firmly  crossed,  while  the  arms  become  flexed  and 
drawn  over  the  chest.  These  cases  often  present  a  peculiar  picture  of  dis- 
tortion. Bed-sores,  if  not  present  before,  make  their  appearance  now.  Other 
trophic  changes,  also,  blebs,  boils,  hsematomata,  herpetic  eruptions  are  the 
rule.  The  skin  has  a  dirty  hue  and  a  greasy  feel.  The  loss  of  control  over 
the  sphincters  is  now  pronounced,  and  this  condition  adds  greatly  to  the 
difliculty  of  nursing  the  patient.  In  addition,  he  can  hardly  swallow  with- 
out the  risk  of  suffocation.  The  mental  faculties  are  completely,  or  almost 
completely  abolished.  At  times  some  trace  of  cerebration  is  observed,  but 
this  is  all.  From  now  on,  until  life  terminates,  the  existence  of  the  patient 
is  purely  vegetative.  Tuberculosis,  diarrhoea,  inflammation  of  the  bladder, 
or  disease  of  the  kidneys  finally  ends  the  picture. 

Summary  of  Symptoms.  Although  the  symptoms  of  paretic  dementia 
vary  greatly,  the  underlying  and  essential  features  are  always  the  same.  A 
brief  review  will  soon  convince  us  that  we  have  everywhere  to  deal  first  with 
gradual  loss  of  function,  and  secondly  with  various  perversions  of  function.  In 
other  words,  we  have,  first,  a  quantitative,  and  secondly  a  qualitative  change. 
For  convenience  it  is  well  to  divide  the  various  symptoms  into  (a)  psychic, 
(6)  motor,  (c)  sensory,  and  {d)  general  somatic,  trophic,  and  visceral  symp- 
toms. 

(a)  Psychic  Symptoms.  Here  the  initial  symptoms  are  those  indicative 
of  loss,  and  this  fact  is  especially  noticeable  as  regards  those  faculties  which 
are  among  the  latest  acquired  in  the  development  of  the  individual  or  in  the 
evolution  of  the  race.  It  is  seen,  for  instance,  in  the  loss  of  the  aesthetic 
faculty,  in  the  loss  of  the  sense  of  the  proprieties,  of  the  sense  of  shame,  and 
of  the  sense  of  obligation  to  family  and  to  friends.  The  same  fact  is  also 
evident  in  loss  of  memory,  loss  of  will  power,  loss  of  judgment,  and  the  loss 


684  NERVOUS  DISEASES  AND  THEIR  TREATMENT 

of  power  to  appreciate  properly  the  current  events  and  the  current  demands 
of  daily  life. 

At  the  same  time  that  these  losses  are  observed,  or  subsequently,  various 
other  changes  qualitative  in  character  make  their  appearance.  Prominent 
among  these  are  the  perversions  of  the  moral  sense  which  we  have  already 
considered.  The  patient  may  lie,  steal,  deceive,  and  commit  forgery  or  be 
guilty  of  other  immoral  and  illegal  acts,  such  as  destruction  of  property,  in- 
cendiarism, burglary,  and  even  murder  (Mickle).  We  should  remember  in 
this  connection  that  crime  committed  by  paretics  is  characterized  by  feeble 
and  erratic  motive,  by  aimlessness  and  transparency.  Either  no  attempts 
whatever,  or  absurdly  ineffectual  attempts  at  concealment,  are  made. 
Many  minor  crimes,  also,  arise  not  so  much  from  the  perversion  of  the  moral 
nature  as  from  simple  loss  of  memory  and  loss  of  appreciation  of  the  environ- 
ment. This  is  evidently  the  case  in  many  small  purposeless  lies  and  thefts, 
the  patient  in  the  one  instance  merely  forgetting  what  has  actually  occurred, 
and  in  the  other  mistaking  the  belongings  of  others  for  those  of  his  own. 
This  is  also  usually  the  case  with  minor  errors  of  accounts  and  with  mistakes 
made  in  paying  out  or  in  changing  money.  The  grosser  acts  sometimes  have 
their  origin  in  the  expansive  or  depressive  delusions  of  the  patient. 

By  reason  of  the  blunting  of  the  higher  faculties,  the  inhibition  of  the 
lower  and  coarser  tendencies  is  lessened,  and  in  consequence  various  excesses 
are  committed.  We  have  already  spoken  of  the  alcoholism  so  frequently 
observed  in  these  cases,  as  well  as  of  the  tendency  to  sexual  excess.  The  lat- 
ter may  lead  to  improper  proposals,  attempts  at  rape,  adultery,  bigamy,  mar- 
riage with  prostitutes,  and  various  forms  of  abnormal  sexual  gratification. 

In  addition  to  loss  and  perversion  of  function,  other  psychic  anomalies, 
hallucinations,  illusions,  and  delusions  make  their  appearence.  The  hallucina- 
tions may  consist /r.si,  of  anomalies  of  the  general  "body  sense,"  the  coenges- 
thesis,  the  "  Gemeingefiihl "  of  the  Germans,  and  secondly,  of  anomalies  of  the 
various  special  sensations. 

The  heightened  sense  of  physical  well-being  or  of  the  opposite  condition  of 
physical  ill-being,  is  best  interpreted,  in  the  opinion  of  the  writer,  as  an  halluci- 
nation of  the  coensesthesis  or  body  sense,  that  vague  feeling  of  existence  to  de- 
scribe which  we  have  no  special  English  word.  Hallucinations  of  this  sense 
may  also  take  the  form  of  various  anomalies  of  consciousness.  The  patient,  for 
instance,  may  feel  as  though  he  possessed  a  double  personality,  or  as  though 
his  personality  were  changed.  He  may  feel  as  though  his  former  personality 
were  passed  and  gone,  and  he  may  speak  of  himself  in  the  third  person ;  or 
the  feeling  may  be  such  as  to  give  origin  to  the  delusion  that  he  has  died. 

Hallucinations  of  the  various  special  senses  are  not  infrequently  present. 
Visual  and  auditory  hallucinations  predominate.  They  appear  to  be  present 
in  an  almost  equal  degree.  They  are  found,  according  to  Mickle,  in  about 
40  per  cent,  of  the  cases.  Tactile,  gustatory,  and  olfactory  hallucinations 
are  present  in  about  12  per  cent.  The  various  disorders  of  the  muscular 
sense  are  also  to  be  relegated,  in  great  part,  to  the  field  of  hallucinations. 
The  fictitious  sense  of  great  muscular  strength,  or,  on  the  other  hand,  the 
sense  of  inability  to  move  are,  properly  speaking,  hallucinatory.  As  a  whole, 
hallucinations  are  met  with  to  a  greater  extent  in  the  depressive  form  than 
in  the  expansive  form  of  the  disease.  Not  infrequently,  as  might  be  ex- 
pected, they  are  linked  with  the  various  delusions  of  the  patients. 

As  regards  the  illusions  of  paresis,  it  is  difficult  to  separate  them  from  the 
various  hallucinations.  That,  hoAvever,  they  play  an  important  part,  there 
can  be  no  doubt.  Especially  is  this  the  case  with  the  sense  impressions  de- 
rived from  the  various  viscera  and  structures  of  the  body.  Visceral  sense 
impressions,  it  must  be  remembered,  enter  normally,  but  slightly,  if  at  all. 


PARETIC  DEMENTIA.  685 

into  the  field  of  consciousness.  On  the  other  hand,  in  paretics  they  fre- 
quently enter,  not  only  largely,  but  are  incorrectly  interpreted.  Many  of 
the  delusions  as  to  the  bodily  condition  apparently  owe  their  presence  to 
these  illusions  of  the  visceral-sense  impressions.  This  is  notably  the  case  in 
the  depressive  form  of  the  disease,  in  which,  as  we  have  already  stated,  de- 
lusions of  bodily  and  visceral  ills  are  very  frequent. 

The  delusions  of  paresis  have  been  considered  in  connection  with  the 
various  forms.  Suffice  it  here  to  say  that  for  their  general  character  they 
are  dependent  upon  the  presence  of  the  expansive  or  depressive  mental  state, 
while  for  their  special  character  in  a  given  case  they  appear  to  be  largely 
dependent  upon  the  presence  of  general  and  special  hallucinations.  The 
supervention  of  the  expansive  or  depressive  mental  state  is  doubtless  closely 
related  to,  if  not  dependent  upon,  hallucinatory  conditions  of  the  coensesthesis, 
the  general  sense  of  bodily  and  psychic  existence.  Further,  we  have  also 
learned  that  these  expansive  or  depressive  mental  states  frequently  become 
exaggerated,  so  that  mania,  hypochondriasis,  and  melancholia,  in  various 
forms,  are  simulated.  We  see  at  once  that  it  is  unnecessary  to  suppose,  as 
Baillarger  has  done,  that  paretic  dementia  is  made  up  of  two  different  ele- 
ments, a  dementia  and  a  superimposed  mania,  or  melancholia.  Indeed,  the 
"  dual  theory,"  as  it  is  called,  adds  rather  confusion,  than  clearness,  to  our 
conceptions  of  paresis. 

(h)  Motor  Symptoms.  The  motor  symptoms  may  be  summarized  briefly 
as  general  weakness,  tremor,  twitching,  awkwardness  and  jerkiness  of  move- 
ment, localized  paresis,  ataxia,  abnormalities  of  gait,  and  contractures.  To 
these  are  to  be  added  the  speech  disturbances  and  the  various  apoplectiform 
and  epileptiform  seizures.  Many  of  these  phenomena,  the  reader  will  remem- 
ber, are  only  indicated  in  the  initial  or  prodromal  period,  and  are  not  infre- 
quently im]3erfectly  developed,  even  in  the  first  stage  of  the  established  dis- 
ease, though  in  due  course  they  inevitably  attain  their  full  development. 

The  speech  disturbances  are  made  up  of  various  difficulties  of  articulation 
and  of  defective  action  of  the  motor  speech-centre,  naming-centre,  etc.  To 
these  phenomena  there  are  added,  as  the  case  advances,  difficulties  due  to  the 
increasing  dementia.  The  ideas  which  the  patient  tries  to  convey  become 
more  and  more  fragmentary.  As  the  disease  advances  other  symptoms  may 
be  added — e.  g.,  word-deafness,  word-blindness,  etc.  The  abnormalities  of 
phonation  which  we  have  mentioned  also  make  their  appearance  in  time. 
The  hand-writing,  in  turn,  presents  peculiarities  resembling  those  of  the 
speech.  The  tremor,  ataxia,  and  jerkiness  are  variously  shown  in  the  forma- 
tion of  the  letters,  whilst  the  elision  of  letters,  syllables  and  words,  and  the 
fragmentary  arrangement  of  the  sentences  in  like  manner  indicate  cortical 
involvement. 

Seizures.  The  gradual  and  progressive  course  of  paretic  dementia  may  be 
interrupted,  as  we  have  seen,  by  sudden  convulsive  attacks  or  paralytic  seiz- 
ures. Sometimes  these  attacks  resemble  ordinary  aj)oplexy.  At  other  times 
they  strongly  resemble  epilepsy.  No  sharp  lines  can,  however,  be  drawn 
between  the  so-called  apoplectiform  and  epileptiform  attacks,  as  convulsions 
and  paralysis  may  be  present  in  both.  The  apoplectiform  attacks,  however, 
are  characterized,  as  a  rule,  by  more  or  less  marked  loss  of  consciousness, 
accompanied  by  some  form  of  paralysis,  most  frequently  a  hemiplegia,  and 
by  relaxation  of  the  sj)hincters.  In  an  epileptiform  attack  consciousness 
may  or  may  not  be  lost,  but  there  is  present  a  more  or  less  marked  convul- 
sion, which  may  or  may  not  be  followed  by  local  paralysis.  As  a  rule,  the 
apoplectiform  attacks  occur  either  during  the  initial  or  prodromal  period  or 
in  the  first  stage  of  the  established  disease,  although  they  may  occur  at  other 
periods.     The  epileptiform  convulsions  predominate  in  the  second  and  third 


686  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

stages  of  the  established  disease,  although,  like  the  apoplectiform  convul- 
sions, they  may  occur  in  the  earlier  periods.  It  is  not  unusual  to  find  in  a 
given  case  that  apoplectiform  seizures  occur  first,  and  are  later  replaced  by 
epileptiform  seizures. 

The  seizures  of  paretic  dementia  may  come  on  suddenly  and  without  warn- 
ing. At  other  times  they  are  preceded  by  a  more  or  less  marked  increase 
of  symptoms,  especially  insomnia,  restlessness,  excitement,  flushing  of  the 
face,  tremor  and  twitching  of  the  muscles,  and  sometimes  by  vertigo.  They 
present  also  all  degrees  of  severity,  being  sometimes  exceedingly  slight  and 
sometimes  profound.  Thus  the  epileptiform  convulsions  vary  from  attacks 
which  present  merely  the  severity  of  a  petit  mal  to  attacks  in  which  the  pa- 
tient is  for  many  hours  in  the  status  epilepticus.  The  majority  of  the  epilep- 
tiform attacks,  however,  resemble  an  epilepsy  of  modern  severity.  The  con- 
vulsive movements  may  be  widely  diffused  over  the  body — that  is,  may  be 
general — but  more  frequently  they  involve  especially  the  face  and  arm,  or 
the  face,  arm,  and  leg  of  one  side ;  that  is,  they  are  more  or  less  unilateral. 
Sometimes  the  entire  seizure  is  limited  to  one  limb  or  to  a  single  group  of 
muscles,  and  it  may  thus  simulate  a  Jacksonian  epilepsy.  Again,  it  is  not 
infrequent  for  a  convulsion  to  start  in  one  hand,  one  side  of  the  face,  or  in  a 
leg,  and  only  later  on  become  general.  Further,  the  attacks  do  not  recur  as 
does  epilepsy  ordinarily — i.  e.,  one  attack  now  and  then — but  the  seizures 
come  on,  as  it  were,  in  groups,  though  also  at  irregular  intervals.  One  seizure 
is  rapidly  followed  by  another,  until  the  patient  has  a  series  of  attacks,  with 
but  short  intervals  between  them.  Such  a  group  of  seizures  may  extend  over 
several  hours  or  days.  Having  occurred,  they  may  recur  very  shortly,  or 
after  a  more  or  less  prolonged  interval,  or  perhaps  never  again.  In  the 
slighter  epileptiform  seizures — those,  for  instance,  resembling  petit  mal — 
consciousness  may  not  be  appreciably  affected.  If  the  attack  be  of  marked 
severity,  however,  consciousness  is  apt  to  be  lost.  It  should  also  be  stated 
that  those  attacks  in  which  a  series  of  seizures  occur  are  apt  to  be  followed 
by  paralysis  of  the  parts  that  were  most  violently  convulsed.  It  is  not  infre- 
quent to  note  distinct  paralysis  of  the  face  and  arm  and,  to  a  less  degree,  of  the 
leg  of  one  side.  Sometimes  conjugate  deviation  of  the  eyes  and  head  is  noted. 
At  other  times,  though  rarely,  crossed  or  alternate  hemiplegia  is  found ;  that 
is,  upon  one  side  there  may  be  ocular  paresis,  dilated  pujDil,  strabismus,  ptosis, 
etc.,  and  upon  the  other  paralysis  of  the  leg  and  arm.  It  may  also  happen 
that  during  a  series  of  seizures  the  limbs  of  one  side  may  be  in  a  condition 
of  tonic  spasm. 

Paralysis,  it  must  be  remembered,  does  not  necessarily  follow  an  epilepti- 
form seizure.  Further,  the  degree  of  paralysis  is  very  variable.  It  is  fre- 
quently, but  not  always,  related  to  the  intensity  of  the  seizure.  It  is  most 
marked  immediately  after  the  attack.  Subsequently  it  gradually  disappears. 
Convulsive  jerks,  and  twitchings  may  persist  for  some  hours,  and  even  days, 
in  the  affected  limbs.  In  the  typical  apoplectiform  attack  convulsive  move- 
ments do  not  occur.  However,  it  is  not  infrequent  to  find  some  indications 
of  their  presence.  The  hemiplegia  following  an  apoplectiform  attack  per- 
sists, as  a  rule,  for  several  days ;  sometimes  traces  of  it  never  altogether  dis- 
appear. At  times  a  temporary  aphasia  is  present.  Both  after  apoplectiform 
and  epileptiform  attacks  the  patient  is  dull,  heavy,  somnolent,  and  usually 
presents  a  rise  of  temperature.  The  thermometer  may  indicate  a  rise  of  4°  or 
5°  F.  above  normal.  Sometimes  fever  is  noted  for  a  brief  period  preceding  the 
attack.  It  is  also  noteworthy  that  the  temperature  in  the  axilla  of  the  paralyzed 
side,  on  the  side  which  was  most  convulsed,  is,  as  a  rule,  somewhat  higher  than 
the  axillary  temperature  of  the  opposite  side.  Every  now  and  then,  after  an 
apoplectiform  seizure,  bed-sore,  acute  decubitus,  occurs  on  the  paralyzed  side. 


T^ 


PARETIC  DEMENTIA.  687 


It  also  happens  that  the  seizures  occur  unaccompanied  either  by  convul- 
sive movements  or  by  loss  of  consciousness,  there  being  simply  a  sudden 
attack  of  paralysis.  Again,  instead  of  there  being  a  clonic  convulsion  there 
may  be  a  tonic  spasm  of  the  muscles  of  the  head  and  trunk,  the  head  being 
depressed  into  the  pillow  and  the  neck  and  shoulders  raised,  oposthotonus 
being  simulated.  Sometimes  other  fixed  positions  are  assumed  by  the  patient. 
These  attacks  are  aptly  termed  tetaniform^  seizures.  The  reader,  further, 
will  not  be  surprised  when  he  learns  that  in  some  patients,  more  especially 
among  women,  the  convulsive  attacks  occur  which  closely  resemble  hysteria, 
and  these  are  known  as  hysteriforni''  seizures. 

The  various  forms  of  seizures  occurring  duringparesis  cannot  be  sharply  sepa- 
rated from  each  other.  Besides,  great  variations  may  be  met  with.  How- 
ever, their  influence  upon  the  course  of  the  disease  is  similar,  no  matter  what 
their  form.  It  is  noted  that  after  a  seizure,  all  of  the  symptoms  presented 
by  the  patient  become  accentuated.  This  is  true  not  only  of  the  tremor, 
weakness,  and  ataxia,  but  also  of  the  various  mental  phenomena.  Some- 
times, as  we  will  see,  these  seizures  are  the  first  sign  of  the  terminaton  of  a 
remission. 

(c)  Sensory  Symptoms.  Cutaneous  sensibility  is  rarely  much  modified  in 
the  early  periods.  Sometimes  pricking  and  formication  of  the  skin  are  com- 
plained of.  Hypersesthesia  is  every  now  and  then  noted.  Later  on,  however, 
there  is  a  distinct  lessening  in  cutaneous  sensibility,  the  patient  paying  but 
little  attention,  in  the  advanced  stages,  to  pricks,  pinches,  bruises,  or  injuries 
of  the  surface.  This  loss  is,  as  a  rule,  more  marked  about  the  feet  and  legs 
than  elsewhere,  and  more  marked  about  the  arms  than  about  the  face.  These 
statements  appear  to  be  true  not  only  of  tactile  sensibility,  but  also  largely  of 
the  sensibility  to  pain  and  temperature. 

The  sense  of  taste  is,  probably,  judging  from  the  actions  of  the  patient, 
sooner  or  later  lost  or  perverted,  as  witness  the  eating  of  filth  and  excre- 
ment. Smell  also  appears  to  sufier  in  a  similar  way.  As  regards  hearing, 
hypersesthesia  may  be  noted  in  the  earlier  periods,  and,  later,  more  or  less 
marked  loss  of  hearing. 

Vision  also  sufiers.  Examination  shows  that  there  is  a  more  or  less  marked 
loss  of  vision  both  for  form  and  color.  Indeed,  amblyopia,  loss  of  color 
sense,  or  amaurosis  may  be  noted  early  in  the  case.  In  a  patient  recently 
under  the  observation  of  the  writer  partial  reversal  of  the  color  fields  was 
noted  during  the  prodromal  period.  Examination  of  the  fundus  of  the  eye 
reveals  in  the  advanced  stages  more  or  less  degeneration  and  atrophy  of  the 
optic  nerve.  The  pupils  are,  as  we  have  seen,  during  the  early  periods  apt 
to  be  contracted  and  spastic,  though  later  on  dilated,  sometimes  equally  so. 
Frequently  they  are  oval  or  ovoid,  or  present  other  irregularities  of  shape. 
Generally  the  iris  is  either  sluggish  or  absolutely  immobile  to  light  stimulus. 
Various  external  ocular  palsies  may  be  noted  giving  rise  to  some  form  of  stra- 
bismus, or  sometimes  to  a  partial  ptosis.     Nystagmus*  has  also  been  observed. 

In  addition  to  the  various  disturbances  of  general  and  special  sensibility 
there  are,  it  will  be  remembered,  various  abnormal  sensations  present  in  pare- 
sis, such  as  the  dazed  and  confused  feelings  in  the  head,  the  headache,  the 
neuralgia  and  ataxic  pains  of  the  initial  period,  and  also  the  various  abnor- 
mal visceral  sensations  noted  in  the  established  disease. 

(d)  General  Somatic,  Trophic,  and  Visceral  Symptoms.  The  cir- 
culation, in  the  larger  number  of  cases  of  paresis,  presents  an  increased  arte- 
rial tension.     Examination  of  the  heart  generally  reveals  an  accentuation  of 

1  Mickle  :  loc.  cit.  -  Loc.  cit. 

3  BaUet :  Progres  Med.,  1893,  2  s.  xvii.  433. 


688  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 


t      !«■ 


the  second  sound.  The  pulse-rate  is  not  markedly  changed.  Rarely  it  is 
slower  than  normal.     More  frequently  it  is  slightly  increased. 

The  respiration  presents  no  special  change,  save  that  in  advanced  cases 
disordered  rhythm  may  now  and  then  be  observed — a  rhythm  which  may 
closely  resemble  that  of  Cheyne-Stokes  respiration. 

Digestion  as  a  rule  is  well  preserved.  Decided  gastric  or  intestinal  symp- 
toms are  absent,  save  perhaps  in  the  third  stage  when  diarrhoeas  may  occur. 
Often,  too,  in  the  third  stage  the  movements  contain  undigested  food  or 
there  may  be  evidence  of  mucous  colitis  or  ulceration  of  the  bowel.  Hemor- 
rhages from  the  bowl  also  occasionally  occur. 

The  secretions  are  more  or  less  changed.  This  is  especially  true  of  the 
urine.  The  latter  presents  a  condition  which  is  apparently  related  to  the 
altered  nutritive  processes  which  obtain  in  the  patient.  From  the  studies 
that  have  been  made,  it  appears  that  during  the  earlier  stages,  in  keeping 
with  the  general  increased  activity  and  restlessness  of  the  patient,  the  urea 
and  chlorides  are  increased  in  amount.  Later  on,  as  the  dementia  and  the 
inactivity  increases,  these  constituents  diminish  in  amount.  This  is  notably 
the  case  in  the  last  stage  of  the  disease.  The  phosphates  present  a  variable 
condition ;  they  are  often  increased  in  the  melancholic  and  lessened  in  the 
exalted  and  maniacal  phases  of  the  disease.  Diminution  is  more  marked  in 
the  second  and  third  stages.  The  urates  also  appear  to  undergo  diminution 
with  the  other  solids  of  the  urine  as  the  disease  advances.  Albumin  is  found 
infrequently.  It  is,  however,  at  times,  discovered  after  a  convulsive  seizure. 
Very  rarely  sugar  has  been  found.  Klippel  and  Servaux  have  also  found 
peptone,  and  at  times  acetone.^ 

The  function  of  perspiration  is  also  modified  in  various  ways.  Sometimes 
there  is  a  dryness  of  the  hands  and  other  portions  of  the  body,  or  there 
may  be  a  clammy  sweat,  or  the  skin  may  have  a  greasy  feeling.  Sometimes 
excessive  sweating  occurs,  and  when  this  is  the  case  it  is  generally  local  or 
unilateral.  Sometimes  the  skin  of  certain  regions  looks  dull  and  darkened  in 
hue.     This  is  every  now  and  then  observed  about  the  temples  and  forehead. 

The  saliva  seems  sometimes  to  be  increased.  How^ever,  the  droohng  ob- 
served in  advanced  cases  does  not  depend  uj)on  an  increased  secretion.  The 
latter  is  merely  apparent. 

Various  general  nutritive  changes  occur  in  paresis.  In  the  prodromal  and 
first  stage  of  the  disease  the  patient  frequently  loses  in  weight,  though  later 
on,  as  he  becomes  less  active,  increase  in  weight  occurs,  the  patient  accumu- 
lating a  soft,  flabby  fat.  In  the  latter  part  of  the  second  stage  and  in  the 
third  stage,  however,  he  again  loses  in  weight.  Numerous  exceptions  to  this 
rule  obtain.  An  examination  of  the  blood  reveals  a  moderate  degree  of 
leucocytosis  with  reduction  in  the  percentage  of  haemoglobin,  changes  which 
cannot  be  considered  as  of  much  significance. 

The  temperature  in  paresis,  though  the  disease  is  essentially  afebrile,  may 
present  various  fluctuation  from  the  normal.  Thus  it  is  noted  that  a  rise  of 
temperature  generally  occurs  at  the  time  of  and  following  a  convulsive  or 
apoplectiform  seizure  or  a  maniacal  paroxysm.  Slight  seizures,  however, 
may  occur  without  any  rise  taking  place.  Again,  an  occasional  rise  may 
occur  independently  of  any  seizure  or  disturbance  whatever.  The  tendency 
to  rise  of  temperature  is  seen  more  especially  in  cases  pursuing  a  very  rapid 
course.  Peterson  and  Langdon,'''  who  have  studied  the  temperature  in 
twenty-five  cases,  conclude  that  w^hen  unusual  variations  occur  in  paretics 
their  cause  must  be  sought  for  in  conditions  other  than  the  paralytic  de- 
mentia itself,  for  example,  pneumonia,  bed-sores,  etc. 

1  Gaz.  Med.,  1894,  No.  34.  2  Journ.  Nervous  and  Mental  Dis.,  1893.  xx.  740. 


PARETIC  DEMENTIA.  689 

We  have  just  alluded  to  the  general  appearance  assumed  by  the  skin  in 
speaking  of  the  jDerspiration.  In  addition  to  various  signs  of  dryness  and 
atrophy,  other  changes  due  to  perversion  of  the  sweat  or  oil  glands,  local 
trophic  disorders,  blebs,  herpetic  eruptions,  and  ulcers  may  make  their  ap- 
pearance. They  occur,  as  we  have  seen,  more  frequently  in  the  second  and 
third  stages  of  the  diseases.  The  bed-sores,  which  we  have  mentioned,  may 
be  due  to  the  pressure  of  the  buttocks  or  other  portions  of  the  body  upon  the 
bed,  but  more  frequently  they  are  trophic  in  character  and  occur  inde- 
pendently of  i^ressure.  In  this  connection,  also,  we  should  mention  the 
perforating  ulcer  which  is  now  and  then  found  on  the  ball  of  the  foot.  It 
is  a  deep  trophic  ulcer,  which  is  also  found  in  other  organic  affections,  more 
especially  locomotor  ataxia  More  or  less  marked  evidences  of  vasomotor 
weakness  may  be  presented  by  the  skin.  Thus  tdche  cerehrale  is  some- 
times very  readily  elicited.  If  a  stroke  be  made  with  the  finger  over  the 
skin,  a  red  streak  and  sometimes  slight  swelling  follow.  At  other  times 
this  vasomotor  weakness  is  so  great  as  to  lead  to  the  actual  escape  of  blood 
from  the  vessels.  The  skin  of  paretics  and  the  tissues  generally  bruise  very 
easily,  so  that  subcutaneous  and  other  ecchymoses  are  not  uncommon.  Not 
infrequently  punctiform  hemorrhages  are  noted  in  the  skin,  and  at  other 
times  purpuric  spots  and  blotches.  Sometimes,  indeed,  the  extravasation  is 
more  marked  and  is  accompanied  by  swelling,  as,  for  example,  about  the 
ankles,  knees,  popliteal  spaces,  and  elbows.  The  mucous  membranes  also  show 
evidences  of  the  same  vasomotor  paralysis  in  the  later  stages,  and  hemor- 
rhages may  occur  from  them,  e.  g.,  epistaxis,  hsematemesis,  hemorrhage  from 
the  bowel  and  metrorrhagia.  At  times,  and  doubtless  owing  to  the  same 
loss  of  vasomotor  control,  hsematuria  may  be  noted,  or  hemorrhagic  extra- 
vasation may  occur  on  the  surface  of  the  pleura  or  in  the  substance  of  the 
lung. 

Among  the  most  interesting  angio-paralytic  phenomena  met  with  is  hsema- 
toma  of  the  ear.  Without  apparent  cause,  extravasation  of  blood  takes 
place  in  the  fibrous  tissue  and  beneath  the  skin  of  the  auricle,  and  may 
become  very  extensive.  The  swollen  ear  is  dark  or  reddish-blue  in  color, 
though  at  times,  and  especially  in  a  recent  case,  the  color  may  be  much 
lighter.  As  a  rule,  after  the  extravasation  has  reached  its  limit,  reabsorp- 
tion  takes  j)lace,  followed  by  more  or  less  deformity  of  the  cartilage  of  the 
ear.  In  rare  cases,  where  the  exudation  is  enormous,  rupture  may  take 
place.  .In  other  instances,  again,  suppuration  may  occur,  though  this 
also  is  rare.  Curiously  enough,  the  left  ear  is  more  frequently  affected  than 
the  right,  and  males  suffer  more  frequently  than  females.  Othsematoma 
occurs,  it  must  be  remembered,  in  other  insanities  and  in  other  nervous  dis- 
eases, and,  indeed,  may  occur  independently  of  either  of  these  conditions. 

Trophic  changes  are  also  observed  in  some  of  the  deeper  tissues ;  thus  the 
muscles  may  bruise  very  easily,  or  spontaneous  h^ematomata  may  occur  in 
them  just  as  they  occur  elsewhere.  General  muscular  wasting  may  also 
take  place,  and,  indeed,  is  not  infrequent  in  the  later  stages  of  the  disease. 
However,  in  rare  cases,  true  muscular  atrophy  may  occur  in  various  situa- 
tions due  to  lesions  within  the  cord.^ 

Trophic  changes  occur  also  at  times  in  the  bones.  The  ribs  and  long 
bones  generally  may  become  very  brittle,  so  that  slight  falls  or  blows  result 
in  fractures.  Trophic  changes  in  the  joints  are  also  occasionally  met  with, 
the  changes  being  in  every  way  similar  to  those  found  in  locomotor  ataxia 
(see  p.  639),  and,  like  the  latter,  are  doubtless  dependent  upon  lesions  of  the 
spinal  cord.     We  find  them,  as  may  be  expected,  in  cases  of  the  ascending 

1  Jofifroy  :  Bulletin  M6d.,  1894,  vlli.  533. 
44 


690  NEBVOUS  DISEASES  AND  THEIR  TREATMENT, 

type,  that  is,  in  which  the  spinal  antedate  the  cerebral  symptoms.  Extensive 
disorganization  and  deformity  may  ensue  without  the  least  symptom  of  pain.' 

Remissions.  In  many  cases  of  paretic  dementia,  periods  occur  in  which 
the  patient  is  comparatively  free  from  his  delusions — periods  in  which  he 
seems  to  have  made,  for  the  time  being,  more  or  less  of  a  recovery.  This  is 
one  of  the  most  interesting  facts  connected  with  the  disease.  Remissions  are 
exceedingly  important  from  a  diagnostic  point  of  view,  especially  when  we 
reflect  that  they  may  occur  in  the  prodromal  period.  It  not  infrequently 
happens  that  a  patient  in  this  period  presents  signs  of  the  disease  in  the 
afternoon  or  evening,  but  presents  nothing  that  is  conclusive  the  next  morn- 
ing. At  such  times  an  examination  may  reveal  no  symptoms,  with  the 
possible  exception  of  certain  physical  signs,  such  as  slight  tremor,  ine- 
quality of  the  pupils,  and  the  like.  Even  these  may  be  in  abeyance.  As 
evening  appears,  the  symptoms  again  return  and  may  be  pronounced. 
Similar  in  character  to  these  brief  diurnal  remissions  observed  in  the  pro- 
dromal period  are  the  more  prolonged  remissions  noticed  in  the  established 
disease.  These  may  vary  from  a  few  days  to  months,  or  even  years.  On 
examining  a  patient  in  a  period  of  remission  various  symptoms  become 
apparent  which  prove  that  although  better  he  is  not  well.  It  is  found,  for 
instance,  that  tremor  of  the  lips  or  inequalty  of  the  pupils,  though  less 
marked,  persists  ;  and  that  the  speech,  though  not  much  improved,  is  not 
the  speech  of  a  man  in  health.  Similarly,  the  mental  faculties  may  betray 
slight  weakness  or  impairment.  An  interesting  fact  in  regard  to  remissions 
is  that  the  psychic  phenomena  may  recede  while  the  physical  signs  remain 
pronounced.  It  is  said  that  the  reverse  also  occurs ;  that  is,  more  or  less 
marked  disappearance  of  the  motor  with  persistence  of  the  mental  symptoms. 

The  occurrence  of  a  remission  in  a  patient  may  bring  before  the  alienist  a 
difficult  problem.  The  question  always  arises,  "Should  such  a  patient  be 
dismissed  from  the  asylum  in  which  he  has  been  confined?"  Basing  our 
opinion  upon  the  fact  that  the  remission  is  always  more  apparent  than  real, 
that  the  patient  although  better  is  far  from  well,  and  that  the  disease  will 
sooner  or  later  resume  its  progressive  course,  dismissal  from  the  asylum 
should  be  resisted,  unless  the  period  of  remission  has  persisted  for  a  year  or 
more.  Even  then  the  patient  should  be  committed  to  the  care  of  an  attend- 
ant or  a  faithful  relative,  and  constant  supervision  should  be  practiced. 
Mendel  thinks  the  patient  should  be  retained  in  the  asylum  three  or  four 
years.  It  must  be  remembered  that  such  patients  are  utterly  unfit  to  with- 
stand even  the  ordinary  strains  of  life,  and  that  by  improper  management  the 
period  of  remission  may  be  suddenly  terminated,  the  disease  then  resuming 
its  sway  with  renewed  intensity.  Furthermore,  these  patients  are  as  little  to 
be  trusted  in  transacting  business  or  performing  some  serious  duty,  e.  g.,  the 
making  of  a  will,  as  they  were  during  the  height  of  the  disease.  In  other 
words,  a  paretic  in  the  period  of  remission  cannot  be  regarded  as  possessing 
legal  responsibility. 

In  connection  with  remissions  a  curious  fact  remains  to  be  stated.  Not 
infrequently  they  follow  and  are  apparently  caused  by  severe  traumata,  acute 
illness,  or  profuse  suppuration.  Even  recovei'ies  have  been  attributed  to 
such  factors.  Among  them  we  may  mention  erysipelas,  burns,  abscesses, 
and  fractures. 

Duration.  A  number  of  factors  influence  the  duration  of  paretic  dementia. 
First  among  these  is  the  form  which  the  disease  assumes.     It  is  well  known 

1  The  writer  is  unable  to  confirm  the  statement  of  Regis  that  the  xyphoid  appendix  becomes  "  de- 
pressed, elongated,  and  incurved  toward  the  abdomen."  A  large  number  of  cases  examined  at  the 
■Philadelphia  Hospital  failed  to  reveal  conditions  other  than  the  variations  met  with  in  normal 
individuals.    These  are  admittedly  considerable. 


PARETIC  DEMENTIA.  691 

that  the  expansive  form  pursues  a  more  rapid  course  than  the  depressive 
form,  while  the  simple  demented  form  pursues  the  slowest  course  of  all. 
Secondly,  the  duration  is  markedly  influenced  by  the  sex  of  the  patient.  It 
is  decidedly  longer  in  women  than  in  men.  Thirdly,  all  factors  of  a  violently 
disturbing  character,  such  as  apoplectiform  and  epileptiform  seizures,  espe- 
cially if  the  latter  be  severe  and  frequently  repeated,  as  well  as  the  occur- 
rence of  maniacal  attacks,  greatly  hasten  the  course  of  paretic  dementia. 
Fourthly,  all  factors  that  subdue  and  quiet  the  patient,  such  as  asylum  life, 
and,  especially,  the  occurrence  of  remissions,  more  or  less  prolong  the  disease. 
Visceral  complications,  according  to  their  nature  and  degree,  also,  of  course, 
influence  the  duration. 

It  is  difiicult,  for  the  above  reasons,  to  make  average  statements  as  to  the 
duration  of  the  disease.  Suffice  it  to  say  that  males  generally  die  within  two 
or  three  years,  females  within  three  or  four  years,  while  the  great  majority 
of  all  cases  die  within  five  years.'  Cases  are  occasionally  met  with  in  which 
the  symptoms  pursue  a  ftiribund  course,  the  patient  dying  at  the  end  of  a 
few  months.  Even  here,  however,  we  should  bear  in  mind  the  difficulty  of 
determining  the  time  at  which  the  disease  actually  began.  The  duration  may 
in  reality  be  longer  than  at  first  appears.  Again,  cases  are  occasionally 
reported  in  which  the  course  is  exceedingly  long.  In  these  instances  it  not 
infrequently  happens  that  the  initial  symptoms  are  spinal,  and  that  the  latter 
antedate  the  actual  development  of  the  cerebral  symptoms  by  months  and 
years. 

Pathology  and  Pathological  Anatomy.  As  already  stated,  paretic  dementia 
is  an  affection  which,  more  than  any  other  of  the  insanities,  presents  tangible 
lesions.  The  lesions  affect  at  times  the  skull,  always  the  membranes,  and  the 
brain  itself.  It  is  exceedingly  probable,  however,  that  even  here  they  are 
terminal  in  character. 

With  the  exception  of  rare  cases  dying  from  intercurrent  disease  at  a  very 
eai'ly  period,  the  changes  are  both  gross  and  microscopic.  Among  them  is  a 
chronic  leptomeningitis,  which  is,  however,  distinguished  from  other  forms 
of  meningitis  by  the  fact  that  the  inflamed  and  thickened  membrane  is  ad- 
herent to  the  cortex.  When  the  attempt  is  made  to  strip  off"  the  pia  arach- 
noid a  portion  of  the  cortex  is  always  removed  with  it,  the  lesion  being 
really  one  of  meningo-en cephalitis.  These  changes  in  the  soft  membranes 
are  generally  most  pronounced  over  the  parietal  and  frontal  lobes.  The 
other  portions  of  the  brain  appear  to  suffer  at  a  slightly  later  period.  The 
change  is  sometimes  accentuated  over  the  occipital  lobes.  Sometimes  it  is 
irregularly  distributed,  but  this  is  the  exception. 

Chronic  inflammatory  changes  are  not  limited  to  the  soft  membranes,  but 
in  a  large  number  of  cases  they  also  involve  the  dura.  The  latter  is  fre- 
quently thickened.  Sometimes  the  internal  layer  suffers  alone.  Sometimes 
both  layers  are  affected.  The  change  in  the  internal  layer  is  not  limited  to 
mere  thickening.  It  is  frequently  accompanied  by  spontaneous  hemorrhagic 
exudations.  The  latter  frequently  recur,  and  are  often  so  extensive  as  to 
give  rise  to  large  cysts.  This  condition  is  known  variously  as  h?ematoma  of 
the  dura  mater,  arachnoid  cyst,  or  hemorrhagic  pachymeningitis.  It  has 
already  been  discussed  (see  page  351).  If  the  change  involves  the  external 
layer  of  the  dura  we  notice,  upon  removing  the  calvarium,  that  it  is  very 
adherent,  and,  further,  on  examining  the  cut  surface  of  the  bone,  we  are  apt 
to  find  that  its  density  is  very  much  increased ;  in  other  words,  that  there  has 
been  more  or  less  loss  of  diploic  structure.    It  may  also  be  increased  in  thick- 

1  In  Hougberg's  cases,  one  hundred  and  seven,  the  duration  varied  from  three  months  to  seven 
years.    Loc.  cit. 


692  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ness,  and  sometimes  this  bony  overgrowth  is  accentuated  in  certain  places,  so 
as  to  give  rise,  here  and  there,  to  exostosis.  Even  the  scalp  may  take  part  in 
this  general  thickening  of  tissue,  so  that  it  seems  more  dense  and  tougher 
than  normal.  Exceptionally,  instead  of  osseous  hyperplasia,  we  may  find 
atrophy. 

The  surface  and  the  meshes  of  the  pia  arachnoid  are  oedematous.  The 
convolutions  are  shrunken,  especially  over  the  motor  and  adjacent  areas. 
The  fissures  are  open  and  sometimes  gaping.  The  disease  process  does  not 
by  any  means  limit  itself  to  the  cortex.  It  invades  the  brain  tissue  as  a 
whole.  We  notice  that  the  latter  is  softer  than  normal,  and  that  the  cut 
surface  is  more  moist  than  it  should  be.  Here  and  there  also  we  see  gaping 
spaces,  in  which  bloodvessels  lie  loosely,  and  when  we  turn  to  the  ventricles 
we  find  more  or  less  evidence  of  chronic  inflammation  of  the  lining  mem- 
brane ;  that  is,  an  ependymitis.  The  surface  of  the  ventricles  is  velvety  or 
granular,  while  the  cavities  are  enlarged  and  contain  an  excess  of  cerebro- 
spinal fluid.     Not  infrequently  they  are  much  dilated. 

.  As  might  be  expected,  loss  of  substance  is  readily  demonstrated  on  weigh- 
ing the  brain.  For  instance,  in  thirteen  autopsies  made  by  the  writer  at  the 
State  Hospital  at  Norristown,  the  average  weight  of  nine  male  paretic  brains 
was  merely  41.8,  and  of  four  female  paretic  brains  only  37.1  ounces. 

Early  in  the  history  of  the  case  these  great  nutritive  changes  appear  to  be 
accompanied,  or  perhaps  initiated,  by  marked  disturbances  in  both  the  vascu- 
lar and  lymphatic  supply  of  the  brain.  The  vascular  appear  to  precede  the 
lymphatic  changes,  and  we  have  every  reason  to  believe  that  they  consist  in  a 
passive  paralytic  hypersemia.  Soon  both  bloodvessels  and  brain  tissue  are 
profoundly  affected.  Changes  appear  in  the  connective  and  neurogliar  ele- 
ments. Not  only  do  the  nuclei  in  the  capillary  walls  increase,  but  the  nuclei 
in  the  immediate  neighborhood  of  the  vessels  multiply.  This  is  also  true  of 
the  larger  elements  of  the  neuroglia,  the  cells  of  Deiters,  which  become  so 
numerous  and  so  enlarged  as  to  attract  special  attention.  Their  appearance 
is  so  striking  that  they  have  received  a  characteristic  name,  that  of  "  spider 
cells."  Very  frequently  a  direct  connection  between  the  vascular  sheath 
and  a  spider  cell  can  be  traced.^  As  a  matter  of  course  such  a  chronic 
inflammatory  process  means  sooner  or  later  interference  with  the  perivascular 
spaces ;  and  this  is  the  more  significant  when  we  remember  that  these  peri- 
vascular spaces  are  the  only  lymph  channels  within  the  brain. 

As  a  result  of  the  general  proliferation  of  the  connective  tissue  and  neu- 
rogliar elements  and  of  the  consequent  lymphatic  obstruction,  and  also  pri- 
marily, the  nerve-cells  sooner  or  later  sufier.  They  exhibit  such  evidences 
of  change  as  granular  and  pigmentary  degeneration,  atrophy,  and  loss  of  cell 
processes.  What  the  obstruction  of  tlae  lyruph  path  means  to  the  nerve-cell, 
we  can  perhaps  understand  when  we  reflect  that  the  lymph  space  within 
which  it  lies,  the  periganglionic  space,  is  merely  tributary  to  the  perivascu- 
lar space,  and  if  the  latter  be  obstructed  dilation  of  the  periganglionic  space 
must  sooner  or  later  supervene.  Like  the  nerve-cells,  the  nerve-fibres  un- 
dergo atrophy  and  destruction  especially  in  the  region  of  their  cortical  dis- 
tribution. 

As  might  be  anticipated  from  the  paralysis  of  the  limbs,  which  becomes 
more  and  more  marked  as  the  disease  progresses,  and  which  is  so  often  ac- 
companied by  a  late  oncoming  contracture,  we  find  in  many  cases  evidences 
of  a  descending  degeneration  in  the  motor  pathways.  This  is  every  now  and 
then  seen  well  marked  in  the  lateral  columns  of  the  spinal  cord.  In  those  cases 
of  paresis,  on  the  other  hand,  which  begin  with  symptoms  resembling  locomo- 

1  The  lymph-connective  system  of  Bevan  Lewis. 


PARETIC  DEMENTIA.  693 

tor  ataxia — the  ascending  form — we  find  degenerative  changes  in  the  pos- 
terior cokimns.  The  cord  may  also  reveal  other  degenerative  changes,  e.g., 
relative  increase  of  the  neuroglia  and  connective-tissue  elements,  thickening 
of  the  pia  and  arachnoid,  and  of  the  vessel  walls,  though  these  are  rarely  if 
ever  so  marked  as  in  the  brain.  Degenerative  changes  are  also  noted  in  the 
basal  ganglia,  in  the  medulla,  and  even  in  the  cerebellum.  In  many  cases 
they  are  also  found  in  the  peripheral  nerves.  They  are  noted  in  the  optic 
nerve  during  life,  and  have  also  been  observed  in  other  cranial  nerves,  though 
it  must  be  admitted  rather  rarely.  Similar  changes  have  been  found  by 
various  authors  in  the  spinal  and  even  in  the  sympathetic  nerves. 

The  facts  hei'e  briefly  enumerated,  while  very  suggestive,  leave  the  actual 
cause  of  paretic  dementia  an  open  question.  That  some  other  cause  than 
.simple  nervous  overstrain  is  at  work  there  can  be  no  doubt.  If  nervous  ovei'- 
strain  were  the  essential  factor  it  is  difficult  to  understand  why  a  neuras- 
thenia— in  one  of  its  graver  forms  perhaps — should  not  ensue  rather  than 
this  strange  disease.  We  cannot  avoid  the  fact  that  the  ordinary  result  of 
overwork,  even  when  the  latter  has  been  very  marked,  is  in  reality  a  simple 
neurasthenia,  although  this  may  be  terminal  in  form  (see  page  77).  Again, 
on  the  theory  of  simple  nervous  overstrain,  it  is  diflficult  to  explain  the  rela- 
tive immunity  of  certain  races,  as,  for  instance,  the  Jewish.  It  is  not  im- 
probable that  in  the  production  of  paresis,  agents  are  at  work  akin  to  those 
which  probably  produce  locomotor  ataxia  ancl  other  system  or  tract  degenera- 
tions, and  though  our  knowledge  in  this  field  is  as  yet  extremely  limited  and 
is  confined  to  a  few  facts,  such  as  the  relation  of  cord  degenerations  to  per- 
nicious ansemia  and  various  cachexias,  enough  is  suggested  to  make  it  plaus- 
ible that  profound  disturbances  in  the  constitution  of  the  blood,  chemical 
rather  than  morphological  (for  example,  the  presence  of  some  autotoxine  or 
of  the  toxine  of  some  pre-existent  infectious  disease  as  syphilis),  may  be  the 
initial  cause.  The  theory  of  a  toxine  is  adopted  by  Bannister,'  who  holds 
that  paretic  dementia  is  a  toxine  disease,  the  toxine  being  generally  the  syphi- 
litic poison  ;  that  it  acts  directly  on  the  brain  and  that  syphilis  is  therefore 
not  a  predisposing  but  an  exciting  cause.  A  similar  view  is  held  by  Morel- 
Lavallee.^ 

Two  opposing  theories  are  held  at  present  in  regard  to  the  nature  of  the 
pathological  process :  first,  that  the  disease  is  primarily  an  interstitial  inflam- 
mation, and,  second,  that  it  is  primarily  a  pai'enchymatous  aflection.  The 
first  view  has  been  advocated  especially  by  Slendel.  He  holds  that  the  dis- 
ease begins  in  the  vascular  apparatus  and  rapidly  involves  the  neuroglia,  the 
result  being  a  destruction  and  alteration  of  the  true  nerve  elements.  Men- 
del's reasons  (as  summarized  by  Dagonet^)  are  as  follows  :  First,  the  dilata- 
tion of  the  capillaries  with  thickening  of  their  walls  and  proliferation  of 
their  nuclei ;  second,  the  result  of  his  experiments  upon  dogs.  (Mendel* 
some  years  ago  produced  chronic  hyperaemia  in  the  brains  of  dogs  by  fasten- 
ing them  on  a  revolving  table,  with  their  heads  toward  the  periphery,  and 
subjecting  them  so  fastened  to  a  series  of  rapid  revolutions  for  a  number 
of  minutes  daily.  The  experiments  having  been  continued  for  a  number  of 
weeks  the  animals  were  killed  and  revealed  adherent  membranes,  thickening 
and  infiltration  of  vessel  walls,  and  proliferation  of  the  elements  of  the  neu- 
roglia.) Third,  the  initial  symptoms  are  such  as  suggest  vascular  disturb- 
ances, for  example,  vertigo  and  apoplectiform  a,ttacks. 

The  view  that  paretic  dementia  is  primarily  a  parenchymatous  disease  is 
held  by  a  number  of  observers,  among  them  Tuczek  and  Dagonet,^  Schiitz, 

1  Bannister :  American  Journal  of  Insanity,  1893-n4,  p.  477. 

2  Revue  de  Med.,  Fevrier  1893,  p.  139.  '■>  Ann.  Med.  Psych.,  Paris,  1893,  7  s.  xvii.  p.  395. 
*  Neurolog.  Centrabl.,  May,  1884.  5  Lqc.  cit. 


694  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Joffroy/  and  Carter.-  Tuczek  and  Dagouet,  for  instance,  believe  that  the 
primary  lesion  is  in  the  nerve-fibres  without  any  antecedent  inflammation. 
Schiitz'*  also  takes  this  view  and  holds  that  the  disappearance  of  the  fibres  is 
to  be  considered  analogous  to  the  system  diseases  of  the  cord,  for  example, 
degeneration  of  the  lateral  or  posterior  columns.  If  paresis  has  existed  for 
a  long  time,  the  vascular  and  interstitial  changes  become  marked  and  obscure 
the  primary  lesions.  Joffroy  believes  the  sequence  of  the  pathological  changes 
in  general  paralysis  to  be  as  follows  :  disintegration  of  the  myelin  of  the 
nerve-fibres,  secondary  vascular  changes,  and  finally  neurogliar  hyperplasia. 

Many  facts  relative  to  changes  in  the  cord  and  also  of  the  peripheral 
nerves  are  in  keeping  with  the  view  that  paresis  is  primarily  a  parenchyma- 
tous disease.  Of  special  value  are  the  studies  made  by  Klippel.*  Klippel 
states  that  the  cord  is  almost  invariably  affected,  and  quotes  in  support  of  his 
statement  the  observations  of  Tuczek  and  Fuerstner.  In  twenty-two  of  Tuc- 
zek's  cases  only  one  presented  no  lesions  in  the  cord ;  in  Fuerstner's  cases, 
118  in  number,  cord  lesions  were  present  in  all.  In  his  own  cases,  Klippel 
found  the  cord  also  affected.  His  general  conclusions  are  as  follows :  First, 
if  a  line  be  passed  transversely  through  a  cross-section  of  the  cord,  through 
the  canal  and  cutting  the  cord  into  equal  halves,  the  lesions,  as  far  as  the 
white  matter  is  concerned,  are  situated  in  the  posterior  half — in  the  crossed 
pyramidal  tracts  with  diffusion  into  neighboring  areas  and  into  the  posterior 
columns.  Second,  the  changes  in  the  lateral  columns  are  generally  less 
marked  than  in  secondary  degeneration  following  cerebral  lesion.  Third, 
the  posterior  columns  (although  the  changes  vary)  may  present  the  distinc- 
tive alterations  seen  in  tabes.  Fourth,  regarding  the  gray  matter,  the  lesions 
of  the  horns  are  frequent  and  may  attain  a  marked  degree.  Fifth,  all  lesions 
are  more  marked  in  the  cervical  and  dorsal  than  in  the  lumbar  region.  Sixth, 
the  lesions  present  a  certain  degree  of  difflision,  but  the  areas  which  escape 
are  quite  limited  to  the  anterior  and  antero-lateral  columns.  They  have  a 
systemic  character  in  that  the  uninvaded  portions  are  always  the  same  and 
that  the  portions  involved  constitute  in  their  ensemble  a  physiological  system. 
Klippel  considers  the  histological  process  in  the  cord  to  consist,  first,  of  a 
degeneration  and  absorption  of  the  myelin ;  secondly,  congestion  and  exuda- 
tion ;  thirdly,  secondary  inflammation.  He  separates  the  pathological  pro- 
cesses into,  first,  foci  of  myelitis  produced  directly ;  secondly,  dystrophy  of 
nervous  elements  which  is  dependent  upon  the  brain  lesions ;  then  follow  the 
vascular  and  connective-tissue  changes. 

The  case  reported  by  JoflTroy,^  in  which  there  was  present  atrophy  of  the 
left  hand,  is  also  important,  there  being  atrophy  of  the  large  cells  of  the  left 
anterior  horn  of  the  cervical  cord.  The  absence  of  the  changes  in  the  white 
matter  of  the  cord  makes  this  lesion  necessarily  a  primary  one.  Interesting 
in  this  connection  are  also  the  observations  of  Schiitz,  who  observed  disap- 
pearance of  the  nuclei  of  the  hypoglossal  and  facial  nerves. 

Regarding  the  pathology  of  the  tabetic  form  Joffi'oy®  records  an  interest- 
ing autopsy.  The  latter  revealed  lesions  of  the  posterior  columns,  but  not 
those  of  tabes.  The  posterior  roots  were  but  slightly  aflTected,  and  there  was 
atrophy  of  the  cells  of  the  anterior  horns  and  Clark's  column.  Marie'  points 
out  an  important  difference  between  the  spinal  lesions  of  the  tabetic  form  of 
paretic  dementia  and  the  lesions  of  locomotor  ataxia ;  namely,  in  the  former 
they  rise  within  the  cord,  i.  e.,  are  endogenous,  in  the  latter  they  begin  in 
the  posterior  roots,  i.  e.,  are  exogenous.     Joffi'oy  maintains  that  true  tabes 

'  Bulletin  Med.,  1894,  viii.  p.  532.  2  Brain,  xvi.  p.  393.  ^  Quoted  by  Dagonet,  loc.  cit. 

*  Klippel :  Arehiv.  de  Med.  Experiment,  et  d'Anatomie  Patholog.,  1894,  vi.  p.  75. 
6  Loc.  cit.  8  Ngm.olog.  Centralbl.,  1894,  p.  664. 

■  Gaz.  des  Hopitaux,  1894,  Ixvii.  p.  55. 


PARETIC  DEMENTIA.  695 

complicates  general  paralysis  but  rarely.  In  fact,  he  regards  cases  that  sug- 
gest such  a  coexistence  as  merely  general  paralysis  with  tabetic  symptoms. 

Regarding  the  frequency  of  the  disease  of  the  posterior  columns  in  paresis, 
the  statistics  of  G.  Renaud'  seem  conclusive.  Among  482  cases,  it  occurred 
in  twenty-five,  and  of  these  fourteen  presented  typical  tabes. 

Changes  in  the  peripheral  nerves  and  muscles  have  recently  been  studied 
in  twelve  cases  by  Campbell.^  He  found  frequently  changes  in  the  nucleus 
of  the  vagus,  in  the  ascending  root  of  the  fifth,  and  rarely  in  the  phrenic 
nerve.  In  the  spinal  nerves  he  found  interstitial  and  parenchymatous 
lesions.  The  anterior  roots  and  the  posterior  roots  between  the  ganglion 
and  the  cord  presented  constant  changes.  The  spinal  ganglia  were,  as  a 
rule,  normal.  The  muscles  showed  fatty  degeneration  and  atrophy  and 
hyjierjilasia  of  the  sarcolemma  and  the  connective  tissue.  On  account  of  tbe 
changes  in  the  peripheral  nerves  Campbell  seeks  to  establish  a  relation  be- 
tween general  paralysis  and  the  primary  intrinsic  toxemic  group  of  multiple 
neuritis. 

The  relation  of  the  lesions  of  paresis  to  the  symptoms  seems  clear  as  regards 
the  motor,  sensory,  and  psychic  losses,  i.  e.,  the  palsies  and  dementia.  Regard- 
ing the  expansive  and  depressive  mental  states,  "  the  hallucinations  of  the 
coensesthesis,"  it  is  perhaps  not  going  too  far  to  suppose  that  they  are  the  out- 
come of  toxic  substances  circulating  in  the  blood — substances  having  their 
origin  in  deranged  metabolism  of  the  tissues. 

The  ej^ileptiform  and  apoplectiform  attacks  of  paresis  maybe  explained  in 
various  ways.  Thus,  Mickle''  holds  to  the  view  that  fluctuations  in  brain 
pressure  represent  the  factors  in  paralytic  attacks — fluctuations  called  forth 
by  the  hindered  outflow  of  the  lymphatic  fluid.  This  will  happen  the  more 
easily  the  more  intensely  the  cortical  functions  are  damaged  by  the  difiuse 
disappearance  of  nervous  tissue.  Neisser*  holds  that  the  paralytic  attacks 
depend  upon  degenerations  of  the  cortical  areas.  Mendel,^  on  the  other 
hand,  thinks  that  the  cause  is  disturbance  of  the  circulation.  Mendel's 
view  certainly  accords  best  with  the  clinical  findings. 

Finally,  regarding  the  remissions  of  paresis,  it  is  not  improbable  that  they 
are  the  result  of  the  opening  up  of  the  perivasular  spaces  and  the  temporary 
re-establishment  of  the  lymph  outflow. 

Prognosis.  The  prognosis  of  paretic  dementia  is  uniformly  unfavorable. 
A  few  cases  of  recovery,  it  is  true,  have  been  reported.  The  suspicion  is, 
however,  always  justified  that  such  cases  are  either  instances  of  mistaken 
diagnosis,  that  the  patient  really  suffered  from  brain  syphilis,  or  that  a  very 
prolonged  remission  was  mistaken  for  a  recovery.  The  disease  from  its  very 
nature  is  essentially  progressive,  and  a  fatal  termination  practically  inevi- 
table. 

Diagnosis.  In  the  very  beginning  of  the  disease  the  symptoms  sometimes 
bear  a  superficial  resemblance  to  those  of  neurasthenia.  However,  the  actual 
psychic  losses  of  paresis  are  never  met  with  in  the  latter  disease.  In  paretic 
dementia,  in  addition  to  mere  weakness  and  irritability,  there  is  actual  loss 
of  memory,  loss  of  the  moral  sense,  loss  of  the  aesthetic  sense,  loss  of  judgment, 
of  the  sense  of  the  proprieties,  of  shame,  etc.  No  such  thing,  for  instance, 
as  a  careless  exposure  of  the  person  is  seen  in  the  neurasthenic.  There  is 
no  silly  lying,  no  thieving,  no  eroto-niania,  or  any  of  the  other  numerous 
stigmata  of  paresis.® 

When  the  symptoms  have  become  established  the  diagnosis  of  paretic 

1  Quoted  by  Marie,  loc.  cit.  -  Joum.  Ment.  Sci ,  1894,  xl.  177. 

3  Brain,  1893,  xvi.  50.  *  Xeurolog.  Centralbl.,  1894,  p.  666. 

5  Ibid,  discussion. 
«  For  the  differeutial  diagnosis  of  neurasthenia  the  reader  is  referred  to  Chapter  II.,  p.  77. 


696  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

dementia  can,  as  a  rale,  be  made  with  ease ;  but  every  now  and  then  cases 
are  met  with  in  which  the  differentiation  from  diffuse  syphilis  of  the  cortex 
is  very  difficult  and  indeed  sometimes  impossible.  However,  both  in  their 
general  features  and  in  their  detailed  symptomatology  these  diseases  present 
important  differences.     These  differences  may  be  enumerated  as  follows : 

First.  In  paresis  the  course  of  the  disease  is  in  the  main  gradual  and  pro- 
gressive. Though  here  and  there  it  may  be  interrupted  by  seizures  or  per- 
haps by  a  remission,  it  is  steadily  onward  toward  a  fatal  termination.  In 
syphilis,  on  the  contrary,  the  course  is  very  irregular.  Frequently  the 
very  first  symptom  that  is  noted  is  not  change  of  character  or  altered 
mental  action,  but  an  ocular  palsy  or  a  hemiplegia,  while  mental  symp- 
toms appear  only  later  on.  Again,  even  when  the  mental  symptoms  have 
been  established  they  may  suddenly  recede  and  marked  improvement  may 
take  place,  to  be  followed  after  some  irregular  interval  of  time  by  a  renewed 
accession  of  symptoms.  On  the  other  hand,  spontaneous  arrest  and  disap- 
pearance of  certain  symptoms  may  occur  together  with  the  sudden  appear- 
ance of  othei's  entirely  new.  As  opposed,  then,  to  the  more  or  less  progres- 
sive course  of  paresis,  let  us  repeat  it,  we  have  in  syphilis  a  course  that  is 
decidedly  irregular.  At  times,  indeed,  the  changing  and  shifting  of  the 
symptoms  is  so  marked  as  actually  to  suggest  hysteria. 

Second.  In  syphilis  symptoms  almost  invariably  occur  pointing  to  focal 
and  more  or  less  limited  lesions  of  the  brain.  In  paresis  the  signs  point 
rather  to  diffiise  involvement.  On  the  side  of  syphilis,  we  note  such  symp- 
toms as  a  marked  dilatation  of  one  pupil,  a  marked  strabismus,  a  complete 
ptosis,  or  it  may  be  a  total  facial  palsy  of  one  side. 

Third.  Whilst  symptoms  resembling  the  above  sometimes  occur  in  paresis, 
the  palsy  lacks  the  accentuation  or  completeness  seen  in  syphilis.  Total  palsy 
of  an  ocular  muscle,  such,  for  instance,  as  seen  in  complete  ptosis,  is  rarely  if 
ever  met  Avith  in  true  paresis.  In  the  latter  disease  the  lid  droops  rather 
than  drops. 

Fourth.  In  syphilis  these  palsies  are  characterized  by  the  suddenness  with 
which  they  make  their  appearance,  and  by  the  fact  that  they  are  temporary, 
sometimes  transient,  in  duration. 

Fifth.  In  syphilis  the  physical  symptoms  as  a  rule  suggest  multiplicity  of 
lesions ;  such,  for  instance,  as  the  association  of  left  hemiplegia  with  aphasia. 

Sixth.  Some  of  the  detailed  motor  symptoms  so  common  in  paresis  are  but 
rarely  met  with  in  syphilis.  This  is  especially  true  of  tremulous  and  ataxic 
movements.  In  syphilis,  for  instance,  there  is  no  twitching  or  ataxia  of  the 
muscles  of  expression.  Tremor  of  the  lips  and  tongue  is  seldom  observed, 
and  when  met  with  is  much  less  pronounced  than  in  paresis. 

Seventh.  The  speech  disturbances  of  the  two  diseases  present  important 
differences.  In  paresis  they  are  apt  sooner  or  later  to  be  pronounced.  In 
syphilis,  on  the  other  hand,  speech  difficulties  may  be  but  slightly  marked. 
Again,  in  paresis  we  have  not  only  disturbances  of  the  cortical  centres,  but 
also  tremor  and  ataxia  due  to  involvement  of  the  centres  in  the  medulla. 

Eighth.  Syphilitic  dementia  and  paresis  also  differ  notably  as  regards  the 
character  of  the  delusions.  In  syphilis  mental  depression,  hypochondriasis, 
and  melancholia  are  the  rule,  while  the  expansive  mental  state  is  the  excep- 
tion. In  paresis,  as  we  have  seen,  the  reverse  obtains.  Again,  even  when 
expansive  delusions  do  occur  in  syphilis  they  are  apt  to  be  less  extravagant, 
better  systematized,  and,  taken  all  in  all,  more  plausible.  Tliis  brings  us  to 
the  recognition  of  another  fact,  and  that  is,  that  in  syphilis  dementia  is,  as  a 
rule,  less  pronounced  than  in  paresis. 

Among  the  various  speciarsymptoms  in  which  differences  exist  between 
paresis  and  syphilitic  dementia  we  should  first  mention  headache.     This  iu 


PARETIC  DEMENTIA.  697 

syphilis  is  persistent,  diffuse,  and  nocturnal.  In  paresis,  on  the  other  hand, 
headache  is  apt  to  come  on  in  a  few  isolated  attacks  of  great  severity,  and 
sometimes  resembling  ophthalmic  migraine. 

Secondly,  In  syphilis  optic  neuritis  may  be  observed  at  a  relatively  early 
period,  pronounced  in  type  and  pursuing  an  acute  course.  In  paresis  the 
eye-ground  changes  are  both  late  in  onset  and  chronic  in  character. 

Other  factors  may  prove  of  value  in  enabling  us  to  come  to  a  conclusion 
in  doubtful  cases.  If,  for  instance,  in  a  given  case  there  is  a  history  of  blad- 
der symptoms,  particularly  of  feebleness  of  expulsion,  at  a  relatively  early 
period,  the  indication  is  (see  Chapter  XXIV.)  that  the  lesion  in  the  cord  is  of 
specific  origin.  Especially  significant  is  it,  if  these  symptoms  have  spontane- 
ously disappeared,  i.  e.,  have  been  temporary  in  duration.  These  bladder  signs, 
the  value  of  which  we  are  just  beginning  to  recognize,  are  frequently  among 
the  earliest  indications  of  nervous  syphilis.  Further,  we  are  also  assisted  by 
a  history  of  comparatively  recent  specific  infection.  This,  of  course,  points 
to  syphilis.  In  paresis,  when  a  history  of  infection  is  present,  it  is  invaria- 
bly of  long  standing.  Finally,  we  should  remember,  that  while  paresis  is 
practically  limited  to  a  certain  period  of  life  (see  Etiology,  page  667),  cortical 
syphilis  may  be  met  with  at  almost  any  age. 

While  syphilitic  dementia  and  paresis  undoubtedly  differ  in  the  ways 
above  indicated,  it  cannot  be  denied  that  a  residue  of  cases  exist  in  which 
the  diagnosis  cannot  be  made  except  by  observing  the  effects  of  antisyphilitic 
treatment  and  watching  the  progress  of  the  case  for  a  period.  Even  then, 
for  obvious  reasons,  we  may  fail,  for  syphilitic  dementia  of  long  duration  is 
attended  by  permanent  cortical  changes,  so  that  improvement  under  treat- 
ment does  not  occur. 

Again,  when  we  reflect  that  the  lesions  of  paresis  and  of  syphilis,  though 
essentially  distinct,  may  and  often  do  affect  similar  regions  and  similar  struc- 
tures, it  cannot  be  surprising  that  the  symptoms  of  the  two  diseases  may  so 
closely  resemble  each  other  that  a  differentiation  is  practically  impossible. 
However,  in  the  writer's  experience,  the  more  closely  the  principles  here  in- 
dicated are  applied,  the  smaller  is  the  number  of  doubtful  cases. 

As  regards  diseases  other  than  syphilis,  of  which  dementia  may  be  a  promi- 
nent symptom,  e.  g.,  alcoholism,  lead  encephalopathy,  tumor  and  other  gross 
organic  disease  of  the  brain,  it  may  be  stated  that  the  differentiation  can,  as  a 
rule,  be  readily  made  by  bearing  in  mind  the  characteristic  features  of  these 
affections.  For  a  consideration  of  these  the  reader  is  referred  to  Chapters  V., 
XIII.,  and  XVI. 

Treatment.  The  treatment  of  paretic  dementia  separates  itself  naturally 
into  the  management  of  the  initial  period  and  of  the  well-developed  disease. 
The  patient  who  presents  some  of  the  suspicious  symptoms  of  the  initial 
period  should  at  once,  if  possible,  be  withdrawn  from  his  ordinary  occupa- 
tion and  surroundings.  All  work,  physical  and  mental,  should  be  absolutely 
stopped.  All  sources  of  worry,  annoyance,  care,  or  excitement  must  be 
avoided.  A  rest-cure,  partial  or  complete,  should  be  instituted.  If  _  the 
patient  has  lost  in  weight,  rest  in  bed  for  a  long  period  should  be  insisted 
upon.  Unfortunately,  and  especially  with  men,  this  radical  plan  cannot,  as 
a  rule,  be  carried  out,  and  we  are  generally  compelled  to  adopt  a  system  of 
partial  rest  treatment.  For  details  of  this  measure  the  reader  is  referred  to 
the  chapter  upon  Neurasthenia. 

A  number  of  symptoms  demand  special  attention.  The  paretic,  in  the 
initial  period,  is  frequently  a  sufferer  from  insomnia,  and  to  combat  this 
symptom  some  mild  hypnotic  should  be  used.  Paraldehyde  in  doses  of  from 
20  to  30  minims  may  be  given  at  bedtime,  or  double  this  quantity  niay  be 
administered,  suspended  in  thin  mucilage,  by  the  bowel.     A  drug  which  is. 


698  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

however,  of  especial  use  in  this  condition,  and  which  unfortunately  has  met 
with  but  little  recognition,  is  antipyrin.  This,  if  used  in  sufficiently  large 
doses  (ten,  fifteen,  or  even  twenty  grains  every  four  hours),  produces  a  most 
beneficial  effect  upon  the  excitement.  Trional  in  doses  of  gr.  xv.  to  gr.  xx. 
is  also  serviceable.  Sponge-baths  before  retiring,  hot  foot-baths,  or  brief  im- 
mersions of  the  entire  body  in  a  hot  bath,  often  has  a  most  beneficial  effect 
in  favoring  sleep.  Tonics,  nutrients,  and  reconstructives  generally  are,  of 
course,  indicated,  though  little  good  is  traceable  to  their  use. 

As  already  indicated  in  discussing  remissions,  improvement  occasionally 
follows  surgical  procedures.  Tuke  and  Claye-Shaw  have  noted  improvement 
after  trephining  over  the  parietal  region.  The  operation  was  originally  pro- 
posed with  the  idea  that  in  paresis  there  was  present  an  increased  intra- 
cranial pressure.  Blisters,  setons,  and  issues  to  the  scalp  and  back  of  the 
neck  have  also  been  followed  at  various  times  by  improvement. 

Though  the  ultimate  outcome  of  paresis  is  unfavorable,  it  is  very  proba- 
ble that  remissions  can  be  brought  about  by  a  properly  directed  treatment. 
The  remissions  which  we  at  times  see  in  cases  admitted  to  the  hospitals  are 
due  to  the  rest,  quiet,  regular  feeding,  and  the  monotony  of  institution  life. 
General  principles  must  guide  the  treatment.  The  same  care  that  is  used  in 
the  management  of  other  demented  patients  is  to  be  used  here.  The  same 
watchfulness  is  necessary.  It  is  worth  while  mentioning  that  in  his  hurried 
gulping  of  food  the  paretic  is  every  now  and  then  in  danger  of  choking. 

Sooner  or  later  he  becomes  bed-ridden.  Because  he  can  no  longer  feed 
himself,  he  must  be  fed  by  the  attendant,  and  here  it  must  not  be  forgotten 
that,  because  of  the  benumbed  condition  of  the  fauces  and  epiglottis,  food 
may  readily  enter  the  trachea  and  give  rise  to  inspiration  pneumonia.  Again, 
the  bed-sores,  which  develop  sooner  or  later,  require  constant  attention.  We 
must  remember,  too,  that  most  of  the  sores  are  really  not  due  to  pressure, 
but  are  trophic  in  character,  as  they  frequently  occur  in  situations  in  which 
the  skin  has  at  no  time  been  subjected  to  pressure.  The  importance  of  clean- 
liness and  the  difficulty  of  obtaining  this  end  in  cases  in  which  paralysis  of 
the  sphincters  exists  need  only  be  mentioned. 

It  is  important,  however,  to  allude  to  a  remarkable  method  of  treatment 
of  these  trophic  sores  of  the  insane  which  has  been  instituted  in  the  Phila- 
delphia Hospital  by  the  chief  resident  physician.  Dr.  Daniel  E.  Hughes. 
Corrosive  sublimate  and  other  antiseptic  washes  are  abandoned.  The  sore  is 
simply  thoroughly  washed  with  warm  water  and  castile  soap,  and  then 
thoroughly  rinsed.  Following  this  a  liquid  preparation  of  beef,  Bovinine, 
is  poured  over  the  surface  of  the  ulcer,  whilst  pledgets  of  lint  are  also  satu- 
rated with  the  same  material.  The  whole  surface  is  then  carefully  covered 
as  in  ordinary  surgical  dressing.  On  removing  the  latter  in  the  course  of  a 
day  or  two  great  improvement  in  the  sore  is  observed.  Granulations  spring 
up  with  rapidity  and  soon  reach  the  general  level  of  the  skin.  In  due  course 
they  assume  an  epithelial  covering.  The  repair  brought  about  by  this 
novel  method  appears  to  be  quite  durable.  The  tissue  does  not  seem  to  be 
any  less  resistant  than  the  neighboring  skin.  Should  it  break  down  anew, 
the  treatment  is  repeated  as  before.  This  novel  and  remarkable  method 
should  certainly  be  adopted  in  hospitals  generally.  It  appears  applicable, 
furthermore,  to  trophic  sores  of  all  kinds. 


CHAPTER   XXIY. 

SYPHHJS  OF  THE  NERVOUS  SYSTEM. 

By  F.  X.  DERCUM,  M.D. 

In  other  portions  of  this  vokime  various  diseases  due  directly  or  indirectly 
to  syphilitic  infection  are  considered.  It  is  the  object  of  the  present  chap- 
ter to  present  a  resume  of  syphilis  of  the  nervous  system  and  especially  to 
call  attention  to  the  general  principles  which  must  guide  the  practitioner  in 
diagnosis  and  treatment. 

The  lesions  of  syphilis  are  peculiar  in  that  they  are  especially  attended  by 
a  formative  exudation  or  deposit.  The  extent  to  which  this  peculiarity  may 
be  present  in  a  giv^en  lesion  varies,  however,  greatly.  Thus  a  specific  inflam- 
mation may  be  so  slightly  formative  as  almost  to  resemble  a  simple  inflamma- 
tion, or  it  may  be  attended  by  so  large  a  plastic  exudation  as  to  lead  to 
extensive  new  formations.  The  latter  is  most  frequently  the  case.  These  new 
formations,  gummata,  or  gummatous  exudations,  as  they  are  termed,  closely 
resemble  in  their  intimate  structure,  when  recent,  ordinary  granulation  tissue. 
This  tissue  may  develop  rapidly  and  as  quickly  disappear,  and  this  cycle  of 
rapid  growth  and  rapid  retrogression  may  be  often  repeated.  However,  if 
the  new  formation  persists  for  any  length  of  time  it  may  become  the  seat  of 
various  degenerative  changes,  chronic  in  character.  Thus  in  an  old  gumma 
we  occasionally  observe  caseous  degeneration.  If  a  gumma  be  at  all  lai'ge,  a 
number  of  foci  of  caseous  change  may  be  seen.  Fibrous  degeneration  may 
also  take  place,  and  this  may  be  so  complete  that  after  a  time  nothing  but  a 
welt  of  connective  tissue  remains  of  the  former  syphilitic  deposit.  Very 
frequently  both  caseous  and  fibrous  changes  take  place  in  the  same  gumma, 
the  caseous  degeneration  taking  place  in  the  interior  and  the  fibrous  upon 
the  surface. 

Syphilitic  inflammation  aflfects  primarily  the  mesoblastic  tissues  of  the 
nervous  system — that  is,  the  membranes  and  the  bloodvessels.  It  is  extremely 
probable  that  even  when  an  isolated  gumma  is  found  deep  within  the  ner- 
vous substance,  for  example,  in  the  centrum  ovale,  that  it  has  had  its  origin 
in  the  wall  of  some  vessel  or  in  some  extension  of  the  pia  mater.  The  mem- 
branes may  undergo  either  difflise  inflammation,  or,  what  is  more  common, 
more  or  less  extensive  local  deposits  of  gummatous  material  may  take  place. 
In  the  vessels,  similarly,  we  may  have  either  difflise  thickening  of  the  walls 
or  local  deposits  somewhat  resembling  atheroma.  Syphilitic  inflammation 
of  the  dura  is  generally  diffuse,  while  in  the  pia  arachnoid  local  gummatous 
deposit  is  more  apt  to  take  place.  This  is  true  alike  of  the  membranes  of 
the  brain  and  of  the  spinal  cord.  Gummata,  though  occurring  in  all  situa- 
tions, are  more  common  at  the  base  of  the  brain  than  elsewhere.  They  fre- 
quently involve  the  cranial  nerves  and  pons,  though  they  rarely  attack  the 
cerebellum.  When  involving  the  Avails  of  the  arteries,  they  may  lead  to 
thrombosis  and  to  consequent  softening  of  the  nervous  structures  supplied  by 
the  vessels.     At  other  times  rupture  and  hemorrhage  may  result.     Sometimes 


700  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

aneurisms  are  formed.  Not  infrequently  one  of  the  larger  arteries  of  the 
base,  such  as  the  middle  cerebral  or  the  basilar,  is  thus  affected. 

The  symptoms  to  which  the  above-described  changes  give  rise  are  varied 
and  manifold.  They  depend  in  each  particular  case  upon  the  location  and 
extent  of  the  lesions.  The  latter  are  radically  different  from  those  observed 
in  the  various  degenerative  diseases  which  also  occur  in  syj)hilitic  subjects. 
Thus  in  locomotor  ataxia  we  have  an  extensive  degeneration  of  certain 
tracts  or  systems  of  fibres  (see  p.  640)  ;  that  is,  a  slow  progressive  change 
Avhich  takes  place  in  the  posterior  columns  of  the  spinal  cord,  and  which, 
while  it  may  occur  in  a  specific  subject,  is  at  no  time  specific^  in  character. 
This  fundamental  distinction  between  true  syphilitic  processes  affecting  the 
nervous  system  and  tract  degenerations  occurring  in  syphilitic  subjects  is  of 
the  greatest  importance.  The  latter  appear  to  be  due  to  the  profound 
depression  of  nervous  nutrition  seen  in  so  many  syphilitics,  or  possibly,  as 
Striimpell  supposes,  to  some  toxine,  itself  a  product  of  the  syphilitic  germs, 
whatever  they  may  be.  These  degenerative  diseases  also  occur,  it  must  be 
remembered,  in  non-syphilitic  patients. 

Syphilitic  lesions  of  the  nervous  system  occur  both  in  the  acquired  and  in  the 
inherited  forms  of  the  disease.  When  they  occur  in  the  acquired  form  they  are 
frequently  present  as  late  manifestations.  Indeed,  it  has  been  the  custom  to 
classify  the  symptoms  of  nervous  syphilis  as  among  the  tertiary  symptoms.  The 
patient  generally  presents  a  history  of  several  years  inteivening  between  the 
initial  sore  and  the  outbreak  of  nervous  phenomena.  The  interval  is  at  times 
exceedingly  long — ten,  twelve,  and  fifteen  years  being  not  unusual.  Gowers 
mentions  nineteen  years  as  one  of  the  longer  intervals  observed  by  him.  The 
writer  himself  has  observed  one  of  twenty,  another  of  twenty-nine,  and 
Wood  speaks  of  even  thirty  years.  A  period  of  from  three  to  ten  years 
is  an  interval,  however,  more  commonly  met  with.  Although  nervous  syph- 
ilis is,  as  a  rule,  a  late  manifestation,  numerous  instances  are  on  record  in 
which  it  has  occurred  very  soon  after  infection.  Thus  in  speaking  of  syphil- 
itic thrombosis,  Gowers  mentions  an  interval  of  but  six  months,  and  another, 
less  certain,  of  three  months.  Wood  has  placed  on  record  a  case  of  two 
months  and  eight  days,  and  in  Manchon's  collection  of  cases  of  precocious 
syphilis  intervals  of  two  and  even  one  month  are  given. 

Regarding  the  frequency  of  precocious  nervovis  syphilis,  i.  e.,  syphilis 
occurring  very  early  after  infection,  the  statistics  of  Fournier  are  interest- 
ing, although  they  refer  purely  to  spinal  cases.  This  writer  collected  71 
cases  of  spinal  syphilis.  In  8  of  these  the  symptoms  appeared  during  the 
first  year,  18  in  the  second  year,  10  in  the  third,  10  in  the  fourth,  17  in  the 
fifth  to  the  tenth,  and  8  from  the  tenth  to  the  twenty-fifth  year.  In  Sav- 
ard's  figures,  quoted  by  Boulloche,^  there  were  26  cases  in  which  the  outbreak 
of  symptoms  coincided  with  secondary  manifestations,  7  which  appeared 
during  the  transition  period,  and  35  in  the  tertiary  stage.  Precocious  spinal 
syphilis  appears  to  be  somewhat  more  common  than  precocious  cerebral 
syphilis.  There  are  no  special  exciting  causes  which  determine  these  preco- 
cious attacks.  In  only  7  out  of  56  cases  collected  by  Gilbert  and  Lyon^  was 
the  onset  ascribed  to  exciting  causes. 

Inherited  syphilis  may  act  in  various  ways.  First,  it  may  so  affect  the 
nervous  system  of  the  foetus  as  to  seriously  influence  its  development.  This 
is  especially  seen  in  an  arrest  of  growth  and  development  of  the  brain,  many 
cases  of  idiocy  being  directly  traceable  to  this  cause.  Secondly,  lesions  iden- 
tical in  character  with  those  of  the  acquired  form  may  be  present  in  the 

1  The  terms  specific  arid  syphilitic  are  here  used  interchangeably. 
-  Boulloche  :  Ann.  de  Dermatolog.  et  Syphil.,  1891,  35,  ii.  753. 
3  Gilbert  et  Lyon  :  Archiv.  gen.  de  Med.,  1889,  ii.  404,  536,  662. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  701 

newborn  or  may  manifest  themselves  at  a  later  period.  If  not  present  at 
birth  they  generally  make  their  appearance  in  early  childhood.  However, 
contrary  to  the  usual  belief,  nervous  symptoms  due  to  hereditary  syphilis 
may  make  their  appearance  late.  They  may  not  be  noted  until  the  child  is 
seven  or  eight  years  of  age,  or  may  even  be  delayed  much  longer.  Cases 
from  seventeen  to  twenty-three  years  of  age  have  been  placed  on  record.  In 
one  instance  of  twenty  years  the  diagnosis  was  confirmed  by  an  autopsy  by 
the  writer.  Charcot'  records  the  case  of  a  woman,  aged  thirty  years,  who 
was  seized  with  focal  epilepsy  and  in  whom  acquired  syphilis  could  be 
excluded.  The  diagnosis  was  based  upon  optic  neuritis  clependent  upon 
syphilitic  basilar  meningitis,  specific  choroiditis,  and  characteristic  headache, 
linked  with  focal  symptoms ;  from  the  early  history  of  the  case  it  appears 
that  sjnnptoms  of  hereditary  syphilis  first  manifested  themselves  at  seven  and 
again  at  fourteen  years  of  age.  Not  only  does  hereditary  syphilis  occasionally 
make  its  appearance  late,  but  it  sometimes  manifests  itself  in  unusual  and 
unexpected  ways  ;  thus  Nolan^  reports  a  case  of  paretic  dementia  in  a  boy  of 
eighteen  years  of  age,  the  subject  of  inherited  syphilis.  Though  such  cases 
are  rare,  it  is  important  to  remember  the  possibility  of  their  occurrence.  (See 
also  p.  668.)  Evidences  of  inherited  syphilis  should  be  sought  for  in  all 
unusual  or  anomalous  cases  of  organic  nervous  diseases  in  childhood,  early 
youth,  and  even  the  beginning  of  adult  life.  We  should  remember,  how- 
ever, that  the  probability  of  specific  disease  diminishes  with  the  length  of 
time  intervening  between  birth  and  the  outbreak  of  symptoms. 

Etiology.  In  the  present  state  of  our  knowledge  it  is  impossible  to  ex- 
plain Avhy  syphilis  in  one  instance  should  attack  the  nervous  system  and  why 
in  another  the  latter  should  escape.  It  may  be  that  causes  that  impair  the 
vitality  or  the  resistance  of  the  nervous  system  invite  or  predispose  to  the 
occurrence  of  specific  lesions.  Among  such  causes  various  writers,  especially 
Heubner,  place  excessive  brain-work,  excesses  of  all  kinds,  long-continued 
strain,  whether  mental  or  physical,  and  profound  shock  and  fright.  In  some 
instances  trauma  also  appears  to  be  an  exciting  cause.  Thus  blows  upon  the 
skull  may  lead  indirectly  to  syphilitic  disease  of  the  bone  or  even  of  the 
membranes  of  the  brain ;  in  other  words,  in  persons  who  have  had  syphilis, 
the  lesions  produced  by  trauma  may  assume  a  specific  character.  Lastly,  it 
is  not  improbable  that  persons  who  are  hereditarily  neuropathic  suffer  more 
frequently  from  nervous  syphilis  than  others. 

Symptoms.  As  already  stated,  syphilis  produces  its  peculiar  pathological 
changes  primarily  in  the  membranes  and  bloodvessels.  These  changes  are 
generally  widespread  and  but  rarely  limited.  The  symptoms,  therefore,  in 
a  given  case  are  generally  such  as  point  to  a  number  of  lesions,  or  to  some 
widely  diffused  pathological  condition,  rather  than  to  a  single  focus  of  dis- 
ease. While  this  is  true,  it  must  be  remembered  that  syphilitic  exudations 
occur  most  frequently  in  certain  situations,  and,  as  a  consequence,  certain 
groups  of  symptoms  are  met  with  more  frequently  than  others.  However, 
the  fact  that  the  involvement  of  the  nervous  system  is  frequently  generalized 
or  multiple  in  character  cannot  be  too  strongly  insisted  upon.  To  see,  for 
instance,  brain  and  spinal  syphilis  associated  is  one  of  the  most  frequent  of 
occurrences ;  so  much  so,  indeed,  that  this  association  when  present  consti- 
tutes one  of  the  diagnostic  features  of  the  disease. 

Numerous  writers  have  at  various  times  attempted  to  set  up  clinical  types 
of  brain  or  spinal  syphilis,  but  each  of  these  types  or  symptom-grouj)s  has 
been  found  by  increasing  experience  to  be  inconstant  and  variable.  It  oc- 
casionally happens  that,  in  a  given  case,  at  one  time  cerebral  symptoms  pre- 

1  Charcot :  Bull,  med.,  1891,  v.  131.  2  Nolan  :  Journ.  of  Ment.  Sei.,  1893,  sxxix.  217. 


702  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

dominate  and  at  another  spinal  symptoms,  and  the  same  variability  is  noted 
throughout  the  entire  symptomatology.  Nothing,  for  instance,  like  a  fixed 
type  of  cerebral  syphilis  can  be  said  to  exist.  A  case  that  at  one  time  pre- 
sents the  symptoms  of  basal  syj^hilis  may  at  another  present  signs  of  cortical 
inyolyement.  In  the  same  way,  we  find  that  no  one  set  of  symptoms  can  be 
said  to  represent  syphilis  of  the  spinal  cord.  Similar  groups  of  symptoms 
are  all  that  we  meet  with — nothing  approaching  a  fixed  clinical  type. 

For  practical  purposes  it  will  be  best  to  consider  the  symptoms  according 
to  whether  the  lesions  ^predominate  in  the  brain,  in  the  cord,  or  in  the  periph- 
eral neryes. 

CEREBRAL  SYPHILIS. 

Syphilitic  deposits  take  place  either  at  the  base  or  at  the  convexity  of  the 
brain,  and  in  these  situations  give  rise  to  well-recognized  trains  of  symptoms ; 
that  is,  in  one  grouj^  of  cases  basal  symptoms  predominate,  and  in  the  other 
vertical  symptoms.  In  a  third  group,  instead  of  either  of  these  lesions, 
there  is  a  widely  diffused  inflammation  of  the  membranes  and  cortex ;  the 
symptoms  differ  largely  from  those  of  either  of  the  other  forms  in  that  they 
present  psychic  anomalies.  Frequently  they  closely  resemble  those  of  paretic 
dementia. 

General  Symptoms.  We  will  consider  first  briefly  the  symptoms  common 
to  or  liable  to  occur  in  all  forms  of  brain  syphilis.  Among  the  most  striking 
and  most  important  of  these  is  headache.  This  is  dull  in  character  and  as  a 
rule  diffuse.  Occasionally  it  is  referred  to  the  vault  of  the  cranium,  at  other 
times  to  the  base ;  it  may  even  be  referred  to  some  limited  area,  though  this  is 
comparatively  rare.  Like  other  headaches  dependent  upon  organic  cause, 
it  is  constant  and  subject  to  but  little  variation.  At  times,  however,  marked 
exacerbations  occur,  most  frequently  at  night,  though  sometimes  in  the 
morning.  The  symptom  is  of  special  value  only  when  associated  with 
others.  It  may  precede  more  definite  symptoms  by  weeks  or  months.  Not 
infrequently  it  is  accompanied  by  giddiness  and  vomiting. 

Next  in  importance  are  disturbances  of  sleep.  In  the  early  period  of 
cerebral  syphilis  the  patient  frequently  sufiers  from  insomnia.  Often  this 
insomnia  is  accompanied  by  much  irritability,  and  both  symptoms  are 
frequently  prodromal  to  some  apoplectic  or  other  outbreak.  At  times  the 
insomnia  is  caused  by  the  intense  headache ;  at  other  times  it  seems  to  be 
due  to  meningeal  irritation.  The  opposite  condition,  that  of  somnolence, 
more  or  less  pronounced,  is  even  more  frequent  than  insomnia.  It  is  noticed, 
for  instance,  that  a  patient  will  retire  early,  will  sleep  through  the  entire 
night  and  perhaps  late  into  the  day,  and,  notwithstanding  this  increased 
amount  of  rest,  will  often  fall  asleep  while  at  work,  especially  if  the  occu- 
pation is  sedentary.  Somnolence  may  indeed  be  so  pronounced  as  to  unfit 
the  patient  altogether  for  his  business.  In  some  cases,  the  patient  seems, 
while  awake,  to  be  but  half  conscious,  and  sometimes  he  acts  as  though  he 
were  under  the  influence  of  a  drug.  Often  he  can  only  be  awakened  tem- 
porarily, or  he  may  act  automatically,  very  much  as  do  intoxicated  persons. 
He  may  leave  his  bed,  void  the  urine,  evacuate  the  bowels,  or  perform  some 
other  long-accustomed  act  mechanically.  In  short,  every  possible  phase,  from 
great  insomnia,  which  is  comparatively  rare,  to  almost  continuous  sleep,  is  met 
with.  Somnolence,  it  should  be  remembered,  often  precedes  thrombosis  of 
the  vessels. 

That  other  symptoms  indicative  of  general  cerebral  disturbance  should  be 
present  is  not  surprising.  The'patients  are  frequently  apathetic.  Often  there 
is  a  distinct  loss  of  memory  with  slowing  of  thought  and  speech.     General 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 


70^ 


mental  failure  variable  in  degree  is  also  noted.  There  is  often  a  slight 
smoothing  out  of  the  lines  and  wrinkles  of  the  face,  such  as  is  seen  in  a  more 
pronounced  degree  in  dementia. 


Fig.  232. 


Fig.  233. 


Facial  expression  in  a  case  of  brain  syphilis. 
Patient  apathetic  and  somnolent.  (Philadel- 
phia Hospital.) 


Paralysis  of  left  ahducens  in  a  case  ot  alter- 
nate hemiplegia  of  syphilitic  origin.  (Phila- 
delphia Hospital.) 


Special  Symptoms.  Syphilis  of  the  Base.  As  already  stated,  gummatous 
exudations  take  place  far  more  frequently  at  the  base  than  at  the  vertex.  They 
are  prone,  further,  to  occur  in  the  most  central  portions  of  the  base,  namely,  in 


Fig.  234. 


Fig.  235. 


Piosis  in  a  case  of  alternate  hemiplegia  of 
syphilitic  origin.    (Philadelphia  Hospital.) 


Paralysis  of  internal  rectus  and  dilated 
pupil ;  partial  internal  and  external  ophthal- 
moplegia of  syphilitic  origin.  No  hemiplegia. 
(Jefferson  Hospital.) 


the  neighborhood  of  the  optic  chiasm,  the  interpeduncular  region,  and  adja- 
cent portions  of  the  middle  and  posterior  cranial  foss?e.  That  in  brain  syphilis, 
therefore,  we  should  have  involvement  of  cranial  nerves  is  not  surprising. 
The  latter  may  be  more  or  less  imbedded  in  the  exudation  and  suffer  both 
from  pressure  and  from  infiltration  of  their  sheaths,  or  the  vessels  supplying 


704  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tlieir  nuclei  of  origin  may  be  the  seat  of  gummatous  deposit,  with  subsequent 
thrombosis  and  softening.  As  a  consequence  numerous  special  symptoms  are 
present.  It  is  very  common,  for  instance,  to  meet  with  unequal  jDujDils,  ptosis, 
strabismus,  and  other  svmjDtoms  indicating  interference  with  the  oculo-motor 
nerves.  Affections  of  the  optic  nerves  are  also  exceedingly  common,  as  is 
shown  especially  by  abnormalities  in  the  visual  fields.  The  latter  are  aj)t  to 
be  more  or  less  irregular  and  contracted,  but  often  distinctive  forms  of  field 
disturbance  are  present.  Thus  a  specific  exudation  at  the  base  may  so  affect 
the  chiasm  as  to  give  rise  to  a  blindness  of  both  nasal  halves  of  the  retina, 
that  is,  a  bitemporal  hemianopsia ;  or  it  may  so  involve  an  optic  tract  on 

Fig.  236. 


Ocular  palsies  of  both  sides  in  a  case  of  double  hemiplegia.    (Jefferson  Hospital.) 

either  side  as  to  produce  a  lateral  or  homonymous  hemianopsia.  Xot  infre- 
quently the  loss  of  vision  becomes  so  great  that  total  blindness  supers^enes. 
These  facts,  considering  the  frequency  of  syphilitic  exudation  in  the  region 
of  the  chiasm,  are  of  the  utmost  importance.     They  are  too  often  neglected. 

While  involvement  of  the  optic  nerve  tracts  and  chiasm  is  most  frequently 
indicated  by  changes  in  the  visual  field,  optic  neuritis  is  also  frequently  met 
with.  We  must  remember  that  syphilitic  meningitis  and  localized  gumma- 
tous deposits  may  give  rise  to  this  symptom  just  as  do  other  new  formations. 
However,  as  Gowers  has  pointed  out,  the  optic  neuritis  of  sj'philis  is  of  the 
acute  form,  and  rapidly  becomes  intense,  differing  in  this  respect  from  the 
neuritis  present  in  tumors. 

Not  infi"equently  the  olfactory  nerves  are  attacked,  with  a  resulting  loss  of 
the  sense  of  smell.  The  trifacial  nerve  may  also  suffer.  Anaesthesia  and 
hypersesthesia  are  rare,  but  neuralgic  pains  are  occasionally  met  with.  These 
owe  their  existence  to  involvement  of  the  roots  of  the  nerve  or  of  the  Gas- 
serian  ganglion  in  the  gummatous  exudation.  (Oppenheim^  mentions  a  case 
in  which  there  was  complete  anaesthesia  of  one  side  of  the  face,  with  absence 
of  the  corneal  reflex  and  a  beginning  neuro-paralytic  keratitis.  In  the  same 
case  loss  of  ta.ste  on  the  same  side  of  the  tongue  was  also  noted.)  Less  fre- 
quently we  have  involvement  of  the  facial  nerve  with  a  consec[uent  ''  com- 
plete "  facial  paralysis,  that  is,  one  embracing  the  entire  peripheral  distrilui- 
tion  of  the  nerve.  Involvement  of  the  auditory  nerve  aj^pears  to  be  quite 
rare.     Wood  mentions  deafriess  as  occurring.     The  roots  of  other  cranial 

Oppenheim  :  Syph.  Erkrankung.  des  Central.  Nervensyst.    Berlin,  1890. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 


705 


nen^es,  such  as  the  h^-poglossal,  the  vagus,  the  spinal  accessory,  may  also  be 
attacked,  though  such  an  involvement  is  quite  infrequent. 

Just  as  the  various  cranial  nei'ves  may  be  involved  in  the  exudation 
so  may  the  vessels  of  the  base.  The  arteries  supplying  the  basal  ganglia 
and  capsules  and  those  supplying  the  motor  area,  the  middle   cerebrals, 


Fig.  237. 


Visual  fields  in  syphilis  of  the  base,  showing  marked  contraction.    (Infirmary  for  Nervous  Diseases, 

Philadelphia.) 

are  among  the  most  frequent  to  be  affected.  It  cannot  be  surprising  that 
in  such  instances  symptoms  indicating  gross  lesions  of  the  brain,  hemi- 
plegias, and  other  palsies  are  present.  Thase  are  due  either  to  thrombosis 
or  to  hemorrhage,  thrombosis  being  the  more  common  of  the  two  condi- 
tions. The  symptoms  resemble  in  a  general  way  those  occurring  from 
ordinary  vascular  disease  of  the  brain.      They  present,  however,   certain 

Fig.  238. 


Visual  fields  in  same  patient  as  Fig.  2-<l  six  months  later,  showing  extreme  contraction. 

important  peculiarities.  First,  the  history  of  the  onset  is  seldom  that  of 
an  ordinary  apoplexy ;  the  attack  is  rarely  .sudden.  Much  more  fre- 
quently the  onset  is  gradual  and  is  attended  by  a  preservation  of  conscious- 
ness. However,  hemiplegia,  the  result  of  a  non-specific  thrombosis,  may 
also  be  gradual  in  its  onset,  as  may  the  hemiplegia  of  ingravescent  hem- 

45 


706  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

orrhage.  These  peculiarities  cannot,  therefore,  be  considered  as  pathogno- 
monic ;  but  their  presence  in  a  given  case  should  always  suggest  syphilis  as  a 
possible  cause.  Again,  the  hemiplegia,  or  rather  the  hemiparesis  of  syphilis, 
for  the  palsy  is  rarely  complete,  is  apt  to  be  transient  or  fugacious  in  charac- 
ter. A  cerebral  artery  may  have  its  lumen  encroached  upon  by  specific  de- 
posit, but  the  nature  of  this  new-formed  tissue  permits  the  blood-current 
after  a  time  to  be  more  or  less  re-established,  and,  as  a  consequence,  the  palsy 
disappears  or  becomes  markedly  diminished.  Later  on,  narrowing  in  the 
calibre  of  the  vessel  again  occurs  with  a  renewal  of  the  paralysis,  and  this 
cycle  is  repeated  until  more  or  less  permanent  paralysis  results.  The  hemi- 
plegia of  syphilis  is  further  characterized  by  the  association  of  other  symp- 
toms indicating  basal  lesions.  Important  among  these  are  the  various  cranial 
nerve  involvements,  especially  the  oculo-motor.  It  is  a  common  experience 
to  see  a  hemiplegia  of  one  side  of  the  body  with  a  dilated  pupil  or  other 
evidence  of  oculo-motor  palsy  upon  the  other  side.  (See  Figs.  233  and  234.) 
In  other  words,  crossed  or  alternate  paralyses  are  here  very  common.  (See 
also  Chapter  XV.,  page  459.) 

Again,  a  patient  the  subject  of  syphilis  may  not  only  have  a  hemiplegic 
attack  upon  one  side,  but  later  also  a  hemiplegia  of  the  opposite  side.  The 
exudation  at  the  base  having  become  very  extensive,  involves  in  such  a  case 
the  vessels  of  both  sides  of  the  base  of  the  brain  in  succession.  Other  things 
equal,  a  history  of  double  hemiplegia,  one  attack  following  the  other,  points 
to  syphilis. 

Among  the  interesting  complications  met  with  in  specific  hemiplegia  is 
aphasia.  This  may  follow  the  same  laws  as  it  presents  when  due  to  vascular 
disease  from  other  causes,  or  it  may  be  of  the  fugacious  character  just  de- 
scribed. It  is,  important  to  remember  that  if  aphasia  be  associated  with  a 
left  hemiplegia,  our  inquiries  should  always  be  directed  toward  determining 
possible  syphilitic  infection.  Indeed,  quite  a  number  of  cases  have  been 
collected  in  which  aphasia  has  been  associated  with  left  hemiplegia  in  syphi- 
litic subjects.  This  is  doubtless  due  to  the  frequency  of  multiple  lesions  in 
the  latter. 

Syphilis  of  the  vessels  of  the  base  does  not,  of  course,  always  result  in 
hemiplegia.  Every  now  and  then  involvement  of  the  basilar  and  the  verte- 
bral arteries  give  rise  to  symptoms  referable  to  the  pons  and  medulla. 

Syphilis  of  the  Convexity.  The  symptomatology,  as  thus  far  described, 
is  more  especially  that  of  basal  syphilis.  When  the  disease  attacks  the  con- 
vexity there  are  present,  in  addition  to  the  headache,  insomnia  or  somnolence, 
mental  impairment,  and  other  general  manifestations,  certain  special  symp- 
toms dependent  uj)on  the  particular  location  of  the  lesion.  Thus,  the  occlu- 
sion of  a  vessel  or  a  gummatous  deposit  in  the  motor  area  will  give  rise  to 
characteristic  focal  symptoms ;  that  is,  there  may  be  an  arm,  leg,  or  other 
limited  palsy  of  the  opposite  side  of  the  body,  or  the  patient  may  suffer  from 
epileptiform  attacks,  Jacksonian  in  type.  Focal  symptoms,  sensory  in  char- 
acter, are  also  occasionally  met  with,  though  they  are  decidedly  less  frequent. 
Again,  in  addition  to  or  in  place  of  focal  symptoms,  others  may  be  present 
indicative  of  diffuse  or  multiple  involvement  of  the  membranes  and  vessels. 
It  is  needless  to  say  that  such  symptoms  point  strongly  to  syphilis. 

EjDileptic  seizures  are  frequently  the  outgrowth  of  a  general  nervous  in- 
volvement, and  in  such  cases  lack  a  focal  character.  Like  ordinary  epilepsy, 
the  attacks  may  be  present  either  in  the  form  of  jietit  mal  or  of  grand  vial, 
and  may  closely  resemble  essential  epilepsy.  However,  in  some  cases  con- 
sciousness is  not  as  completely  lost  as  in  the  essential  form.  The  latter, 
as  a  rule,  makes  its  appearance  long  before  adult  life  is  reached.  If,  there- 
fore, an  epilepsy  occurs  at  a  relatively  late  period,  the  presumption  is  strongly 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  707 

in  favor  of  syphilis.  This  general  truth  in  regard  to  syphilitic  epilepsy  was 
first  pointed  out  by  Fournier,  who  says :  "  True  epilepsy  never  begins  at 
adult  age,  at  mature  age.  If  an  adult  man,  above  thirty,  thirty-five,  or  forty 
years  of  age,  is  seized  for  the  first  time  by  an  epileptic  attack,  and  while  in 
apparent  good  health,  there  are,  I  repeat  it,  eight  or  nine  chances  out  of  ten 
that  this  ei^ilepsy  is  of  a  syphilitic  origin."  (See  also  Chapter  XI.)  Of 
course,  other  causes,  such  as  lead  and  alcohol,  and  gross  pathological  condi- 
tions, tumors,  traumata,  etc.,  must  be  excluded. 

Among  the  less  frequent  symptoms  of  brain  syj^hilis  must  be  mentioned 
polydypsia  and  polyuria.  Even  melituria  and  paroxysmal  hemoglobinuria 
have  been  recorded.^  It  is  probable  that  in  these  cases  the  lesion  involves  the 
medulla  or  is  in  close  proximity  to  it.  Pierre,  for  instance,  found  a  small 
gumma  pressing  on  the  fourth  ventricle. 

When  brain  syphilis  is  precocious  it  attacks  the  membranes  and  vessels  in 
a  manner  in  no  way  distinguishable  from  the  ordinary  form.  However, 
Schmitt^  some  years  ago  stated  that  there  is  a  precocious  form  of  cerebral 
sypliilis  which  manifests  itself  as  a  hemianeesthesia  which  may  or  may  not  be 
associated  with  hemiplegia.  It  may  appear  in  the  fourth  month  after  infec- 
tion, and  yields  only  slowly  to  antisyphilitic  treatment.  A  lesion  of  the 
arterial  walls  seems  to  be  the  pathological  basis  of  the  aflfection.  This  form 
must  certainly  be  infrequent,  as  these  statements  have  not  been  confirmed. 

Diffuse  Syphilis  of  the  Cortex,  Syphilitic  Demextia.  As  already 
stated,  no  sharp  distinction  can  be  drawn  between  the  various  forms  of  cere- 
bral syphilis,  and  it  is  not  infrequent  to  find  symptoms  indicative  of  cortical 
involvement,  such  as  dementia  and  other  psychic  anomalies,  in  both  syj)hilis 
of  the  base  and  syphilis  of  the  convexity.  In  addition  there  is  a  form  clini- 
cally well-recognized  in  which  mental  symptoms  predominate  and  constitute 
the  most  striking  features  of  the  disease. 

In  this  group  the  general  symptoms  of  cerebral  syphilis  already  described 
(see  p.  702)  are  also  noted.  Prominent  among  these  is  headache,  which,  as 
before,  is  dull,  difilise,  and  persistent.  Often  it  is  a  headache  that  grows 
worse  at  night.  Sometimes  it  is  increased  by  pressure  upon  the  skull.  Som- 
nolence, too,  is  also  noted,  and  is  apt  to  be  excessive.  Often  it  j^ersists  for 
very  long  periods,  though  not  infrequently  it  is  broken  in  upon  by  shorter 
periods  of  insomnia.  Vertigo,  present  in  the  other  forms,  may  also  be  a 
striking  symptom  here. 

In  addition  to  these  general  symptoms,  various  psychic  anomalies  make 
their  appearance.  The  patient  presents  a  change  in  character  and  dispositioii. 
It  is  noticed  by  his  friends  that  he  has  become  morose,  irritable,  and  de- 
pressed, that  his  memory  has  become  impaired,  and  that  his  capacity  for 
intellectual  labor  has  become  diminished.  He  is  easily  tired  out.  His  facial 
expression  is  dull  and  heavy,  and  his  attitude  is  one  of  general  relaxation. 
Most  commonly  the  depression  of  the  patient  deejDens,  and  is  soon  associated 
with  melancholic  or  hypochondriacal  delusions.  Not  infrequently  these  take 
the  form  of  delusions  of  persecution.  Sometimes  the  depression  becomes  very 
pronounced,  and  there  may  even  be  a  tendency  to  suicide.  Hallucinations 
of  hearing,  or  of  taste  and  smell,  also  commonly  make  their  appearance. 

In  other  cases,  and  by  far  the  smaller  number,  instead  of  being  in  a  condi- 
tion of  depression,  the  patient  may  be  more  or  less  exalted,  and  now  expansive 
delusions,  "delusions  of  grandeur"  similar  to  those  met  with  in  paretic  de- 
mentia (see  p.  677),  may  be  present.  These,  however,  as  a  rule,  are  not  quite 
so  extravagant,  not  quite  so  variable,  and  a  little  better  systematized  than  in 

1  CoUeville  :  Gaz.  Hebdom.  de  med.,  1890,  2  s.  xxvii.  448. 

-  Schmitt ;  Congrts  Internal,  de  Dermat.  et  Syph.,  1889,  1890,  726. 


708  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  latter  disease.  In  many  cases,  again,  well-marked  delusions  are  absent,  a 
mild  cerebral  excitement  being  the  only  indication  of  the  patient's  condition. 
On  the  other  hand,  the  excitement  may  increase  until  there  is  great  restless- 
ness, anxiety,  agitation,  violence,  or  a  condition  of  actual  mania.  Indeed, 
we  may  meet  with  all  degrees  of  violent  cerebral  disturbance,  varying  from 
an  intense  mania  to  an  acute  delirium. 

The  reader  will  see  at  once  that  syphilis  may  simulate  both  the  expansive 
and  the  depressive  forms  of  paretic  dementia,  and  it  is  not  surprising  to  find 
that  the  course  pursued  is  at  times  similar  to  that  of  the  simple  and  uncom- 
plicated form  of  paresis ;  that  is,  there  may  simply  be  blunting  of  the  facul- 
ties, slowness  of  thought,  and  impairment  of  memory.  These  symptoms  may 
gradually  deepen  until,  together  with  the  somnolence  so  frequently  present, 
stuporous  conditions,  coma,  or  a  condition  of  sleep-drunkenness  may  be 
present. 

As  a  rule,  the  symptoms  are  slow  in  development,  but  their  course  instead 
of  being  continuous  is  more  or  less  interrupted.  Intermissions  occur,  during 
which  the  patient  remains  in  his  previous  condition  or  in  which  spontaneous 
improvement  takes  place.  Sometimes  a  recession  takes  place  which  not  only 
embraces  individual  symptoms,  but  sometimes  the  entire  group  of  symptoms. 
However,  after  an  interval,  which  is  sometimes  long  or  sometimes  short,  a 
fresh  accession  occurs.  The  course  of  the  disease  is  also  peculiar  in  that 
physical  symptoms  indicative  of  focal  lesions  occur  early  or  even  precede  the 
mental  symptoms.  It  is  very  common,  for  instance,  to  observe  various 
ocular  palsies,  such  as  strabismus,  dilated  pupil,  and  ptosis.  At  other  times, 
aphasia,  hemiplegia,  or  loss  of  power  in  one  extremity  may  be  noted.  These 
focal  symptoms  present  the  usual  characteristics  of  syphilitic  phenomena,  in 
that  they  are  sudden  in  onset,  but,  as  a  rule,  temporary  in  duration.  As  in 
other  forms,  they  are  shifting  and  fugacious.  Other  symptoms  noted,  also, 
in  the  other  forms  of  cerebral  syphilis  may  make  their  appearance,  such  as 
amblyopia,  amaurosis,  or  optic  neuritis.  The  latter  presents  the  peculiarities 
already  mentioned  (see  p.  704).  At  times  also  the  course  of  the  disease  is 
interrupted  by  convulsive  attacks  which  may  more  or  less  simulate  focal 
epilepsy.  At  other  times  seizures  occur  which  are  apoplectiform  in  type, 
and  accompanied  by  a  hemiplegia  or  other  palsy,  usually  temporary.  Less 
frequently  there  are  attacks  of  cerebral  excitement  which  may  culminate  in 
maniacal  outbursts,  or  the  patient  may  suffer  from  an  hallucinatory  delirium, 
the  hallucinations  being  often  accompanied  by  fear. 

■  While  the  course  of  syphilitic  dementia  is  exceedingly  irregular,  it  not  in- 
frequently simulates  paretic  dementia,  so  much  as  at  times  to  cause  difficulty 
in  diagnosis.  Taken  as  a  whole,  however,  the  clinical  picture  of  syphilitic 
dementia  differs  markedly  from  that  of  paresis.  In  addition  to  the  peculiar 
course  of  brain  syphilis  just  described  and  the  palsies  presenting  the  peculi- 
arities of  syphilis,  we  note  that  the  expansive  mental  state  so  commonly  met 
with  in  paresis  is  in  syphilitic  dementia  the  exception  and  not  the  rule.  For 
the  detailed  differential  diagnosis  between  these  two  diseases  the  reader  is 
referred  to  Chapter  XXIII.,  p.  696. 

Other  forms  of  insanity  are  occasionally  met  with  in  syphilitic  subjects. 
They  are,  however,  in  the  majority  of  cases  an  indirect  outcome  of  the  dis- 
ease, and  not  due  to  lesions  of  the  brain  or  its  membranes.  However,  it  is 
said  that  in  some  cases  during  the  period  of  infection,  that  is,  the  febrile 
period,  delirium  and  even  mania  may  occur,  but  these  phenomena  are  cer- 
tainly rare.  With  the  exception  of  syphilitic  dementia  the  various  morbid 
states  met  with  are  due  to  secondary  and  general  causes.  It  is  not  infre- 
quent to  meet  with  syphilitic  subjects  who,  as  a  result  of  the  knowledge  of 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  709 

their  infection  and  the  probable  character  of  the  disease,  acquire  hypo- 
chondriasis and  sometimes  melancholia  (see  also  p.  712),  Here  heredity  or 
predisposition  to  insanity  is  in  many  cases  doubtless  the  determining  factor. 
Indeed,  similar  conditions  are  sometimes  met  with  in  those  who  have  led  im- 
moral lives  and  having  suffered  exposure  are  in  constant  dread  of  infection, 
or  actually  believe  that  they  have  been  infected.  This  condition,  known  as 
syphilophobia,  may  even  be  observed  in  persons  who  have  never  actually  suf- 
fered exposure,  but  who  have  merely  been  addicted  to  masturbation.  Neuras- 
thenic symptoms  and  general  hypochondriasis  are  usvially  found  in  such  cases. 


SPINAL  SYPHILIS. 

As  in  cerebral  syjDhilis,  the  virus  of  the  disease  expends  itself  mainly  upon 
the  membranes  and  bloodvessels,  and,  because  the  lesions  are  liable  to  be 
both  extensive  and  variable,  the  symptoms  presented  are  manifold.  If  the 
exudation  be  more  or  less  localized,  that  is,  if  gumma  be  present,  the  symp- 
toms are  those  of  spinal  tumor.  If,  as  is  more  frequently  the  case,  the  exu- 
dation be  more  diffuse  and  involve  also  the  bloodvessels,  various  symptoms 
referable  to  involvement  of  the  cord  itself,  of  the  various  roots  of  the  spinal 
nerves,  are  present. 

The  exudation  may  involve  all  three  of  the  membranes  or  may  be  limited 
to  the  pia  and  arachnoid.  The  latter  may  become  more  or  less  fused  with 
each  other  and  adherent  to  the  cord.  The  bloodvessels  are  especially  prone 
to  suffer,  their  walls  becoming  infiltrated,  and  thus  the  blood-supply  of  vari- 
ous portions  of  the  cord  may  be  interfered  with. 

As  in  brain  syphilis,  no  one  "  symptom  group  "  exists  which  is  characteristic 
of  all  cases  of  spinal  syphilis.  It  is  true,  however,  that  certain  clinical  forms 
occur  more  frequently  than  others.  This  fact  led  Erb,^  a  few  years  ago,  to 
describe  a  sj)ecial  complex  of  symptoms  under  the  name  of  syphilitic  spinal 
paralysis.  While,  as  we  will  presently  see,  all  cases  of  spinal  syphilis  do  not 
conform  to  this  description,  it  occurs  with  sufficient  frequency  to  warrant 
special  consideration.  It  is  characterized  as  follows :  Spastic  paralysis  of  the 
lower  extremities,  markedly  exaggerated  tendon  reflexes,  low  muscle  ten- 
sion, disturbances  of  the  bladder,  and  but  slightly  marked  disturbances  of 
sensation. 

The  history,  according  to  Kuh,^  is  somewhat  as  follows :  It  usually  begins 
with  a  slowly  increasing  weakness  and  stiffness  of  the  lower  extremities, 
frequently  accompanied  by  parsesthesias.  These  disturbances  of  sensation 
consist  chiefly  of  formication,  and  are  most  frequent  in  the  legs.  Girdle  sen- 
sations are  also  often  mentioned,  but  the  iDatient  fails  to  accurately  localize 
them.  Other  sensations,  such  as  burning,  velvety  feelings,  feeling  as  though 
the  patient  were  receiving  an  electric  current,  trembling  sensation  in  the 
legs  or  parsesthesias  about  the  anus,  and  drawing  sensations  over  the  back 
and  the  legs,  are  also  occasionally  noted.  These  sensory  disturbances  are, 
not  rarely,  the  only  indications  of  a  lesion  of  the  sensory  tracts.  Occasion- 
ally, also,  hypersesthesia  is  mentioned  as  an  initial  symptom.  Actual  pains 
may  occur  in  the  beginning  of  the  affection,  but  they  are  almost  without  ex- 
ception of  very  slight  intensity.  Most  frequently  they  occur  in  the  vertebral 
column  or  in  the  sacral  region.  At  times  they  are  present  in  the  form  of  a 
girdle.  The  most  varied  portions  of  the  body  may  be  the  seat  of  pains. 
The  breast,  the  intercostal  region,  the  abdomen,  the  legs,  the  knees,  the  hips, 

1  Erb:  Neurolog.  Centralbl.,  1892,  xi. 

2  Kuh :  Deutsche  Zeitschrft.  f.  Nervenheilk,  1893,  iii.  359. 


710  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  iliac  fossa,  the  buttocks,  etc.  Serious  objective  disturbances  of  cutaneous 
sensibility  appear  never,  or  almost  never,  to  occur.  Slight  sensory  and  motor 
disturbances  not  infrequently  begin  in  one  leg,  and  only  later  make  their 
appearance  in  the  opposite  limb.  More  rarely  the  symptoms  pursue  an 
ascending  course,  that  is,  spread  gradually  from  the  feet  upward  to  the 
region  of  the  pelvic  girdle.  jS^ow  and  then,  too,  we  see  in  the  beginning  of 
the  affection  jerkings  in  the  legs. 

To  the  most  important  phenomena  of  this  period  belong  the  disturbances 
of  micturition  that  are  found  in  about  one-half  the  cases  among  the  early 
symptoms.  It  is  characterized  most  frequently  by  a  weakness  of  the  detrusor 
urinas,  more  or  less  marked.  More  seldom  there  exists  in  the  beginning  a 
weakness  of  the  sjDhincter.  In  a  number  of  cases  bowel  disturbances  are 
also  noted,  constipation  being  twice  as  frequent  as  incontinence.  Not  rarely 
we  note  among  the  early  symptoms  an  impairment  of  the  sexual  power 
which  appears  to  be  rapidly  progressive,  amounting  to  actual  impotence. 
Very  rarely,  symptoms  of  sexual  irritation,  e.  g.,  priapism,  are  present.  In 
one  patient  intense  pains  in  the  back  were  attended  by  sexual  excitement, 
which  at  times  increased  up  to  ejaculation. 

When  the  clinical  picture  is  fully  developed  we  find  spastic  paralysis  of 
the  lower  extremities.  It  is  present  in  all  degrees.  Very  seldom  only  is  a 
complete  paralysis  noted,  and  when  this  occurs  it  appears  to  be  temporary  in 
character.  Usually  we  have  a  very  well-developed  spastic  gait,  associated 
with  a  relatively  slight  paresis.  Further,  in  the  early  stage,  the  motor  symp- 
toms are  unequal  on  the  two  sides,  one  leg  being  more  affected  than  the 
other.  In  beginning  or  in  incompletely  developed  cases  the  spastic  paral- 
ysis may  be  more  or  less  limited  to  one  extremity. 

A  sharp  contrast  to  the  markedly  spastic  gait  is  formed  by  the  muscle 
tension,  which  is  remarkably  low.  The  tendon  reflexes  of  the  lower  extrem- 
ities are  always  exaggerated.  Almost  constantly  do  we  find  an  ankle-clonus 
present,  very  frequently  also  a  patellar  clonus.  The  deep  reflexes  of  the 
arms  are  but  seldom  affected.  The  skin  reflexes  are  not  especially  involved. 
Decubitus  and  cystitis  occur  infrequently,  and  then  only  in  very  severe  cases 
and  in  the  later  stages. 

According  to  Kuh,  the  disease  has  its  origin  in  all  probability  in  syphilis 
of  the  vessels  of  the  cord  in  the  dorsal  region,  the  lesions  in  the  cord  being 
secondary  and  involving  mainly  the  lateral  tracts,  and  slightly  invading  the 
posterior  columns.  The  recognition  of  this  type  is  exceedingly  important,  as, 
according  to  Erb,  marked  improvement  is  apt  to  occur.  Kowalewsky,^  who 
has  also  studied  Erb's  symptom-group  (for  it  cannot  be  termed  a  type),  con- 
cludes that  it  is  quite  common,  that  it  belongs  to  the  ages  of  thirty  to  forty- 
five,  and  that  it  is  most  common  in  the  male  sex. 

As  is  well  known,  ataxia  is  every  now  and  then  present  in  syphilis  of  the 
cord.  At  times  this  ataxia  is  associated  with  exaggerated  reflexes,  so  that  a 
condition  is  presented  similar  to  that  which  is  met  with  in  ataxic  paraplegia 
or  combined  sclerosis.  In  other  cases,  again,  the  ataxia  may  be  associated 
with  absence  of  the  tendon  reactions,  and  the  clinical  picture  may  still 
further  resemble  that  seen  in  true  locomotor  ataxia  in  the  presence  of  an 
Argyll-Robertson  pupil. 

When  we  recall  the  fact  that  the  virus  of  syphilis  expends  itself  mainly 
upon  the  membranes  and  bloodvessels,  it  is  not  surprising  that  most  varied 
clinical  pictures  should  present  themselves.  Not  a  single  symptom  can  be 
taken  as  constant  for  all  cases.  Even  the  spastic  character  of  the  gait  may 
be  lacking.     Instead  of  flaccidity  contractures  may  be  present  and,  under 

1  Kowalewsky :  Neurolog.  Centralbl,  1893,  xii.  p.  383. 


SYPHILIS  OF  THE  SEE  VO  US  S YSTEM.  711 

certain  conditions,  the  knee-jerks  may  be  absent.  Indeed,  Oppenheim'  goes 
so  far  as  to  maintain  that  Erb's  type  is  only  a  stage  of  meningo-myehtis. 
Many  cases  present  symptoms  of  meningitic  irritation  and  of  involvement 
of  the  nerve-roots.  Tlae  clearest  and  most  comprehensive  interpretation  of 
the  symptoms  that  has  yet  been  presented  is  that  of  Sachs^  who  says  :  "  If 
the  infiltration  start  from  the  meninges  it  invades  most  frequently  the  lateral 
columns  first,  often  at  symmetrical  points,  and  advances  very  slowly  from 
white  to  gray  matter.  The  intensity  of  the  process  is  spent  often  upon  the 
lateral  columns,  hence  the  frequency  of  the  spastic  symptoms.  It  may  in- 
vade the  gray  matter,  giving  rise  to  sensory  symptoms,  sometimes  to  atrophic 
symptoms.  It  is  very  apt  to  recede  from  the  gray  matter,  restoring  sensa- 
tion, the  conditions  of  nutrition,  and  the  normal  condition  of  the  bladder, 
but  it  seems  to  halt  at  the  lateral  columns,  leaving  the  spastic  symptoms 
intact  for  a  very  long  time."  How  much  the  clinical  picture  of  spinal 
syphilis  may  vary  is  shown  by  the  occurrence  of  such  phenomena  as  Brown- 
Sequard  paralysis.  Hertel,^  Oppenheim,*  and  Gerhard^  especially  note  the 
occurrence  of  this  symptom.  Gerhard,  however,  is  of  the  opinion  that  Erb's 
type  is  an  actual  entity,  at  least  is  not  always  a  mere  stage  of  meningeal 
syphilis,  as  Oppenheim  would  make  it.  Finally,  it  is  important  to  bear  in 
mind  that  in  spinal  syj)hilis,  as  in  brain  syphilis,  the  same  tendency  to 
spontaneous  remissions,  followed  sooner  or  later  by  renewed  accessions,  is 
found. 

The  student  should  be  impressed  with  the  frequency  of  cerebral  complica- 
tions in  spinal  syphilis.  This  fact,  which  is  well  recognized,  has  been  espe- 
cially insisted  upon  by  Oppenheim,  Siemerling,  and  by  Sachs.  Indeed,  the 
diagnosis  of  a  given  case  of  nervous  syphilis  should  more  frequently  read 
"  multiple  cerebro-spinal  syphilis "  than  either  syphilis  of  the  brain  or 
syphilis  of  the  cord,  and,  when  we  reflect  upon  the  infectious  nature  of  the 
disease  and  the  consequent  tendency  to  wide  distribution  of  the  lesions,  this 
statement  will  not  cause  surprise. 

Spinal  syphilis  is  not  infrequently  precocious  in  its  onset.  Erb  states  that 
the  type  of  spinal  syphilis  described  by  him  appears  in  over  half  the  cases 
in  the  first  three  years  after  infection — sometimes  in  the  first  year.  Gilbert 
and  Lyon,^  however,  in  their  studies  of  precocious  spinal  syphilis,  tell  us  that 
the  spinal  cord  may  become  the  seat  of  spinal  lesions  from  the  third  month 
after  syphilitic  infection,  more  fi'equently,  indeed,  from  the  third  to  the  sixth 
month  than  later.  As  a  pathological  groundwork  they  distinguish  a  men- 
in go- myelitis,  which  is  either  necrobiotic  or  which  is  attended  by  cellular 
hyperplasia,  by  diffuse  sclerosis,  or  by  localized  gummatous  formations. 

Sottas'  in  discussing  the  pathology  of  spinal  s}'3)hilis  maintains  that  the 
condition  is  due,  not  to  inflammation,  but  to  a  process  of  softening,  that 
meningeal  and  vascular  alterations  first  ensue  which  result  in  the  oblitera- 
tion of  the  vessels  and  consequent  softening  of  the  cord  tissue,  and  that  the 
sclerosis  which  results  is  due  to  a  reactive  inflammation.  A  similar  view  is 
adopted  by  Dejerine.®  There  is  apparently  never  a  true  primary  syphilitic 
myelitis. 

Every  now  and  then  gummata  are  found  in  the  cauda  equina,  and  in  such 
case  give  rise  to  symptoms  similar  to  those  which  other  tumors  of  the  cauda 
produce.     (See  page  652.) 

1  Oppenheim  :  Berlin,  klin.  Wochenschrift,  1893,  xxx.  837. 

=  Sachs:  Brain,  1893,  p.  405. 

3  Hertel :  Charite  Annalen,  1890,  xv.  214  <  Loc.  cit. 

5  Gerhard  :  Berlin,  klin.  V>'ochensch.,  1893,  xxx.  1209. 

6  Loc.  cit. 

'  Sottas  :  Compt.  Rend.  Soc.  de  Biolog.,  1893,  9  s.  v.  359. 
8  Dejerine  :  Compt.  Rend.  Soc.  de  Biolog.,  1893,  9  s.  v.  432. 


712  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


SYPHILIS  OF  THE  NERVES. 

Ceaxial  Nerves.  Syphilis  may  attack  the  cranial  nerves  primarily, 
but  more  often,  being  exposed  to  syphiHtic  exudation,  they  become  involved 
secondarily,  or  the  minute  vessels  supplying  their  nuclei  become  occluded  by 
gummatous  deposit.  Especially  frequent  is  the  involvement  of  the  oculo- 
motor nerve,  as  already  stated.  In  such  instances  a  dilated  pupil,  external 
strabismus,  prominence  of  the  eyeball,  ptosis,  or  various  derangements  of 
vision  may  be  present.  Whenever  such  phenomena  make  their  appearance 
as  isolated  symptoms  without  special  cause,  syphilis  should  be  suspected. 
The  sixth  nerve  may  be  similarly  attacked,  the  symptoms  then  being  inter- 
nal strabismus  and  diploplia.  The  facial  nerve  is  very  infrequently  aiFected ; 
the  palsy  is  generally  a  complete  one,  that  is,  it  involves  the  entire  distribution 
of  the  nerve,  the  orbicularis  palpebrarum  suffering  along  with  the  other 
facial  muscles.  The  trigeminus  also  is  every  now  and  then  involved,  either 
at  its  roots  or  at  the  Gasserian  ganglion,  and  in  such  an  instance  pain,  in- 
tense in  character — a  severe  and  persistent  neuralgia — is  present.  The  optic 
nerves,  as  already  stated,  also  frequently  suffer.  Involvement  of  the  spinal 
accessory  and  hypoglossal  is  also  occasionally  met  with.  For  a  detailed 
description  of  the  svmptomatologv  of  disease  of  these  nerves  the  reader  is 
referred  to  Chapters  XXYI.  and  XXYII. 

Spixal  Xerves.  S}^hilis  of  the  spinal  nerves  is  excessively  rare.  As 
in  the  case  of  the  cranial  nerves,  the  various  nerve-roots  may  be  involved  in 
syphilitic  exudation,  and  thus  special  symptoms  may  arise.  Single  nerve- 
trunks  may  also  be  affected,  but  acute  multiple  neuritis,  primary  and  directly 
due  to  s}"philitic  infection,  is  exceedingly  rare,  if,  indeed,  it  ever  occurs.  As 
shown  by  Peret,  Dejerine,  and  others,  changes  take  place  in  the  peripheral 
spinal  nerves  in  many  cases  of  locomotor  ataxia.  The  lesion  is,  however,  a 
degenerative  one,  and  not  due  to  direct  specific  inflammation. 


FUNCTIONAL    NERVOUS  DISEASES. 

Kecently  Kowalewsky^  has  studied  the  relation  of  syphilis  to  various  func- 
tional nervous  affections.  Syphilis  can  doubtless  produce  nutritional  dis- 
turbances which  will  not  manifest  themselves  by  any  visible  changes  in  the 
central  nervous  organs.  These  disturbances  may  be  secondary,  first,  to 
changes  in  the  blood ;  secondly,  to  changes  in  the  tissues  following  energetic 
antisyphihtic  treatment ;  thirdly,  to  changes  in  the  bloodvessel  walls,  due  to 
pathological  processes ;  fourthly,  to  changes  in  the  nerve  elements  resulting 
from  the  psychic  shock  arising  from  the  knowledge  of  having  acquired  so 
terrible  a  disease  ;  and,  lastly,  to  alteration  of  the  nervous  tissues  due  to  their 
permeation  with  the  chemical  poison  of  syphilis.  The  blood  changes  of 
syphilis  probably  begin  on  the  first  day  of  infection,  increase  progressively, 
and  reach  their  acme  during  the  secondary  stage.  Afterward  the  blood 
appears  gradually  to  return  to  normal.  These  same  blood  changes  are  met 
with  in  inherited  syphilis.  Antis33»hilitic  treatment  with  mercury  in  large 
doses  causes  a  diminution  in  the  red  blood-corpuscles,  a  loss  in  weight,  and 
impairment  of  nutrition.  In  this  way  Kowalewsky  explains  the  frequency 
of  functional  disturbances  in  tertiary  syphihs,  especially  the  occurrence  of 
neurasthenia. 

The  alteration  in  the  vessel  walls  commonly  met  with  in  tertiary  syphilis 

1  Kowalewsky :  Archiv  f.  Psychiatrie,  ssvi.  ii.  p.  552. 


SYPHILIS  OF  THE  NEB  VO  US  SYSTEM.  713 

is  a  periarteritis.  lu  addition,  as  we  have  above  pointed  out,  there  are,  par- 
ticularly in  the  cerebral  vessels,  gummatous  deposits.  These  changes  neces- 
sarily influence  exosmosis  and  endosmosis,  and  consequently  the  regularity 
of  nutrition  of  the  structures  supplied.  Under  the  influences  of  these  con- 
ditions we  find  the  development  of  temporary  alterations  in  the  nervous 
system,  such  as  transient  palsies,  aphasias,  etc.,  and  also  hysteria. 

The  moral  influence  of  the  knowledge  of  the  existence  of  the  disease  is  a 
powerful  factor  in  depressing  the  nervous  system.  This  has  also  been  pointed 
out  by  Fournier.  According  to  the  latter,  neurasthenia  is  apt  to  come  on 
between  the  fourth  and  fifth  month  after  the  initial  sore.  It  is  especially 
frequent  in  women.  It  is  not,  however,  limited  to  the  secondary  stage,  but 
may  also  come  on  during  the  tertiary  period.  According  to  Fournier,  it 
attacks  especially  the  educated  classes  in  the  cities,  and  not  the  polyclinic 
patients.  The  neurasthenia  in  these  cases  is,  of  course,  merely  symptomatic, 
and  does  not  differ  essentially  from  the  neurasthenia  which  makes  its  appear- 
ance in  the  course  of  other  grave  diseases. 

The  direct  action  of  the  syphilitic  poison  is  probably  a  chemical  one,  and 
it  may  affect  the  function  or  the  structure  of  the  nerve  elements.  Accord- 
ing to  Kowalewsky,  four  so-called  functional  disturbances  are  probably 
attributable  to  this  action  of  the  poison,  namely,  neurasthenia,  hysteria, 
chorea,  and  angina  pectoris.  The  neurasthenia  here  alluded  to  is,  of  course, 
different  from  that  due  to  the  moral  shock  already  mentioned.  It  is  probable 
that  in  this  form  of  neurasthenia,  to  which  the  term  syphilitic  neurasthenia 
should  properly  be  restricted,  the  chemical  com230sition  as  well  as  the  molec- 
ular structure  of  the  nerve-cells  suffer  change.  Three  factors  may  bring  this 
about :  first,  insufficient  quantity  of  nutritive  material ;  secondly,  a  nutritive 
material  altered  in  its  chemical  nature ;  thirdly,  inadequate  removal  of  the 
waste  products.  All  three  of  these  factors  are  present  in  syphilis.  They  are 
probably  also  responsible  for  the  neurasthenia  which  we  every  now  and  then 
see  in  the  subjects  of  hereditary  syphilis.  True  syphilitic  neurasthenia  occurs 
most  frequently  during  the  height  of  the  blood  changes,  that  is,  during  the 
secondary  period.  This  neurasthenia  is  distinguished  from  oi'dinary  neuras- 
thenia by  the  fact  that  it  is  successfully  treated  by  ordinary  antisyphilitic 
remedies.  It  differs,  of  course,  radically  from  the  pseudo-neurasthenia  fol- 
lowing the  too  free  use  of  mercurials.  It  is  probable  that  in  many  cases  of 
syphilis  the  neurasthenia  present  is  of  mixed  origin,  that  is,  is  in  part  due 
to  the  direct  action  of  the  poison,  and  in  part  to  the  moral  shock.  Instead 
of  neurasthenia,  hysteria  may  be  developed,  and  it  is  not  uncommon  to  find 
hysteria  during  the  secondary  stage.  This  was  also  pointed  out  by  Fournier. 
Psychic  and  moral  factors  doubtless  play  a  part  in  some  cases.  It  is  also 
important  to  remember  that  every  now  and  then  the  children  of  syphilitic 
parents  suffer  especially  from  hysteria.  Hysteria  is  essentially  a  degenerative 
neurosis. 

Kowalewsky  cites  two  cases  of  chorea  attributed  to  acquired  syphilis. 
Chorea  appears  to  be  quite  rare  as  the  direct  result  of  syphilis,  but,  according 
to  Kowalewsky,  is  frequent  in  the  offspring  of  syphilitic  parents. 

Regarding  angina  pectoris,  Kowalewsky  believes  that  syphilis  may 
produce  it  in  three  ways:  (1)  by  exciting  pathological  changes  in  the 
heart  wall,  (2)  by  morbid  changes  in  the  vessels,  (3)  by  alterations  in  the 
nerves. 

While  the  relations  of  syphilis  to  ftinctional  nervous  diseases  are  less  clear 
and  less  striking  than  in  the  case  of  the  organic  afifections,  there  can  be  no 
doubt  that  these  relations  are  frequently  of  great  practical  importance,  and 
in  many  forms  of  obscure  functional  nervous  disorders  the  question  of  sjqDhilis, 
either  directly  acquired  or  inherited,  should  be  investigated. 


714  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Inherited  Syphilis.  As  abeady  stated,  the  lesions  of  inherited  syphilis 
are  not  distinguished  by  any  peculiarity,  save  when  occuning  in  the  early 
developmental  periods.  Gross  phenomena,  such  as  various  arrests  of  develop- 
ment entailing  striking  deformities,  may  then  be  j)roduced.  The  pathological 
changes  noted  from  time  to  time  are  most  varied.  Sclerosis  of  the  cranium, 
pachymeningitis,  leptomeningitis,  ependymitis  and  hydrocephalus,  softening 
and  sclerosis  of  the  brain,  gummata  of  the  brain,  gummata  of  the  cord,  etc., 
are  among  the  various  lesions  that  have  been  described.  It  is  not  surprising 
that  idiocy  and  epilepsy  frequently  accompany  inherited  syphilis.  The  vari- 
ous pathological  changes  "we  have  summarized  need  no  elaboration  to  explain 
this  fact.     (See  Chapter  XII.) 

Friedmann^  maintains  that  there  is  also  a  typical  spastic  paraplegia  in  chil- 
dren, apart  from  congenital  spastic  palsy,  dependent  upon  hereditary  syphilis. 
It  is  curable,  but  apt  to  recur.  It  is  related  to  Erb's  type  of  syphilitic  palsy 
in  the  adult,  and  is  perhaps  its  analogue. 

Syphilitic  Spondylitis.  Syphilis  of  the  spinal  vertebrse,  that  is,  specific 
spondylitis,  requires  mention  inasmuch  as  the  symptoms  presented  now  and 
then  suggest  disease  of  the  spinal  cord.  Further,  the  recognition  is  of 
importance,  as  the  suffering  accompanying  the  affection  is  very  great,  and 
as  our  therapeutic  measures,  as  a  rule,  readUy  control  the  progress  of  the 
disease.  There  is  present  deep-seated  pain  in  the  back,  generally  in  the 
neighborhood  of  the  dorso-lumbar  juncture.  Pain  is  also  excited  by  various 
movements  of  the  trunk,  but  especially  by  transmitted  shock.  If  such  a 
patient,  while  standing,  raise  himself  upon  the  toes  and  then  allow  himself 
to  fall  heavily  upon  the  heels,  great  pain  is  experienced.  Torsion  and  flexion 
of  the  trunk  likewise  excite  pain,  though  to  a  less  extent.  In  addition,  we 
have  now  and  then  symptoms  indicating  the  involvement  of  various  nerve- 
trunks.  Thus,  severe  pain  resembling  a  girdle  pain,  or  shooting,  darting 
pain,  may  follow  the  course  of  one  or  more  of  the  intercostal  nerves,  or  may 
pass  along  the  ilio-hypogastric  or  the  ilio-inguinal  nerves.  In  one  case 
which  it  was  my  fortune  to  see  in  consultation,  the  pain  followed  the  distri- 
bution of  the  ilio-inguinal  so  closely  as  to  suggest  the  pain  often  present  in 
renal  calculus. 

In  syphilitic  spondylitis  deformity  of  the  spine  is  not  present,  as  a  rule,  the 
suffering  caused  by  compression  or  inflammatory  infiltration  of  the  nen^e- 
roots  being  so  great  that  that  the  patient  seeks  relief  at  a  relatively  early 
stage.  Specific  lesions  of  the  vertebrae  can  hardly  be  confused  with  specific 
disease  of  the  cord,  but  the  distinction  between  it  and  syphiHs  of  the  mem- 
brane LS  not  always  easy. 

Diagnosis.  In  many  cases  a  history  of  specific  infection  as  well  as  a  history  of 
secondary  manifestations  is  readily  elicited.  Xot  infi-equently  it  happens,  how- 
ever, that  a  clear  history  of  syphilitic  disease  is  wanting,  and  even  exjDOSure 
to  possible  infection  may  be  denied.  In  such  cases,  we  sometimes  obtain  a 
history  of  frequent  miscarriages  on  the  part  of  the  wife,  of  stillborn  chil- 
dren, of  the  death  of  children  in  early  infancy,  or  other  history  suggestive 
of  syphiKs.  Sometimes  the  patient  admits  the  history  of  a  sore,  but  denies 
all  knowledge  of  secondary  symptoms.  This  occurrence  is  indeed  so  frequent 
among  polycHnic  cases  that  many  neurologists  look  upon  this  history  as  of 
itself  significant.  To  say  the  least,  a  history  of  secondary  symptoms  is  not 
at  all  necessary  to  establish  the  diagnosis  of  nervous  syphiHs. 

Of  equal  if  not  greater  importance  than  a  history  of  infection  are  the  fol- 
lowing general  diagnostic  features :     First,  multiplicity  of  ledon-?.     S^^^hilis 

1  Friedmann  :  Deutsche  Zeitsch.  f.  Nervenheilk,  1S92-93. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  715 

gives  rise  to  diffuse  and  multiple  lesions  of  the  nervous  system.  Therefore, 
symptoms  which  require  for  their  explanation  a  number  of  independent  foci 
of  disease  point  to  syphilis.  Secondly,  the  i^^Guliar  progress  of  the  symptoms, 
namely,  intermissions  followed  by  renewed  accessions  of  symptoms.  In  this 
connection  the  fugacious  character  of  many  of  the  palsies  is  of  gi'eat  signifi- 
cance. This  remarkable  peculiarity  is  doubtless  due,  as  Oppenheim  points 
out,  to  the  nature  of  the  new  formation,  namely,  a  rapidly  forming  and,  at 
the  same  time,  perishable  granulation  tissue.  The  pressure  or  irritation 
caused  by  such  a  new  formation  must  necessarily  be  very  variable.  It  is  not 
at  all  uncommon,  for  instance,  to  note  marked  variations  in  the  character  of 
the  visual  fields,  showing  that  the  optic  nerve  is  being  exj)osed  to  constantly 
changing  pathological  conditions.  This  is  also  especially  true  of  the  pupil- 
lary reactions  and  of  the  knee-jerks.  Finally,  there  is  the  general  subacute 
character  of  the  affection.  The  symptoms  of  a  gumma  may  make  their  ap- 
pearance suddenly,  but  if  the  patient  be  questioned  closely  it  will  be  found 
that  various  symptoms,  perhaps  slightly  marked,  preceded  the  sudden  out- 
break. In  other  words,  while  the  symptoms  often  make  their  appearance 
suddenly,  the  growth  producing  them  occupies  some  little  time  in  its  forma- 
tion ;  but  it  is  to  be  remembered  that  the  course  of  a  gumma  is  far  more 
rapid  than  that  of  other  tumors.  Symptoms  of  brain  tumor  persisting  with 
little  change  for  months  or  years  are  incompatible  with  syphilis.  Finally, 
in  the  detailed  diagnosis  of  the  position  of  the  lesion  the  involvement  of  the 
various  cranial  nerves,  the  occurrence  of  Jacksonian  or  focal  epilepsy,  or  of 
special  palsies,  must  be  taken  into  consideration. 

While  the  diagnosis  of  most  cases  of  cerebral  syphilis  can  be  readily 
made,  diffuse  syphilis  of  the  cortex  presents  special  difficulties.  It  may 
simulate  paretic  dementia,  and  the  differential  diagnosis  between  the  two  af- 
fections may  be  almost  impossible,  especially  as  true  paresis  is  itself  often  an 
outcome  of  syphilis.  However,  diffiise  cortical  syphilis  pursues  a  course 
that  when  contrasted  with  true  paresis  is  decidedly  atypical.  Unfortunately 
this  fact  is  merely  suggestive,  as  instances  of  atypical  true  paresis  are  not 
uncommon.  However,  in  many  cases  of  diffuse  cortical  syphilis  there  are 
present  recent  secondary  manifestations  in  the  skin,  mucous  membrane, 
hair,  etc.  The  discovery  of  such  signs  at  once  settles  the  diagnosis.  Finally, 
the  occurrence  of  ejoileptic  attacks,  hemiplegias,  or  other  palsies  in  a  manner 
conformable  to  syphilis,  also  assists  in  the  diagnosis.  A  history  of  com- 
paratively recent  specific  infection,  if  present,  is  also  of  value ;  although  a 
large  number  of  paretics  present  a  history  of  syphilis,  the  infection  is  gen- 
erally of  long  standing.  Paretic  dementia,  as  already  pointed  out,  belongs 
to  the  degenerative  affections  which  are  apt  to  occur  in  syphilitic  subjects, 
and  is  not  directly  dependent  upon  specific  inflammation.^ 

If  cerebral  symptoms  are  largely  in  excess,  i.  e.,  if  the  case  be  one  of  cere- 
bral or  encranial  syphilis,  the  existence  of  headache,  characteristic  sleep-dis- 
turbances, epileptic  or  apoplectiform  attacks,  vertigo,  and  the  peculiar  blunt- 
ing of  the  mental  faculties  already  described,  assist  us  in  making  a  diagnosis. 
Headache  is  generally,  though  not  invariably,  a  marked  feature.  Exacer- 
bations, as  already  stated,  frequently  occur.  Gray^  lays  especial  stress  upon 
the  tendency  of  syphilitic  headache  to  periodicity,  that  is,  to  a  tendency  to 
recur  at  a  certain  time  in  the  twenty-four  hours ;  most  frequently  at  or 
toward  night,  less  frequently  in  the  afternoon  or  morning.  It  owes  its 
origin  to  pressure  or  irritation  of  the  membranes,  and  may  therefore  be 
simulated  by  various  forms  of  organic  encranial  disease,  but  here  the  char- 

1  For  the  detailed  differential  diagnosis,  see  p.  696. 

2  Gray  :  Am.  Journ.  Med.  Sci.,  1892,  ciii.  30. 


716  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

acteristic  sleep-disturbances  come  to  our  assistance.  Marked  insomnia,  occur- 
ring usually  at  the  outset  and  lasting  for  a  few  weeks,  is  insisted  upon  by 
Gray,  who  also  considers  as  significant  the  sudden  cessation  of  the  headache 
and  insomnia  upon  the  appearance  of  paralytic  or  convulsive  phenomena. 
Somnolence  and  the  mental  phenomena  have  already  been  sufficiently  de- 
scribed in  the  symptomatology. 

If,  in  addition  to  the  general  symptons  indicative  of  cerebral  syphilis,  there 
occur  a  hemiplegic  attack  which  is  incomplete  and  rapidly  improves,  that  is, 
is  evanescent  or  fugacious,  syphilis  is  again  indicated.  Especially  is  this  the 
case  if  the  attack  occur  at  a  time  of  life  preceding  that  at  which  degenera- 
tion of  bloodvessels  from  non-syphilitic  causes  generally  ensues.  Gowers,^ 
for  instance,  holds  that  if  a  hemiplegic  attack  occurs  previous  to  forty-five 
years  of  age,  a  specific  origin  is  indicated.  Again,  if  instead  of  a  hemiple- 
gia or  other  palsy,  there  are  present  epileptic  attacks,  occurring  for  the  first 
time  in  an  individual  over  thirty  years  of  age,  syphilis  is  also  suggested. 
Headache  and  sleep-disturbances,  it  should  be  remembered,  are  not  always 
prominent  features  of  cerebral  syphilis,  and  specific  epilej)sies  and  palsies 
may  be  present  when  these  symptoms  are  but  slightly  marked. 

In  the  diagnosis  of  spinal  syphilis  we  are,  as  before,  to  be  guided  by  gene- 
ral principles.  Pain  referable  to  the  membranes  or  to  the  nerve-roots,  and 
various  motor  disturbances  are  significant.  We  have  seen,  in  discussing  the 
symptomatology,  that  the  symptoms  may  simulate  various  tract  degenerations 
of  the  cord,  but  they  are  always  atypical.  Thus,  while  syphilis  of  the  cord 
frequently  simulates  the  paraplegia  of  lateral  sclerosis,  muscular  rigidity,  so 
constant  in  the  latter  disease,  is  generally  wanting.  Further,  bladder  palsies, 
sensory  disturbances,  belt-like  pains,  etc.,  symptoms  not  present  in  lateral 
sclerosis,  may  be  present  here.  This  is  also  true  when  the  disease  simulates 
locomotor  ataxia  or  combined  sclerosis.  An  interesting  instance  of  a  case 
simulating  locomotor  ataxia  occurred  in  a  negro,  a  patient  in  my  ward  of 
the  Philadelphia  Hospital.  All  of  the  typical  symptoms  were  present  with 
the  exception  of  the  Argyll-Robertson  pupils  and  the  ataxic  pains.  Inas- 
much as  locomotor  ataxia  is  practically  unknown  in  the  negro,  and  as  the 
symptoms  presented  differed  in  at  least  two  important  points  from  those  of 
typical  locomotor  ataxia,  large  doses  of  iodide  of  potassium  were  adminis- 
tered, with  the  result  of  a  rapid  and  complete  cure  of  the  patient. 

The  fact  of  the  atypical  character  of  the  cord  symptoms  in  syphiHs  cannot 
be  too  strongly  insisted  upon.  Thus  it  may  simulate  myelitis.  However,  as 
pointed  out  by  Sachs,'''  there  is  not  in  syphilis  a  morbid  process  "  which 
rapidly  advances  across  the  entire  cross-section  of  the  cord,  involving  all  the 
symptoms  due  to  loss  of  function  of  the  various  spinal  systems.  If  the 
syphilitic  disease  be  the  result  of  a  specific  endarteritis  of  the  vessels  of  the 
cord,  we  know  that  some  and  by  no  means  all  of  these  vessels  are  aflfected, 
and  that  the  disease  advances  slowly  from  one  group  of  vessels  to  another. 
If  there  be  diffuse  specific  infiltration,  it  also  invades,  but  very  slowly,  one  part 
after  the  other.  It  has  a  remarkable  tendency,  too,  to  increase  for  a  time 
and  then  to  recede,  whether  as  a  result  of  treatment  or  not,  and  then  possi- 
bly to  increase  with  renewed  force." 

As  illustrating  the  irregularity  of  the  symptoms  we  should  again  mention 
the  not  infrequent  occurrence  of  Brown-Sequard  paralysis.  In  this  connec- 
tion also  a  case  recorded  by  Beevor'  is  interesting.  The  patient  presented 
inira  vitam  the  symptoms  of  syringomyelia,  but  at  the  autopsy  a  syphilitic 
tumor  was  found  on  each  side  of  the  cord  in  the  cervical  region. 

1  Gowers  :  Syphilis  and  tlie  Nervous  System,  Philadelphia,  1892. 

2  Loc.  cit.  3  Beevor  :  Lancet,  1893,  ii.  p.  1252. 


SYPHILIS  OF  THE  NERVOUS  SYSTE3L  717 

Recognitiou  of  the  symptom  group  described  by  Erb  is  of  importance  be- 
cause of  the  frequency  of  its  occurrence,  but  that  it  by  no  means  represents 
all  cases  of  spinal  syphilis  cannot  be  too  strongly  insisted  upon.  The  diag- 
nosis should  always  be  made  upon  general  principles,  and  among  these  the 
following,  formulated  by  Sachs,i  may  be  considered  as  established  :  First,  the 
relatively  slight  intensity  of  the  disease,  the  palsies  rarely  being  complete. 
Secondly,  the  wide  distribution  of  the  symptoms,  indicating  often  simulta- 
neous involvement  of  the  cervical,  dorsal,  and  lumbar  enlargements ;  and, 
finally,  the  tendency  to  remissions  and  relapses. 

Regarding  the  diagnosis  of  syphilis  of  the  nerves,  the  facts  already  stated 
in  discussing  the  symptomatology  must  be  borne  in  mind.  Important  is  it 
to  remember  that  isolated  disease  of  any  of  the  cranial  nerves,  especially  of 
the  optic  and  oculo-motor,  points  to  syphilis. 

In  many  cases  the  diagnosis  of  syphilis  is  confirmed  by  the  "  therapeutic 
test."  If  the  symptoms  disappear  after  the  administration  of  iodide  of  potas- 
sium or  mercurials,  the  inference  is  often  justified  that  the  lesion  is  syjDhilitic. 
We  must  remember,  however,  that  the  iodides  sometimes  have  a  remarkable 
effect  upon  neoplasms  that  are  non-syphilitic  in  origin.  Among  these  we 
must  especially  mention  gliomata.  Further,  should  a  negative  result  follow 
the  administration  of  specific  remedies,  the  non-syphilitic  character  of  the 
afiection  cannot  always  be  inferred,  as  the  remedies  are  sometimes  unable  to 
arrest  the  progress  of  the  disease.  Finally,  it  must  be  borne  in  mind  that 
the  symptoms  in  a  given  case  are  often  the  result,  not  of  syphilitic  deposit, 
but  of  the  secondary  changes  in  the  nerve-tissues  themselves,  permanent  in 
character. 

In  studying  cases  of  suspected  hereditary  syphilis,  interstitial  keratitis, 
notched  or  Hutchinson's  teeth,  and  other  signs  should  be  looked  for.  A  his- 
tory of  parental  syphilis  is  of  course  of  great  assistance  in  making  the  diag- 
nosis. 

Prognosis.  As  we  have  just  seen,  the  diagnosis  of  a  syphilitic  lesion  in 
the  nervous  system  does  not  necessarily  imply  a  favorable  prognosis.  Not 
only  may  a  gumma  produce  permanent  changes  in  the  nerve-tissue  with 
which  it  is  in  contact,  but  it  may  also  undergo  retrograde  metamorphosis 
itself;  and  when  caseous  and  fibrous  changes  have  once  taken  place,  neither 
iodides  nor  mercurials  can  bring  about  its  removal.  Further,  a  symptom, 
e.  g.,  a  hemiplegia,  may  be  due  to  syphilis  of  the  walls  of  a  vessel,  and  in 
such  case  permanent  changes,  softening,  etc.,  take  place  in  the  affected  nerve- 
centres,  changes  which  our  remedies  can  in  no  way  influence.  The  same  is 
necessarily  true  when  a  hemiplegia  is  due  to  a  hemorrhage  occurring  from  a 
syphilitic  vessel.  In  syphilitic  epilepsies,  also,  it  is  extremely  probable  that 
the  affection  is  often  the  outcome  of  vascular  disease  associated  with  perma- 
nent changes  in  the  cortical  tissues.  In  such  cases,  again,  our  remedies  may 
fail  to  arrest  the  convulsive  attacks. 

As  a  rule,  the  prognosis  in  a  given  case  is  unfavorable  in  proportion  to  the 
length  of  time  the  symptoms  have  existed.  A  further  unfavorable  factor  is 
the  appearance  of  symptoms  while  the  patient  is  under  active  treatment.  It 
is  probable  in  such  cases  either  that  the  organism  has  become  "accustomed" 
to  or  excessively  tolerant  of  the  iodides  and  mercurials,  or  that  the  attack  of 
syphilis  is  of  especial  virulence.  Frequently,  however,  especially  if  the 
patient  be  seen  early  after  the  appearance  of  symptoms,  the  prognosis  is  very 
favorable  and  very  brilliant  results  are  accomplished.  Cerebral  palsies,  para- 
plegia, headache,  somnolence,  and  other  symptoms  may  under  these  circum- 
stances rapidly  disappear. 

1  Loc.  cit. 


718  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

It  often  happens  that  great  improvement  takes  place  in  a  given  case,  but 
not  absohite  cure ;  for  example,  a  palsy  may  disapjDear,  but  some  residual 
weakness  may  remain  ;  or  headache  and  somnolence  may  vanish,  but  mental 
weakness  and  apathy  may  persist.  Frequently,  too,  though  the  principal 
symptoms  rapidly  improve,  S23ecial  symptoms,  such  as  result  from  the  involve- 
ment of  some  of  the  cranial  nerves,  remain  unchanged.  Thus,  there  may  be 
a  residual  inequality  of  the  pupils,  some  strabismus,  or  some  degree  of  ptosis. 
Finally,  the  age  of  the  j)atient  appears  to  influence  the  prognosis.  Hjelman^ 
thinks  that  after  thirty-nine  years  the  jDi'Ognosis  is  not  as  favorable  as  in  ear- 
lier periods.  The  interval  between  infection  and  brain  syj)hilis  he  believes 
to  be  of  no  consequence,  provided  the  interval  be  under  ten  years.  After  a 
longer  interval  than  this  the  prognosis  becomes  proportionately  unfavorable. 

Treatment.  The  treatment  of  syphilis  of  the  nervous  system  should  be 
instituted  at  as  early  a  moment  as  possible,  and  should  always  be  of  an  active 
character.  The  remedies  consist  especially  of  the  iodides  and  mercurials. 
IS^eurologists  differ  in  reference  to  the  relative  value  of  these  two  classes  of 
remedies.  The  iodides  have,  as  a  rule,  a  rapid  action.  However,  the  re- 
sults, though  they  are  often  brilliant,  may  not  be  durable.  The  mercurials, 
like  the  iodides,  cause  the  rapid  absorption  of  syphilitic  dei^osits,  and  it  is 
observed  that  the  effects  of  a  thorough  mercurial  course  of  treatment  are 
more  persistent  than  if  the  iodides  are  used  alone.  Besides  stimulating  ab- 
sorption, the  mercurials  appear  to  act  in  a  manner  antagonistic  to  inflamma- 
tory processes  in  general,  and,  further,  it  is  not  improbable  that  they  have  a 
destructive  or  antagonistic  action  upon  the  speciflc  virus  itself. 

The  objects  to  be  gained  in  treating  cases  of  nervous  syphilis  are,  first,  to 
remove  the  deposit  or  infiltration  with  the  greatest  possible  rapidity,  and, 
secondly,  to  make  this  result  as  lasting  as  possible.  Reliance  should,  there- 
fore, not  be  placed  upon  one  drug  to  the  exclusion  of  the  other.  It  is  the 
writer's  custom  either  to  use  both  together  or  to  follow  one  by  the  other.  A 
good  plan  is  to  administer  the  iodide  of  potassium  in  rapidly  increasing  doses 
until  20,  30,  40,  or  even  60  grains  are  given  three  times  a  day.  For  short 
periods  of  time,  in  urgent  cases  even,  this  quantity  may  be  exceeded,  as  the 
tolerance  to  the  drug  is  exceedingly  great.  At  the  same  time  that  the  iodides 
are  being  administered  mercurials  in  some  form  or  other  should  be  added  to 
the  treatment.  The  writer's  preference  is  the  use  of  the  protosalts,  so  guarded 
as  to  prevent  purgation,  or,  what  is  better  still,  the  cautious  use  of  mercurial 
inunction.  A  small  quantity  of  the  ointment,  say  20  grains,  should  be  rubbed 
into  the  axillae  every  day,  and,  should  the  patient  prove  tolerant  to  the  drug, 
this  amount  may  rapidly  be  increased  to  80  or  40  grains  or  more.  In  urgent 
and  desperate  cases  much  larger  quantities  should  be  used.  As  soon  as  ten- 
derness of  the  gums  is  noticed  the  inunctions  should  be  absolutely  stopped, 
but  as  soon  as  this  symptom  subsides  they  should  be  cautiously  resumed 
and  the  patient  kept  under  the  influence  of  the  drug  off  and  on  for  a  long 
time. 

The  question  next  arises  as  to  how  long  an  active  course  of  antisyphi- 
litic  treatment  should  be  pursued.  If  the  case  be  amenable  to  treatment, 
improvement  is  noted  at  the  end  of  several  weeks.  Sometimes  the  imjDrove- 
ment  is  noted  in  a  few  days.  More  often  it  happens  that,  after  a  certain 
amount  of  improvement,  the  case  reaches  a  standstill.  Under  these  circum- 
stances it  is  advisable  to  increase  the  amount  of  the  iodide  or  the  mercury 
administei-ed.  If  under  increased  dosage  no  improvement  takes  place,  it  is 
j)robable  either  that  the  patient  has  become  habituated  to  the  medicines  or  that 
a  maximum  amount  of  recovery  for  the  time  being  has  been  attained.    Under 

1  Hjelman  :  Helsingfors,  1892. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  719 

these  circumstances  it  is  better  to  abandon  the  specific  treatment  altogether 
for  a  time  and  to  administer,  together  with  a  liberal  diet,  reconstructive 
remedies,  such  as  iron,  the  hypophosphites,  cod-liver  oil,  and  such  tonics  as 
strychnine  and  arsenic.  We  habitually  underestimate  the  reparative  powers 
of  the  nervous  system.  Very  frequently,  after  specific  lesions  have  been 
removed,  the  symptoms  persist,  but  the  nervous  tissue,  freed  from  pressure 
or  other  pathological  interference,  in  the  course  of  time,  weeks  or  months, 
recovers,  and  the  symptoms  eventually  disappear.  This  process  can  take 
place  only  if  the  interference  has  not  been  of  such  a  nature  as  absolutely  to 
destroy  the  parts  afiected. 

In  some  instances  it  is  advisable  to  return  to  the  use  of  the  iodides  and 
mercurials  after  an  interval  of  several  weeks  or  months.  Very  frequently  a 
persistent  treatment,  in  which  specific  remedies,  reconstructives,  and  tonics 
are  alternated,  is  followed  in  the  course  of  months,  and  sometimes  years,  by 
the  most  gratifying  results.  In  two  instances  in  the  experience  of  the  writer 
the  maximum  amount  of  improvement  was  only  attained  by  this  method  at 
the  end  of  three  years.     Both  were  grave  cases  of  syphilis  of  the  cord. 

Persistence  in  treatment  is  especially  indicated  because  of  the  well-known 
tendency  of  syphilitic  lesions  to  recur.  Gowers'  states  that  every  patient 
who  has  had  syphilis  should  take  at  least  eight  years  from  the  primary  dis- 
ease, or  for  five  years  from  the  last  manifestation  of  it,  a  course  of  iodide  for 
three  weeks,  twice  a  year. 

The  hypodermatic  method  of  administering  mercurials  has  nothing  special 
to  recommend  it  in  the  treatment  of  nervous  syphilis,  the  most  rapid  impres- 
sion being  made  by  the  method  of  inunction.  However,  when  it  is  essential 
that  the  nature  of  the  malady  should  be  concealed,  or  when  inunctions,  be- 
cause of  hot  weather,  become  exceedingly  unpleasant,  the  hypodermatic  method 
may  be  resorted  to  with  advantage.  One-tenth  of  a  grain  of  bichloride  of 
mercury,  dissolved  in  10  or  15  drops  of  distilled  water,  may  be  administered 
every  second  or  third  day.  The  injection  is  best  made  into  the  buttock  or 
into  the  loose  tissues  of  the  back.  "  Gray  oil "  is  also  occasionally  used.  It 
consists  of  an  emulsion  of  metallic  mercury  in  lanoline,  in  the  proportion  of 
two  to  one ;  this  is  diluted  for  hypodermatic  use  in  the  proportion  of  three 
parts  of  ointment  to  one  part  of  olive  oil.'''  One  to  two  minims  may  be  ad- 
ministered at  intervals  of  every  second  or  third  day.  Sacaze  and  MagnoP 
state  that  in  three  cases  of  cerebral  syphilis  they  obtained  very  prompt  results 
from  its  Use. 

1  Gowers:  Internat.  Med.  Mag.,  1893,  ii.  823. 

-  L.  Wolf:  "  Hypodormatic  Medication  in  Syphilis,"  Tlie  College  and  Clinical  Kecord,  May,  1893. 

3  Sacaze  et  Magnol :  Ann.  de  Dermat.  et  Syph.,  1893,  35,  iv.  943. 


CHAPTEK    XXY. 

DISEASES  OF  THE  NERVES. 

By  WHARTON  SINKLER,  M.D. 

The  diseases  of  the  nerves  are :  Congestion  or  hypersemia,  inflammation, 
degeneration,  new  growths,  and  functional  disorders. 

HYPEREMIA. 

Hypersemia  may  occur  as  the  result  of  exposure  to  cold,  injuries  of  various 
kinds,  or  compression.  Rheumatism  or  gout  may  also  give  rise  to  congestion 
of  nerve-trunks.  Hypersemia  may  occur  as  the  result  of  disturbances  of 
nutrition  connected  with  the  menopause,  or  with  overuse  of  a  part. 

The  symptoms  of  hypersemia  of  a  nerve  are  principally  sensory.  There  is 
a  sense  of  burning  or  numbness  in  the  distribution  of  the  afiected  nerve,  and 
various  forms  of  parsesthesia.  The  numbness  and  tingling  may  be  so  intense 
as  to  amount  to  positive  pain ;  but  in  the  majority  of  instances  there  is 
merely  a  sense  of  prickling  and  formication,  such  as  occurs  when  the  part  is 
"  asleep."  Tenderness  is  sometimes  found  over  the  nerve-trunks,  but  this  is 
rarely  met  with.     A  slight  amount  of  muscular  weakness  is  also  present. 

Acroparesthesia  (Numb  Fingers,  Waking  Numbness.  This  dis- 
ease may  be  considered  in  this  connection,  as  it  is  probably  due  to  hyper- 
semia of  the  peripheral  nerves.  It  is  met  with  commonly  in  women  at  about 
the  cHmacteric,  but  it  may  occur  in  either  sex.  It  occurs  most  frequently 
in  women  who  have  hard  manual  work,  such  as  washing,  scrubbing,  cutting 
with  scissors,  and  sewing.  It  can  sometimes  be  traced  to  a  gouty  or  rheu- 
matic diathesis.  In  other  cases  there  is  no  history  of  excessive  use  of  the 
hands,  but  it  appears  to  be  connected  with  disturbances  resulting  from  the 
menopause. 

The  symptoms  are  numbness  and  formication  of  the  extremities,  which 
first  begin  in  the  hands.  Usually  the  numbness  is  felt  when  the  patient 
wakes  in  the  morning,  and  it  soon  passes  off  after  the  hands  have  been  used. 
As  the  disease  advances  the  numbness  extends  up  the  arms  to  the  shoulders, 
and  invades  the  lower  extremities.  It  then  comes  on  when  the  patient  has 
been  lying  down  only  for  a  short  time,  and  persists  for  longer  periods.  In 
aggravated  cases  the  patient  is  awakened  from  sleep  by  the  numbness,  and 
is  obliged  to  get  up  and  walk  about  and  rub  the  extremities  before  the 
discomfort  is  relieved.  In  some  cases  the  numbness  becomes  painful,  like 
the  distressing  sensations  which  occur  in  a  limb  which  has  been  "  asleep." 
In  women  there  is  frequently  associated  with  the  parsesthesia,  general  flush- 
ings followed  by  profuse  sweating.  Usually  there  is  no  muscular  weakness 
or  ansesthesia,  but  the  fingers  are  clumsy,  and  the  patient  is  unable  to  sew  or 
button  her  clothes.  In  some  cases  the  parsesthesia  is  confined  to  the  ulnar 
distribution  alone ;  but,  in  other  cases,  the  scalp  and  ears  are  affected  as 


DISEASES  OF  THE  NEEVES  IN  GENERAL.  721 

well  as  the  extremities.  The  symptoms  are  frequently  accompanied  by  gen- 
eral nervousness  and  restlessness.  The  urine  is  often  excessive  in  quantity, 
and  contains  an  undue  proportion  of  phosphates  or  urates. 

Prognosis.  The  disease  may  last  only  for  a  few  weeks  or  months,  but  re- 
lapses are  frequent,  and  sometimes  after  a  whole  year  there  will  be  a  return 
of  the  affection.  Although  the  condition  is  often  of  long  standing,  it  never 
runs  into  any  serious  disorder. 

Diagnosis.  The  disease  is  to  be  distinguished  from  hysteria  or  organic 
disease  of  the  brain  or  cord.  In  hysteria,  the  distribution  of  the  numbness 
is  generally  localized  or  unilateral,  and  there  are  other  evidences  of  hysteria ; 
in  organic  diseases  of  the  brain  or  cord,  the  numbness  is  either  unilateral 
or  confined  to  the  lower  extremities,  and  is  associated  with  paralysis.  In 
Raynaud's  disease,  there  is  spasm  of  the  bloodvessels,  producing  pallor  of  the 
fingers. 

Treatment.  The  most  successful  plan  of  treatment,  in  my  experience,  has 
been  the  administration  of  ergot  in  fairly  large  doses.  Relief  usually  follows 
this  remedy  in  a  short  time.  Faradization  and  massage  are  useful  adju- 
vants in  treatment ;  and  sjDecial  attention  should  be  paid  to  the  general 
health.  Salt  baths  and  tonics  are  always  of  advantage ;  and  change  of 
air,  when  it  can  be  obtained,  is  very  desirable.  After  the  acute  symptoms 
have  subsided,  strychnine  or  arsenic,  combined  with  iron  and  quinine,  should 
be  administered. 


NEURITIS  (Inflammation  of  the  Nerves). 

Neuritis  is  met  with  in  two  forms,  inflammation  of  a  single  nerve  or  groups 
of  nerves,  and  multij)le  neuritis,  or  a  general  inflammation  of  all  of  the  periph- 
eral nerves. 

When  inflammation  of  a  single  nerve  occurs  it  is  generally  as  a  perineu- 
ritis, in  which  the  outer  sheath  of  the  nerve  is  affected,  or  it  may  involve  the 
connective  tissue  between  the  bundles  of  the  nerve-fibres,  constituting  an 
interstitial  neuritis.  When  the  nerve-fibres  are  affected,  as  occasionally 
occurs,  it  is  then  called  parenchymatous  or  degenerative  neuritis.  In  simple 
neuritis  one  nerve-trunk  alone  may  be  affected,  but  two  or  more  may  suffer 
at  the  same  time. 

Neuritis  may  be  acute,  subacute,  and  chronic,  and  the  inflammation  may 
begin  near  the  periphery  of  a  nerve  and  extend  upward— neuritis  migrans. 

Etiology.  Simple  neuritis  results  most  frequently  from  injuries,  wounds, 
and  contusions,  or  compression  of  the  nerve-trunk,  either  from  external  pres- 
sure or  from  tumors  and  growths,  which  squeeze  the  nerve  in  a  bony  canal, 
through  which  it  passes.  Nerves  in  the  neighborhood  of  joints  are  frequently 
injured  by  dislocations,  and  occasionally  a  nerve  undergoes  compression  or 
contusion  through  extreme  muscular  action.  In  fractures  a  nerve  is  occasion- 
ally caught  in  the  callus,  and  thus  injured.  Neuritis  may  also  arise  from 
an  extension  of  inflammation  in  adjacent  organs,  as  in  arthritis.  Cold 
and  the  rheumatic  and  gouty  poisons  are  also  sources  of  neuritis.  Inflam- 
mation of  nerve  trunks  may  also  be  due  to  a  cachexia,  syphilitic  or  can- 
cerous, and  may  also  arise  from  leucocythsemia.  Occasionally  an  injury  of 
a  nerve  near  its  periphery  will  cause  an  ascending  inflammation — neuritis 
migrans — which  may  extend  as  high  as  the  plexus,  from  which  it  arises,  and 
involve  other  nerves.  Injuries  of  nerves  from  cuts  with  glass  seem  espe- 
cially prone  to  be  followed  by  ascending  neuritis.  In  a  patient  whom  I  saw 
several  years  ago,  the  extensor  tendon  of  the  middle  finger  was  divided  by  a 
broken  pane  of  glass.     The  wound  healed  speedily  and  without  ill  eftects, 

46 


722  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

but  the  patient  was  unable  to  extend  the  finger  on  account_  of  the  divided 
tendon.  An  operation  was  performed  to  suture  the  ends  of  the  severed 
tendon,  and  care  was  used  to  observe  all  antiseptic  precautions.  The  tendon 
united  in  a  short  time,  and  the  perfect  use  of  the  finger  was  restored,  but  a 
neuritis  began  at  the  point  of  incision  and  extended  up  the  forearm  and  up 
to  the  shoulder,  causing  much  pain  and  joint  difiiculties. 

Pathological  Anatomy.  An  acutely  inflamed  nerve  is  red  and  swollen, 
the  bloodvessels  are  distended,  and  are  plainly  visible  on  the  surface  in  the 
nerve-sheath.  This  condition  is  soon  followed  by  oedema  or  sero-fibrinous 
exudation,  and  sometimes  the  exudation  is  jelly-like.  Under  the  microscojie 
leucocytes  are  found  surrounding  the  vessels  and  infiltrating  the  sheaths  of 
the  nerves.  Small  extravasations  of  blood  are  also  met  with.  When  these 
changes  are  confined  to  the  nerve-sheath  the  condition  is  known  as  perineu- 
ritis ;  but  if  it  extends  into  the  tissue  between  the  bundles  of  neiTC-fibres  it 
constitutes  an  interstitial  neuritis.  In  the  latter  condition  leucoc}i:es  are 
found  in  the  septa  between  the  nerve-bundles,  and  may  even  be  found  in 
the  fasciculi.  These  changes  may  extend  the  whole  course  of  a  nerve,  but 
generally  the  entire  nerve-trunk  is  not  affected,  and  intervals  of  healthy 
tissue  are  found. 

The  nerve-fibres  do  not  show  much  change  in  perineutritis  unless  the  ners^e 
has  undergone  compression  through  the  swelling,  and  the  fibres  have  in  this 
manner  been  injured.  In  interstitial  neuritis  the  fibres  are  frequently 
affected,  but  not  invariably  so.  In  parenchymatous  neuritis  the  inflamma- 
tion begins  in  the  nerve-fibres,  and  the  interstitial  connective  tissue  Ls  not 
much  disturbed.  In  parenchymatous  neuritis  the  changes  in  the  nerve-fibres 
are  the  same  as  in  degeneration  ;  the  medullary  sheath  is  first  SAVollen,  then 
the  myelin  breaks  up  into  segments,  greater  or  less  in  size,  and  in  time  these 
become  divided  into  small  ti-agments.  The  masses  tilling  the  nerve-tube 
then  become  cloudy  and  granular,  and  the  axis-cylinder  is  interrupted 
wherever  the  myelin  is  divided.  The  nuclei  of  the  sheaths  are  increased. 
Later  the  axis-cylinder  disappears  entirely,  the  sheaths  become  empty  and 
shrivel,  and  are  replaced  by  connective  tissue  which  contains  much  fat — the 
lipomatous  neuritis  of  Leyden.  The  degenerative  process  often  stops  at 
the  first  node  of  Ranvier  above  the  seat  of  the  injury,  but  it  may  extend 
upward  and  through  the  whole  length  of  the  nerve.  The  process  goes  on  to 
complete  destruction  of  most  of  the  fibres  in  the  nerve,  with,  occasionally,  a 
few  unchanged  fibres  remaining.  After  a  time  regeneration  begins.  This 
occurs  either  from  the  development  of  new  axis-cylinders  and  sheaths  from 
the  nuclei  in  the  old  sheaths  or  from  the  growth  of  axis-cylinders  from  the 
undegenerated  part  of  the  old  nerve-fibre ;  the  latter  view  is  held  by  Ranvier. 

Symptoms  The  symptoms  of  neuritis  depend  largely  upon  the  function  of 
the  nerve  which  is  affected.  Pain  is  a  prominent  symptom  in  all  cases,  and  there 
is  more  or  less  tenderness  over  the  course  of  the  nerve.  In  the  case  of  a  sen- 
sory nen^e  there  is  severe  pain  in  the  distribution  of  the  nerve,  with  cutaneous 
hypersesthesia  and  sometimes  impaired  sensibility.  The  pain  is  sometimes 
almost  unbearable.  In  a  case  of  median  neuritis  under  my  care  the  thumb, 
index,  and  middle  fingers  felt  swollen  and  acutely  painful,  as  if  they  were 
about  to  "burst."  In  inflammation  of  a  mixed  neiTe  there  is  a  sense  of 
pain,  burning,  or  tearing  in  the  course  of  the  nerve,  and  the  motor  symptoms 
are  also  conspicuous.  There  is  paralysis  of  the  muscles  supplied  hy  the 
nerve.  The  degree  of  paralysis  varies,  according  to  the  extent  of  the  neu- 
ritis. In  some  cases  loss  of  power  is  only  partial,  but  in  many  cases,  espe- 
cially those  in  which  the  neuritis  has  resulted  from  injury  or  compression, 
there  is  a  total  loss  of  power. '  The  electrical  reactions  are  altered,  and  within 
a  few  days  there  is  marked  quantitative  change  to  the  faradic  and  galvanic 


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DISEASES  OF  THE  NERVES  IN  GENERAL.  723 

currents.  After  a  short  time  there  is  complete  loss  to  the  faradic  current, 
and  the  reaction  of  degeneration  to  the  galvanic  current  is  then  present. 
(See  p.  38.)  Trophic  changes  are  frequently  met  with,  and  the  joints  be- 
come swollen,  inflamed,  and  the  skin  red  and  glossy.  In  the  fingers  there  is 
often  atrophy  of  the  subcutaneous  tissue,  so  that  the  fingers  become  thin  and 
tapering  to  the  extremity — the  bone  may  be  atrophied.  The  nails  become 
brittle,  rough,  and  ridged,  showing  transverse  furrows,  and  the  whole  nail 
may  be  lost.  (See  Plate  IV.  The  illustration  shows  beautifully  the  change 
in  the  skin  and  nails  in  a  patient  of  Dr.  Weir  Mitchell,  in  whom  a  fracture 
of  the  forearm  had  injured  the  median,  ulnar,  and  radial  nerves,  setting  up 
a  neuritis.)  The  growth  of  hair  is  altered  ;  it  may  fall  out  or  become  coarse. 
Qildema  often  occurs  in  parts  where  there  is  much  subcutaneous  cellular 
tissue.  In  wrist-drop  from  muscu.lo-spiral  palsy  there  is  usually  a  thick  hump 
on  the  back  of  the  hand  (Fig.  239). 

Fig.  239. 


Wrist-drop  from  division  of  musculo-spiral  nerve.    The  white  line  encloses  an  area  of  partial 

anaesthesia. 

Vesicles,  bullae,  or  herjDetic  eruptions  may  form  in  the  parts  supplied  by 
the  affected"  nerves,  as,  for  example,  in  herpes  zoster,  herpes  frontalis,  and 
herpes  cruralis.  In  a  case  of  neuritis  which  I  saw,  the  result  of  division  of 
one  of  the  digital  nerves  by  a  piece  of  broken  glass,  a  series  of  bullae  formed 
in  succession  on  the  finger.  In  another,  a  case  of  median  neuritis,  large 
blisters  occurred  on  the  index  finger,  and  these  were  followed  by  ulcers, 
which  healed  slowly. 

Among  the  nerves  most  frequently  aflfected  is  the  facial,  which  is  liable  to 
neuritis,  from  compression  in  the  aquseductus  Fallopii,  in  which  case  all  of 
the  muscles  supplied  by  the  nerve  are  completely  paralyzed.  The  nerve  may 
also  undergo  inflammation,  as  the  result  of  cold  draughts  against  the  face  or 
of  rheumatic  influences. 

The  musculo-spiral  nerve  is  frequently  the  seat  of  inflammation,  and  the 
most  common  cause  of  this  is  injury.  The  palsy  resulting  from  compression 
neuritis  of  the  musculo-spiral  nerve  has  been  called  "Saturday-night  palsy" 
or  "Sunday-morning  palsy,"  because  frequently  a  man  who  has  been  drink- 
ing heavily  on  Satuixlay  night,  sleeps  with  his  head  upon  his  arm,  or  he  may 
sleep  sitting  up,  with  his  arm  resting  against  the  back  of  a  bench  or  chair, 
so  that  the  musculo-spiral  nerve  is  compressed.  The  musculo-spiral  nerve 
may  also  be  injured  by  sudden  and  violent  action  of  the  triceps  muscle. 
Another  way  in  which  I  have  known  this  nerve  to  be  injured  is  when  a 


724  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

patient  has  been  placed  upon  a  narrow  table  for  a  gynecological  operation, 
and  the  arm  allowed  to  fall  over  so  that  the  back  of  the  arm  just  above  the 
elbow  rested  against  the  sharp  edge  of  the  table.  Lead-poisoning  often  attacks 
the  musculo-spiral  nerve  alone,  giving  rise  to  a  neuritis.  Many  years  ago  I 
called  attention  to  the  similarity  between  lead  palsy  and  paralysis  from 
musculo-spiral  compression,^  and  expressed  the  belief  that  lead  paralysis  was 
due  to  a  lesion  of  the  peripheral  nerves.  The  musculo-spiral  nerve  lies  so 
superficially  that  when  a  person  is  exposed  to  severe  cold,  as  in  driving 
through  a  snow-storm,  the  nerve  may  become  inflamed. 

The  median  nerve  is  not  infrequently  the  seat  of  neuritis,  and  when  this 
occurs  there  is  disturbance  of  sensation  on  the  palmar  surface  of  the  thumb, 
fore-,  and  middle-finger.  There  is  more  or  less  anaesthesia  in  this  region, 
depending  upon  the  degree  of  neuritis;  but  in  most  cases  the  angesthesia 
does  not  extend  beyond  the  palmar  surface  of  the  thumb  and  first  two  fingers, 
although  it  is  stated  that  there  is  also  loss  of  sensation  on  the  back  of  the 
last  phalanges  of  those  fingers,  and  also  of  the  radial  half  of  the  ring-finger. 
This  extensive  anaesthesia  does  not  occur  except  when  there  has  been  com- 
plete abolition  of  the  function  of  the  nerve.  There  is  pain  and  tenderness 
in  the  course  of  the  nerve,  and  pain  in  the  thumb  and  first  two  fingers,  Avhich 
is  frequently  intense.  In  a  case  which  I  have  seen,  a  tap  on  the  end  of  the 
forefinger  would  cause  an  acute  pain,  running  up  the  whole  course  of  the 
nerve.  The  forefinger  is  often  swollen,  and  trophic  changes  occur,  such  as  I 
have  already  described.  There  is  loss  of  power  in  the  pronators  of  the 
wrist,  which  is  usually  incomplete,  and  inability  to  flex  the  first  two  fingers 
or  to  abduct  the  thumb.  The  median  supplies  the  flexor  communis,  but  the 
outer  half  receives  branches  from  the  ulnar  nerve,  so  that  the  third  and 
fourth  fingers  can  be  flexed. 

The  causes  of  median  neuritis  are  exposure  to  cold,  or  direct  violence.  I 
saw  recently  a  young  man,  who,  in  a  wrestling  bout,  was  grasped  violently 
by  his  op]Donent  about  the  junction  of  the  middle  and  upper  third  of  the 
arm.  The  median  nerve  must  have  been  tightly  squeezed  by  the  ends  of  the 
fingers.  When  the  patient  was  seen  by  me  there  was  but  little  tenderness  at 
the  seat  of  the  injury,  but  the  nerve  below  the  elbow  was  exquisitely  sensi- 
tive, and  there  was  paralysis  of  the  flexors  of  the  thumb  and  forefinger,  with 
inability  to  abduct  the  thumb.  There  was  anaesthesia  on  the  palmar  surface 
of  the  thumb,  index,  and  middle-fingers  to  light  touches.  These  fingers  were 
the  seat  of  such  acute  pain  of  a  throbbing  and  burning  character  that  the 
patient  was  unable  to  sleep  at  night.  Another  case  of  median  neuritis  was 
caused  in  a  patient  who  had  been  cutting  meat  with  a  dull  knife,  so  that 
great  pressure  was  made  upon  the  palm  of  the  hand  against  the  back  of  the 
blade.  The  neuritis  extended  up  the  forearm,  causing  much  tenderness  in 
the  course  of  the  nerve  and  anaesthesia  in  the  region  supplied  by  the  nerve. 

In  ulnar  neuritis  there  is  pain  and  loss  of  sensation  in  the  outer  half  of  the 
third  finger  and  in  the  fourth  finger,  with  paralysis  of  the  flexor  carpi 
ulnaris,  and  the  outer  half  of  the  deep  flexors  of  the  fingers,  together  with 
the  intrinsic  muscles  of  the  little  finger,  the  interossei  lumbricales,  and  the 
adductor  of  the  thumb.  In  cases  of  long  standing  of  ulnar  neuritis  there 
occurs  the  typical  "  claw-like  hand,"  owing  to  overextension  of  the  first 
phalanges  and  flexion  of  the  last  two.  Ulnar  neuritis  often  results  from 
pressure  upon  the  nerve  during  sleep,  or  from  direct  injury  to  the  nerve 
where  it  passes  between  the  projecting  bones  of  the  external  condyle  and 
olecranon.  Gowers  speaks  of  a  case  in  which  there  had  been  two  attacks  of 
ulnar  neuritis  following  successive  confinements.     In  a  patient  which  Dr.  H. 

1  American  Psychological  Journal,  November,  1875 


DISEASES  OF  THE  NERVES  IN  GENERAL.  725 

R.  Wharton  kindly  allowed  me  to  see,  the  blow  of  a  stick  displaced  the 
nerve  from  its  groove  behind  the  internal  condyle  of  the  humerus  so  that  it 
lay  on  the  outside  of  the  condyle. 

The  circumflex  nerve  is  quite  frequently  the  seat  of  neuritis,  either  from 
injuries,  like  blows  upon  the  shoulder,  or  cold  and  rheumatic  influences.  I 
saw  a  case  of  neuritis  in  this  nerve  in  a  professional  athlete,  who  had  been  in 
the  habit  of  allowing  a  bar  of  iron  to  be  bent  by  a  blow  over  his  shoulder,  in 
order  to  show  his  muscular  development.  Pressure  dui'ing  sleep,  or  during 
a  prolonged  illness,  is  sometimes  the  cause  of  inflammation  of  this  nerve. 
Overuse  of  the  arm  may  bring  it  on,  as  in  the  case  of  a  girl  whom  I  had 
under  my  care,  who  was  continually  turning  sheets  of  paper  for  a  press. 
Sensation  may  be  impaired  in  the  skin,  and  there  is  pain  and  rapid  atrophy 
of  the  shoulder  muscles.  The  shoulder-joint  may  become  much  relaxed,  or 
false  anchylosis  may  occur  from  contraction  of  the  muscles,  and  in  some 
cases  adhesions  about  the  joint  take  place. 

Duration.  An  attack  of  neuritis  may  last  from  a  few  weeks  to  several 
months,  and  in  some  cases  complete  recovery  in  the  function  of  the  part  may 
not  be  restored  for  years.  The  prognosis  is  said  by  some  writers  to  be  invari- 
ably good,  but  in  many  cases  there  is  never  restoration  of  the  function  of  the 
nerve.  In  cases  where  the  nerve  has  undergone  injury  from  dislocation  of 
the  humerus,  paralysis  is  prominent ;  and  in  some  cases  of  facial  neuritis  the 
paralysis  remains  complete  for  years. 

Treatment.  The  application  of  moist  heat,  such  as  fomentations  and  poul- 
tices, gives  great  relief  to  the  pain  and  discomfort  from  an  inflamed  nerve. 
The  part  should  be  kept  absolutely  at  rest  for  a  few  days,  and  counter- 
irritation,  in  the  form  of  blisters  or  sinapisms,  may  be  applied  over  the  course 
of  the  nerve.  In  cases  that  are  seen  early  the  best  method  of  treatment  is 
the  application  of  the  ice-bag  directly  over  the  nerve.  If  the  pain  is  intense 
and  not  relieved  by  local  means,  subcutaneous  injections  of  morphine  or 
cocaine  may  be  employed.  Small  doses  of  salicylate  of  sodium  and  salol  are 
useful  in  this  condition,  and  the  several  coal-tar  derivations,  acetanilid,  phena- 
cetin,  and  antipyrin  are  useful  in  allaying  the  pain  and  formication.  Gal- 
vanism is  frequently  of  value  in  allaying  the  local  discomfort.  Passing  a 
mild  continuous  galvanic  current  over  the  course  of  the  nerve  for  a  few 
minutes  is  usually  followed  by  relief  of  pain  for  several  hours. 

The  most  important  indication  in  the  treatment  of  neuritis  is  to  keep  the 
affected  part  absolutely  at  rest.  In  a  case  of  inflammation  in  the  nerves  of 
one  of  the  extremities  the  limb  should  be  placed  on  a  well-padded  splint,  so 
as  to  insure  absolute  muscular  repose.  Turkish  baths  are  sometimes  of  marked 
benefit,  even  where  the  neuritis  is  localized  in  a  single  nerve-trunk.  In  cases 
of  gouty  or  rheumatic  origin,  a  dose  of  blue  mass,  followed  by  saline  purga- 
tives and  the  free  use  of  the  alkaline  waters,  is  indicated.  In  all  cases 
particular  attention  should  be  paid  to  the  general  health,  Avhich  is  usually 
disturbed  in  some  way.  Alteratives  and  tonics  are  usually  required.  As 
soon  as  the  hypersesthesia  and  tenderness  in  the  course  of  a  nerve  and  other 
acute  symptoms  have  subsided,  the  use  of  massage  and  electricity  should  be 
resorted  to,  in  order  to  restore  the  functions  of  the  nerve  and  muscles.  Great 
care,  however,  must  be  observed  in  the  application  of  these  remedies.  Fara- 
dization should,  on  no  account,  be  employed  as  long  as  acute  symptoms 
remain ;  and  in  the  beginning  of  treatment  the  massage  should  be  emj^loyed 
only  by  a  person  thoroughly  skilled  in  the  use  of  this  agent. 


726  NEEVOUS  DISEASES  AND  THEIR  TREATMENT. 


MULTIPLE  NEURITIS. 

Synonyms.     Polyneuritis ;  Peripheral  Neuritis ;  Disseminated  Neuritis. 
The  following  classification  of  the  different  forms  of  multiple  neuritis  has 
been  made  by  Ross  •} 

I.  Idiopathic  form. 

1.  Acute  (Landry's  paralysis). 

2.  Subacute  form. 

3.  Chronic  form. 

II.  Toxic  form. 

1.  Difilisible  stimulants :  alcohol,  carbon  monoxide,  bisulphide  of  car- 

bon, dinitro-benzine,  aniline. 

2.  Animal  poisons  :  diphtheria,  typhoid  and  other  fcA^ers,  septicsemia, 

syphilis,  pneumonia,  tubercle,  malaria,  beri-beri,  leprosy. 

3.  Metallic  f)oisons :  lead,  arsenic,  mercurial,  phosphorus,  and  silver. 

4.  Endogenous :  rheumatism,  gout,  chorea,  puerperal  state,  and  dia- 

betes. 

III.  The  dyscrasic  form :  chlorosis,  marasmus,  cancerous,  and  other  forms 

of  cachexia,  vascular  degeneration. 

IV.  Sensory,  vasomotor,  and  trophic  neuritis. 

1.  The  neuritis  found  in  ataxia  (neuro-tabes  j)eripherica). 

2.  The  vasomotor  neurosis-erythromelalgia. 

3.  Raynaud's  disease. 

V.  The  irritative  form  of  neuritis,  in  which  spasm   predominates  over 

paralysis. 

1.  Tetany. 

2.  Professional  hyperkineses. 

Multiple  neuritis  is  the  term  applied  to  the  condition  when  many  periph- 
eral nerves  are  afiected  at  once.  It  is  a  disease  which  has  been  recognized 
only  during  the  past  few  years,  although  its  existence  was  suspected  by  sev- 
eral writers.  Dumesnil  first  described  multiple  neuritis  in  1864  ;  Joffroy 
made  additional  observations  on  the  disease  in  1879,  which  were  confirmed 
by  Leyden  in  1880  ;  and  in  1881  Grainger  Stewart  wrote  fully  on  the  subject. 
It  is  only  since  the  observations  of  the  last-mentioned  writer  that  general 
attention  has  been  directed  to  the  malady  in  this  country.  Since  that  time 
contributions  to  the  subject  have  been  almost  innumerable. 

Many  years  ago  Graves  indicated  by  his  writings  that  he  thought  that 
many  cases  of  paralysis  might  be  due  to  diseases  of  the  peripheral  nerves ; 
James  Jackson,  of  Boston,  described  alcoholic  paralysis  in  1822,  and  Barwell, 
prior  to  1870,"  expressed  the  opinion  that  infantile  paralysis  was  a  lesion  of 
the  peripheral  nerves. 

Idiopathic  multiple  neuritis  occurs  at  various  ages,  from  infancy  to  old 
age,  although  the  majority  of  cases  occur  in  adult  life.  Among  ninety  cases 
collected  by  Ross  most  of  the  patients  were  attacked  between  the  ages  of 
twenty  and  forty  years,  but  in  one  case  the  disease  was  said  to  have  begun 
at  two  years,  and  another  patient  was  sixty-seven  when  attacked. 

I  have  recently  seen  a  case  of  multiple  neuritis  in  a  lad  of  fifteen,  in 
Avhom  no  exciting  cause  could  be  traced.  The  boy  was  a  patient  of  Dr. 
Allison's,  and  was  seized  quite  abruptly  with  general  pain  and  slight  loss  of 
power  in  the  extensor  muscles  of  the  limbs.  There  was  tenderness  over  the 
nerve-trunks  and  muscles  in  the  lower  extremities.  In  three  days  there  was 
complete  loss  of  power  in  both  arms  and  legs.     The  reflexes  were  all  lost, 

1  "Peripheral  Neuritis,"  James  Ross,  M.D.,  and  Judson  S.  Bury,  M.D.,  London,  1893. 
-  St.  Thomas's  Hospital  Reports,  N.  S.  vol.  i.  p.  201. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  "J^l 

but  there  was  no  impairment  of  sensibility.  The  patient  states  that  he  was 
unable  to  articulate  distinctly  on  the  day  that  the  attack  occurred,  but  the 
speech-disturbance  was  only  transient. 

There  are  more  males  than  females  the  subjects  of  idiopathic  multiple 
neuritis.  In  Ross's  ninety  cases,  sixty-two  were  males  and  twenty-three 
females.  It  is  likely  that  this  is  due  to  the  fact  that  men  are  more  exposed 
to  the  exciting  causes  of  multiple  neuritis  than  the  other  sex. 

Acute  polyneuritis  may  follow  exposure  to  cold,  or  chilling  of  the  body 
after  being  overheated,  and  it  may  come  on  spontaneously  without  any  ex- 
citing cause  being  traceable.  The  onset  is  usually  like  that  of  an  acute 
infectious  disease.  The  attack  is  frequently  ushered  in  with  a  chill,  followed 
by  pain  in  the  back  and  limbs,  with  a  rise  of  temperature  to  103°  or  104°. 
There  is  usually  headache,  loss  of  appetite  and  general  malaise.  Tingling 
and  formication  are  felt  in  the  feet  and  hands,  and  there  is  general  muscular 
aching  and  tenderness.  There  is,  at  times,  soreness  throughout  the  entire 
limbs,  the  muscles  and  nerves  being  equally  sensitive,  so  that  it  is  not  easy 
to  distinctly  define  the  nerve-trunks  themselves. 

Loss  of  power  is  manifested  early  in  the  disease.  It  usually  begins  in  the 
flexors  of  the  feet,  and  extends  upward,  as  in  Landry's  paralysis.  How- 
ever, loss  of  power  sometimes  begins  in  the  arms,  and  involves  the  legs 
secondarily.  In  severe  cases  paralysis  is  general  in  a  few  days,  extending  to 
the  muscles  of  the  trunk  and  the  special  muscles  of  respiration.  The  mus- 
cles atrophy  rapidly  and  become  soft  and  flabby.  The  deep  reflexes  are  lost 
early,  but  the  state  of  the  skin  reflexes  vary,  being  preserved  in  some  cases 
and  lost  in  others.  The  electrical  reactions  of  the  muscles,  however,  do  not 
undergo  change  except  in  severe  cases  and  after  the  disease  has  lasted  for 
some  time.  In  the  early  stages  the  muscles  respond  to  the  faradic  current, 
and  this  is  a  point  to  be  borne  in  mind  in  the  diagnosis  between  a  periph- 
eral neuritis  and  a  spinal  paralysis.  The  sensory  disturbances  vary  in  differ- 
ent cases ;  sometimes  there  are  merely  the  subjective  sensations  of  formication 
and  numbness,  Avith  hypergesthesia ;  but  in  other  cases,  in  addition,  there  is  a 
distinct  anaesthesia.  Sometimes  the  anaesthesia  occurs  only  in  circumscribed 
patches. 

The  disease  has  been  divided  into  a  motor  and  a  sensory  type,  depending 
upon  the  most  prominent  symptoms  of  the  attack.  Ross  believed  that  Lan- 
dry's paralysis  and  acute  multiple  neuritis  were  one  and  the  same  disease ; 
but  other  writers,  like  Hun,  consider  that  they  are  two  distinct  diseases.  The 
truth  is,  that  in  some  cases  of  acute  ascending  paralysis  the  lesion  is  that  of 
multiple  neuritis,  while  in  others  there  is  cord  disease.  I  have  recorded  a 
case  of  acute  ascending  paralysis^  in  which  the  patient  died  on  the  twelfth 
day  after  the  attack.  The  symptoms  corresponded  very  closely  with  those 
of  an  attack  of  acute  multiple  neuritis,  but  the  autopsy  showed  distinct  mye- 
litis in  the  upper  part  of  the  cervical  cord. 

The  course  of  the  affection  varies  with  the  extent  and  intensity  of  the 
attack.  A  case  may  terminate  fatally  within  a  week  from  bulbar  paralysis, 
or  it  may  last  five  or  six  weeks  before  any  material  change  takes  place.  The 
paralysis  may  remain  for  months  or  years,  with  atrophy  and  contraction  of 
the  muscles,  but  with  gradual  improvement  as  to  muscular  power. 

Alcoholic  Neuritis.  This  form  of  multiple  neuritis  differs  materially 
in  its  symptoms  from  the  idiopathic  variety.  It  is  the  result  of  the  excessive 
use  of  alcohol  in  any  form.  Persons  who  take  small  quantities  of  spirits 
frequently  and  steadily  are  more  liable  to  alcoholic  neuritis  than  those  who 
drink  to  excess  periodically.     Drinkers  of  beer,  however,  suffer  from  the 

1  Medical  News,  November  7, 1891. 


728  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

affection,  as  well  as  those  persons  who  drink  gin  and  brandy  constantly. 
Women  suffer  more  frequently  from  alcoholic  neuritis  than  men,  there  being 
three  times  as  many  cases  in  women  as  in  men.  This  is  probably  because 
when  a  womaii  has  once  acquired  the  habit  of  taking  alcoholic  stimulants 
she  is  a  more  continuous  "  tippler  "  than  is  a  man.  Gowers  suggests  that 
there  may  be  some  difference  in  the  nervous  system  of  the  two  sexes  which 
may  explain  why  the  peripheral  nerves  in  women  are  more  liable  to  alcoholic 
neuritis,  and  in  men  delirium  tremens  is  more  common. 

The  earlier  symptoms  of  alcoholic  neuritis  are  sensory  disturbances,  pain 
in  the  extremities,  with  sensations  of  pins  and  needles,  and  formication. 
There  is  a  sense  of  numbness  and  blunted  tactile  sense,  and  sometimes  there 

Fig.  240. 


V" 


Multiple  neuritis.    Double  Avrist-drop  and  double  foot-drop.    (Lloyd.) 

is  hypersesthesia.  Soon  motor  symptoms  begin,  and  the  extensors  of  the  feet 
and  hands  are  primarily  attacked,  producing  the  characteristic  foot-drop 
and  wrist-drop.  Foot-drop  is  as  typical  a  symptom  of  alcoholic  neuritis  as 
wrist-drop  is  of  lead  palsy.  Usually  the  lower  extremities  suffer  first,  but  in 
some  cases  the  extensors  of  the  hands  are  affected  first,  and  the  paralysis 
may  be  confined  to  the  upper  extremities.  In  a  case  of  alcoholic  neuritis 
which  was  under  my  care,  the  first  symptom  which  was  noticed  by  the  patient 
was  weakness  in  the  hands  while  driving.  All  of  the  limbs  are  not  simul- 
taneously affected,  one  leg  may  become  almost  completely  powerless  before 
there  is  much  motor  change  in  the  other.  With  the  extension  of  the  disease 
there  is  increased  tenderness  over  the  nerve-trunks  and  muscles,  and  the  sen- 
sory disturbances  cause  the  patient  great  distress.  In  some  cases  the  hyper- 
sesthesia of  the  extremities,  especially  the  soles  of  the  feet,  is  so  great  that 
the  patient  is  unable  to  bear  the  slightest  touch ;  and  the  tenderness  over  the 
nerve-trunks  and  muscles  and  cutaneous  hypersesthesia  is  excessive.  The 
muscular  tenderness  is  a  characteristic  symptom  of  this  disease.  It  is  diffi- 
cult to  move  the  patient's  limbs  on  account  of  the  pain  caused  by  every 
motion.  In  the  onset  of  the  attack  the  temperature  is  elevated,  ranging 
from  101°  to  103°,  and  there  is  tachycardia;  the  pulse  being  feeble  and 
rapid,  ranging  from  100  to  150.  The  high  temperature  may  last  for  four  or 
five  weeks.  The  capillary  circulation  is  bad,  the  skin  is  of  a  dusky  hue,  and 
the  finger-nails  blue.  Diarrhoea  is  not  an  unusual  symptom,  but  there  is  no 
loss  of  control  over  the  rectum  or  bladder.  I  have  seen  one  case  in  which 
there  were  intestinal  hemorrhages.  In  most  cases  there  is  a  complication  of 
some  form  of  kidney  disease.  _  The  paralysis  may  extend  rapidly  and  is  often 
complete  in  two  weeks.  The"  disease  may  terminate  fatally  in  a  few  days, 
but  in  most  cases  the  progress  of  the  disease  is  slow,  and  after  an  interval  of 


DISEASES  OF  THE  NERVES  IN  GENERAL.  729 

several  weeks  recovery  may  begin.  In  fatal  cases  bulbar  paralysis  occurs, 
and  paralysis  of  the  diaphragm  is  always  a  grave  symptom.  The  walk  of 
a  patient  with  alcoholic  neuritis  is  characteristic.  Owing  to  the  foot-drop, 
he  is  obliged  to  lift  his  knees  high,  in  order  to  allow  the  toes  to  clear  the 
ground,  producing  the  "  high-steppage  "  gait.  The  tendon  reflexes  are  lost 
early,  but  in  many  cases  the  skin  reflexes  are  unchanged  ;  occasionally  the 
knee-jerk  is  preserved,  but  in  those  cases  the  quadriceps  extensor  has  escaped 
paralysis.^  The  special  senses  seldom  suffer.  There  is  no  disturbance  of 
vision,  hearing,  or  taste.  Optic  neuritis  has  been  observed  in  a  few  cases, 
and  Starr  refers  to  two  cases  in  which  hearing  was  affected  ;  but  these  excep- 
tions merely  prove  the  rarity  of  the  implication  of  the  nerves  of  the  special 
senses.  The  facial  muscles  have  been  affected  in  some  cases,  but  the  muscles 
of  deglutition  are  not  involved  except  in  fatal  cases.  The  paralyzed  muscles 
become  soft,  and  atrophy  very  rapidly.  The  electrical  reactions  are  changed. 
In  some  cases  there  are  merely  quantitative  changes,  a  very  strong  faradic 
current  being  required  to  move  the  muscles.  When  the  paralysis  is  complete, 
there  is  entire  loss  of  muscular  contractility  to  the  faradic  current,  and  a 
strong  galvanic  current  is  necessary  to  cause  any  reaction.  Reaction  of  de- 
generation may  not  occur  until  late  in  the  disease.  Contractures  are  a 
common  accompaniment  of  alcoholic  neuritis ;  the  claw-hand,  and  extreme 
extension  of  the  foot  from  shortening  of  the  tendo-Achillis  are  commonly 
met  with.  In  most  cases  these  deformities  subside  as  recovery  takes  place, 
but  in  some  cases  they  are  permanent.  Trophic  changes  are  not  often  met 
with,  but  occasionally  the  skin  of  the  extremities  becomes  red  and  glossy, 
and  the  nails  are  roughened ;  but  bed-sores  and  ulcerations  are  rarely  met 
with.  Profuse  sweating  occurs  in  some  instances,  the  limbs  being  bathed  in 
perspiration. 

Brain  symptoms  occur  in  most  cases,  but  do  not  begin  until  the  disease  is 
well  established.  They  may  be  present  early  in  the  attack,  and  it  should 
be  remembered  that  neuritis  may  begin  during  an  attack  of  delirium  tre- 
mens. A  few  cases  of  alcoholic  multiple  neuritis  may  escape  brain  involve- 
ment. The  mental  symptoms  begin  in  the  shape  of  hallucinations  of  various 
kinds ;  in  some  instances  there  are  delusions  of  grandeur,  but  in  other  cases 
the  patient  is  merely  confused  as  to  his  surroundings  and  friends.  He  is 
seldom  unhappy,  but  is  apathetic  except  when  disturbed.  A  common  feature 
is  for  him  to  imagine  himself  in  some  strange  place,  and  to  believe  that  he  is 
among  strangers.  The  memory  is  greatly  impaired,  especially  for  recent 
events,  and  laj^se  of  time  seems  to  make  no  impression  upon  the  patient.  In- 
somnia is  an  almost  constant  symptom. 

In  some  cases  inco-ordination  is  a  prominent  feature  of  the  disease,  giving 
to  it  a  close  resemblance  to  locomotor  ataxia.  These  cases  have  been  called 
pseudo-tabes.  Inco-ordination  in  gait,  absence  of  knee-jerks,  neuralgic  pains, 
and  "  Romberg's  symptoms  "  ai'e  points  of  similarity  between  the  two  dis- 
eases, but  in  multiple  neuritis  we  find  absence  of  the  Argyll-Robertson  pupil 
and  muscular  tenderness. 

Duration.  In  mild  cases  the  attacks  last  from  a  month  to  six  Aveeks,  but 
in  severe  cases  which  recover,  the  course  of  the  disease  may  be  one  or  two 
years,  and  complete  restoration  of  motor  power  may  not  occur  for  years. 

Gowers  states  that  jDOwer  returns  first  in  the  muscles  affected  last  and 
least,  but  this  is  not  always  the  case.  Frequently  there  is  a  simultaneous 
return  of  power.  In  a  case  recently  seen  by  me  the  limbs  were  affected 
successively :  first  the  left  leg  became  paralyzed,  then  the  right  leg,  and 

1  Maude  and  Clark  have  reported  two  cases  in  which  the  knee-jerk  was  exaggerated.    British 
Medical  Journal,  Feb.  28, 1893. 


730  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

afterward  the  arms.  The  right  arm  and  left  leg  were  most  completely  para- 
lyzed. Recovery  began  in  the  left  leg,  which  was  the  member  first  affected- 
Diagnosis.  The  history  of  alcoholism,  with  extreme  sensory  disturbance, 
and  the  extensor  paralysis,  together  with  the  peculiar  mental  disorder,  make 
but  little  difficulty  in  arriving  at  a  diagnosis  of  alcoholic  neuritis.  In  cases, 
however,  in  which,  owing  to  the  circumstances  of  the  individual,  one  would 
not  naturally  suspect  alcoholism,  the  diagnosis  is  sometimes  not  so  easy. 
The  groups  of  muscles  afiected  and  the  peculiar  mental  phenomena  should 
lead  one  to  suspect  alcoholic  neuritis,  and  a  careful  search  into  the  history 
of  the  case  will  then  reveal  the  fact  that  the  patient  has  been  using  alcohol 
in  some  form. 

Prognosis.  The  prognosis  in  alcoholic  neuritis  is  far  more  unfavorable 
than  in  other  forms  of  this  disorder.  It  depends,  to  a  great  extent,  upon  the 
age,  the  previous  habits,  and  health  of  the  patient.  In  cases  in  which  ex- 
tensive kidney,  liver,  or  stomach  disease  is  present,  due  to  alcohol,  the  out- 
look is  most  unfavorable.  In  the  class  of  patients  brought  into  the  public 
hospitals  of  large  cities  the  mortality  is  great,  but  in  private  practice  the 
patients  usually  recover.  Death  may  occur  within  the  first  ten  days  from 
rapid  involvement  of  the  respiratory  muscles,  and  in  other  cases  the  patient 
dies  from  pneumonia  or  pulmonary  congestion.  Paralysis  of  the  vagus  is 
another  cause  of  death. 

In  cases  which  recover  the  convalescence  is  frequently  slow,  and  it  may  be 
years  before  the  muscular  wasting  disappears.  In  some  cases  the  foot 
extensors  remain  permanently  weak.  The  contractures  may  also  remain 
throughout  life,  and  the  memory  remains  imperfect  for  a  long  time  after 
the  attack. 

Neuritis  from  Carbonic  Oxide.  In  this  country  cases  of  multiple 
neuritis  from  carbonic  oxide  generally  result  from  the  inhalation  of  illumi- 
nating gas.  It  may  occur,  however,  from  being  in  a  room  in  which  charcoal 
or  coal  fire  is  burning,  and  to  which  oxygen  has  not  sufficient  access.  In  the 
early  stages  of  carbonic-oxide  poisoning  there  is  a  period  of  unconsciousness 
which  generally,  but  not  necessarily,  pi-ecedes  the  symptoms  of  neuritis. 
There  may  be  pain  in  the  hypochondriac  regions,  and  dyspnoea.  Temporary 
mental  symptoms  are  often  present,  such  as  depression  and  loss  of  memory, 
and  the  latter  may  persist  for  several  months. 

The  symptoms  of  neuritis  from  carbonic-oxide  poisoning  are  numbness,  im- 
pairment of  tactile  sensibility,  and  pain  in  the  extremities,  usually  over  the 
afiected  muscles.  There  are  local  palsies  which  are  irregular  and  variable 
in  distribution,  differing  in  this  respect  from  other  forms  of  neuritis.  Occa- 
sionally there  is  wrist-drop  and  foot-drop,  but  in  some  cases  the  paralysis  may 
be  hemiplegic  and  in  others  paraplegic.  Vasomotor  and  trophic  changes  are 
common.  There  is  frequently  redness  of  the  skin,  with  oedema,  and  herpetic 
eruptions  over  the  course  of  the  nerve-trunks  are  common. 

Multiple  neuritis  may  also  arise  from  other  forms  of  diffiisible  poisons, 
such  as  aniline  and  dinitro-benzene,  but  the  symptoms  are  not  materially 
different  from  those  already  described. 

Multiple  Neuritis  from  Lead.  General  peripheral  neuritis  may  be 
due  to  lead-poisoning.  The  symptoms  are  those  of  polyneuritis,  and  the 
most  typical  features  are  those  due  to  the  local  paralysis  of  the  extensors  of 
the  wrists  and  feet.  The  deltoid  and  biceps  muscles  are  more  frequently  in- 
volved than  in  other  forms  of  neuritis.  A  characteristic  feature,  however,  is 
the  fact  that  in  lead  multiple  neuritis  the  supinator  longus  and  extensor  ossis 
metacarpi  pollicis  usually  escUpe  paralysis.  No  one,  hoAvever,  has  yet  sug- 
gested a  reasonable  explanation  of  this  fact.  The  sensory  symptoms  are 
either  slight  or  entirely  wanting. 


BISEASES  OF  THE  NERVES  IN  GENERAL.  731 

Two  types  of  lead  neuritis  are  met  with :  one  in  which  the  affection  re- 
sembles paralysis  from  injury  to  the  musculo-spiral  nerve,  and  in  which  the 
lesion  is  confined  to  the  peripheral  nerves ;  and  in  the  other  resembles  pro- 
gressive muscular  atrophy  in  the  extensive  and  general  muscular  wasting 
which  occurs.  In  the  latter  form  there  is  involvement  of  the  ganglion  cells 
in  the  anterior  horns  of  the  cord. 

In  lead  neuritis  there  is  sometimes  pain  and  slight  tenderness  in  the  mus- 
cles and  nerve-trunks,  and  occasionally  some  anaesthesia  over  the  affected 
muscles.  The  pains,  however,  are  dull  and  rather  deep  seated.  In  some 
cases  there  is  a  considerable  degree  of  tremor  present.  The  tendon  reflexes 
are  lost.  There  is  no  bladder  paralysis,  but  the  bowels  may  be  obstinately 
constipated. 

Diagnosis.  The  presence  of  a  blue  line  upon  the  gums,  the  extreme 
anaemia  and  history  of  colic  point  to  lead-poisoning.  The  sensory  symp- 
toms are  less  marked  than  in  alcoholic  neuritis,  and  the  brain  symptoms 
when  present  are  different  in  character  from  those  of  the  latter  affection. 
The  symptoms  of  lead  encephalopathy  are  accompanied  with  stupor  as  well 
as  delirium.  Lead  neuritis  is  to  be  distinguished  from  progressive  muscular 
atrophy  by  the  fact  that  the  electrical  changes  are  more  marked,  and  by  the 
absence  of  the  knee-jerk,  which  is  usually  preserved  in  progressive  muscular 
atrophy  as  long  as  there  is  a  muscular  fibre  remaining.  Furthermore,  the 
history  of  the  case  is  different. 

Arsenical  Neuritis.  Arsenical  neuritis  occurs  from  the  absorption  of 
arsenic  into  the  system  in  various  ways.  The  drug  may  be  taken  with 
suicidal  intent,  or  it  may  be  administered  with  the  food  wdth  the  view  of 
poisoning.  A  patient  whom  I  saw  some  years  ago  had  been  given  quite 
large  quantities  of  Paris  green  in  his  food.  He  had,  as  a  consequence,  ex- 
tensive motor  and  sensory  paralysis. 

Multiple  neuritis  sometimes  follows  the  medicinal  administration  of  arsenic, 
and  cases  have  been  reported  by  Potts,  Barrs,^  and  Osler.^  Putnam  has  re- 
ported a  most  instructive  case  of  multiple  neuritis,  in  w^hich  arsenic  was  re- 
covered from  the  urine.  The  cause  of  the  attack  was  the  administration  of 
Fowler's  solution  in  doses  of  five  drops  three  times  a  day  for  six  weeks.^ 

The  symptoms  of  arsenical  neuritis  resemble  those  of  lead  and  alcoholic 
neuritis  to  a  considerable  extent.  The  sensory  symjDtoms  are  more  marked, 
however,  than  in  the  former,  and  the  mental  symptoms  characteristic  of  alco- 
holic neuritis  are  seldom  present  in  arsenical  neuritis.  The  pains  in  the 
limbs  are  of  a  shooting  and  darting  character,  and  anesthesia  is  frequently 
present.  Skin  eruptions  and  trophic  changes  are  often  met  with.  In  doubt- 
ftil  cases  an  examination  of  the  urine  will  reveal  the  presence  of  arsenic. 

Diphtheritic  Neuritis.  The  paralysis  begins  commonly  in  the  palate, 
and  is  shown  by  changes  in  the  voice  and  difficulty  of  deglutition,  and 
liquids  may  regurgitate  through  the  nose.  In  many  cases  the  paralysis  is 
confined  to  this  part,  but  usually  after  a  few  days  it  extends  to  the  muscles 
of  the  eyes,  and  the  ciliary  muscle  is  especially  liable  to  be  involved,  giving 
rise  to  loss  of  power  of  accommodation  and  impaired  vision.  The  arms  are 
affected  next  in  order  of  frequency,  and  then  the  legs.  Of  one  hundred  and 
seventy-one  cases  of  diphtheritic  neuritis  collected  by  Ross,*  the  palate  was 
the  part  first  paralyzed  in  one  hundred  and  twenty-eight ;  in  seventy-seven 
cases  the  ocular  muscles  were  afiected ;  in  sixty  cases  paralysis  occurred  in 
the  arms ;  and  in  thirteen  in  the  legs.  Sensation  was  disordered  in  eighty- 
six  of  the  one  hundred  and  seventy-one  cases. 

1  British  Med.  Journ,  February  4, 1893.  ^  Johns  Hopkins  Bulletin,  April,  1893. 

3  Boston  Med.  and  Surg.  Journ.,  September,  1888.  *  Med.  Chronicle,  December,  1890. 


732  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  paralysis  is  seldom  complete,  and  is  almost  invariably  bilateral.  The 
muscles  become  flabby  and  relaxed  at  an  early  period.  The  knee-jerks  are 
lost  early  ;  in  fact,  in  some  cases  there  is  absence  of  knee-jerk  even  where 
no  muscular  paralysis  can  be  detected.  In  severe  cases  the  pneumogastric 
nerve  is  affected,  giving  rise  to  weak  cardiac  action,  and  in  some  cases  sudden 
death  occurs  from  paralysis  of  the  heart.  In  diphtheritic  neuritis  sensory 
svmj)toms  are  not  conspicuous,  but  there  may  be  some  numbness  and  slight 
hypersesthesia  or  anaesthesia  over  the  paralyzed  muscles. 

Diagnosis,  The  diagnosis  usually  depends  upon  the  distribution  of  the 
paralysis  to  the  throat  muscles  and  the  history  of  diphtheria.  There  are 
cases,  however,  in  which  the  local  symptoms  have  been  so  slight  that  they 
have  not  been  observed,  and  the  fact  of  an  attack  of  diphtheria  has  been 
recognized  through  the  paralysis. 

Diphtheritic  neuritis  in  children  may  be  mistaken  for  poliomyelitis.  It 
differs  from  the  latter  in  the  fact  of  the  slower  onset,  the  symmetry  of  paral- 
ysis, and  the  slighter  degi'ee  of  the  loss  of  power  and  atrophy.  In  diph- 
theritic neuritis  the  electrical  reactions  undergo  but  slight  quantitative 
changes.  The  presence  of  sensory  sjTiiptoms  also  distinguishes  the  disease 
fi'om  poliomyelitis. 

Malarial  Neuritis.  Strachan^  has  described  a  form  of  neuritis  which 
he  met  with  in  Jamaica,  and  which  he  ascribed  to  malarial  poisoning. 
According  to  this  observer,  the  muscles  of  the  trunk  and  limbs  and  cranial 
nerves  are  ecjually  involved.  There  is  much  pain  in  the  extremities,  and 
muscular  wasting  is  extreme.  Vesicular  and  other  cutaneous  eruptions  are 
common,  and  the  pigmentation  of  the  skin  is  increased.  The  knee-jerks 
were  absent  in  one-half  of  the  cases  reported  by  Strachan,  but  the  cutaneous 
reflexes  were  variable.     Sensation  was  but  slightly  impaired. 

In  a  case  of  malarial  multiple  neuritis  which  came  under  my  care,  the 
patient,  a  young  woman,  about  thirty  years  of  age,  had  lived  for  the  greater 
part  of  her  hfe  in  a  climate  saturated  with  malaria,  and  had  had  frequent 
attacks  of  remittent  and  intermittent  fever.  AYhen  she  came  under  my  ob- 
servation there  was  marked  paresis  of  the  extensors  of  the  feet  as  well  as  the 
extensors  of  the  wrists  and  arms.  The  paralysis  was  not  complete,  and  the 
knee-jerks,  although  diminished,  were  not  entirely  absent.  There  was  a  con- 
siderable amount  of  paralysis  of  the  muscles  of  deglutition,  causing  much 
trouble  in  swallowing  food,  and  frequent  regurgitations  of  liquids  through 
the  nose,  and  speech  was  imperfect  from  labial  paresis.  There  was  but  little 
sensory  disturbance.  There  was  no  anaesthesia  or  tenderness  over  the  nerve- 
trunks,  but  a  sense  of  numbness  was  complained  of.  The  patient  eventually 
died  from  bulbar  paralysis. 

Typhoid  Xeuritis.  Neuritis  not  infrequently  occurs  in  connection  with 
typhoid  fever.  It  may  come  on  during  the  fever,  or  is  met  with  as  a  sequela. 
It  is  probable  that  many  of  the  cases  of  paralysis  from  typhoid  fever  which 
have  been  reported  in  years  past  have  been  cases  of  neuritis.  In  a  case  of 
neuritis  under  my  care  wliich  occurred  during  an  attack  of  typhoid  fever, 
the  atrophy  of  the  legs  was  extreme,  and  the  contractions  of  the  hamstring 
muscles  were  so  great  that  a  prolonged  and  careful  course  of  massage  and 
other  means  failed  to  relax  the  contractures.  Tenotomy  of  both  outer  and 
inner  hamstring  muscles  was  done,  and  the  patient  entirely  recovered  the 
use  of  her  limits. 

Neuritis  follows  many  other  acute  diseases,  among  which  are  smallpox, 
grippe,  scarlet  fever,  pneumonia,  pleurisy,  and  erysipelas.     Gray^  has  put  on 

1  Annual  of  the  Universal  Medical  Sciences,  1888,  p.  139. 

2  Brit.  Med.  Journ.,  March  31, 1894. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  733 

record  a  case  of  multiple  neuritis  following  varicella  in  a  child  two  years 
and  five  months  old.  There  was  paralysis  of  motion  and  sensation  in  both 
legs,  but  the  patient  recovered  completely. 

Syphilitic  ISTeuritis.  Syphilitic  neuritis  usually  occurs  in  a  single 
nerve,  and  when  syphilitic  multiple  neuritis  is  met  with  it  is  commoner  in 
connection  with  locomotor  ataxia,  the  so-called  "peripheral  neuro-tabes." 

Tubercular  Multiple  Neuritis.  Tubercular  multiple  neuritis  is  of 
occasional  occurrence  in  phthisis.  I  have  seen  cases  of  well-marked  neuritis 
in  tubercular  patients  in  the  Philadeli^hia  Hospital.  In  one  patient  there 
was  also  a  history  of  extreme  alcoholism,  so  that  it  w^as  a  question  as  to 
whether  the  neuritis  w^as  not  due  to  this  cause  rather  than  to  the  tuberculosis 
from  which  he  was  suffering. 

The  facts  seem  to  indicate  that  the  tubercle  bacillus  is  capable  of  pro- 
ducing a  poison  which  has  a  specific  toxic  action  upon  the  nerves.  Gowers 
suggests  that  neuritis  of  branches  of  the  vagus  nerve  may  give  rise  to  a  low 
form  of  pneumonia,  which  makes  the  bacilli  more  effective  if  they  enter  the 
lungs. 

Rheumatic  Multiple  Neuritis.  Neuritis  is  met  ^\iih  as  a  complica- 
tion of  acute  rheumatism,  and  is  probably  the  result  of  a  toxic  infection 
similar  to  the  poison  w^hich  produces  rheumatism.  In  rheumatoid  arthritis 
there  is  almost  always  more  or  less  evidence  of  peripheral  neuritis,  as  shown 
in  the  great  degree  of  muscular  wasting,  glossy  skin,  and  tapering  fingers 
Avhich  are  typical  of  neuritis  ;  in  fact,  it  seems  probable  that  many  cases 
which  have  been  called  rheumatoid  arthritis  are,  in  reality,  a  form  of  periph- 
eral neuritis. 

Peripheral  Neuritis  in  the  Aged,  which  has  been  recognized  as  a 
special  form  of  the  affection,  is  probably  due  to  arterio-sclerosis.  Oppenheim 
has  recently  Avritten  fully  on  the  subject  of  senile  multiple  neuritis,  and  has 
pointed  out  some  special  features  which  characterize  it.  Among  the  indi- 
dividual  characteristics  of  this  form  of  neuritis  are  the  incomplete  develop- 
ment of  motor  and  sensory  symptoms,  the  integrity  of  the  cranial  nerves, 
and  the  tendency  to  recurrence. 

Septicemic  Multiple  Neuritis  is  the  result  of  absorption  into  the  sys- 
tem of  septic  material  from  wounds,  abscesses,  or  other  lesions.  The  knowledge 
of  the  occurrence  of  neuritis  from  these  causes  explains  many  of  the  conditions 
which  are  met  with  following  suppurating  wounds.  In  a  case  recently  seen 
by  me,  the  patient  received  a  slight  wound  of  the  hand  from  the  shell  of  a 
lobster  which  he  was  cleaning.  The  wound  healed  without  trouble,  but  was 
followed  by  pain  and  parsesthesia,  with  swelling  of  the  hand,  stiff  joints,  and 
glossy  skin. 

Diabetic  Neuritis.  Multiple  neuritis  occurs  during  the  course  of  dia- 
betes. The  attack  of  neuritis  does  not  appear  to  depend  upon  the  amount 
of  sugar  in  the  urine,  as  cases  are  met  wdth  in  which  the  percentage  of  sugar 
is  small.  It  is  supposed  to  be  due  to  the  influence  upon  the  peripheral  nerves 
of  toxic  materials  which  are  analogous  to  acetone. 

Endemic  Neuritis,  Beri-beri,  Kak-ke.  This  disease  is  an  infectious  and 
contagious  form  of  neuritis  due  probably  to  a  micro-organism,  and  is  met  with 
in  epidemics  in  Japan,  China,  parts  of  India,  Ceylon,  the  Philippine  Islands, 
the  coast  of  Brazil,  and  other  localities.  Diet  appears  to  have  a  considerable 
influence  in  the  production  of  the  disease,  although  this  has  been  denied  by 
many  writers.  Putnam  has  reported  a  number  of  cases  among  the  fishermen 
on  the  banks  of  Newfoundland,  and  the  disease  seemed  to  have  developed  in 
consequence  of  unsuitable  and  insufficient  food. 

The  disease  has  also  occurred  among  sailors  on  vessels  carrying  cargoes  of 


734  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

sugar,  and  in  these  cases  the  predisposing  cause  was  supposed  to  be  the  car- 
bonic acid  gas  and  toxic  matters  arising  from  the  fermentation  of  the  large 
quantity  of  sugar  in  the  hold  of  the  ship. 

Food  which  is  insufficient  or  lacking  in  albumin  is  considered  a  cause  of 
the  disease,  and  the  epidemics  in  China  and  Japan  have  been  ascribed  to  the 
fact  that  rice  is  a  staple  article  of  food  in  those  countries.  Takaki,*  a  Japa- 
nese physician,  states  that  he  has  succeeded  in  reducing  the  number  of  cases 
in  the  Japanese  marine  service  to  an  enormous  extent,  simply  by  adopting  a 
food  regimen  in  which  beef,  pork,  eggs,  etc.,  are  given  in  addition  to  rice. 
In  1884  there  were  713  cases,  and  in  1889  there  had  not  occurred  a  single 
case. 

It  has  also  been  attributed  to  an  intestinal  parasite. 

Dr.  James  H.  Walker^  has  related  a  summary  of  the  results  of  927  cases 
of  beri-beri  treated  during  the  last  five  years  at  Sandakan  (British  North 
Borneo).  Out  of  this  number,  887  patients  were  examined  with  reference 
to  the  presence  of  intestinal  parasites  in  the  dejecta.  The  results  were  as 
follows  : 

The  ankylostomum  duodenale  was  found  in  756  cases,  or  85.5  per  cent. ; 
the  trichocephalus  in  284,  or  31.5  per  cent ;  the  ascaris  lumbricoides  in  155, 
or  17.4  per  cent.;  the  oxyurus  vermicularis  in  123,  or  13.8  per  cent. ;  the 
distoma  in  2,  or  \  j)er  cent. ;  various  parasites  in  24,  or  2. 6, per  cent.  ;  an 
ascaris  in  3,  or  -^-^  per  cent. 

The  ankylostomum,  generally  speaking,  is  not  very  frequent  among  the 
indigenous  population.  Its  predominance  in  beri-beri  must,  it  seems  to  me, 
be  of  some  significance.  Dr.  Walker  admits,  for  several  reasons,  that  this 
parasite  cannot  be  regarded  as  the  specific  pathogenic  agent  of  beri-beri, 
but  thinks  it  not  impossible  that  it  may  be  a  predisposing  cause  of  this  affec- 
tion ;  at  any  rate,  it  is  an  aggravating  factor.  In  his  opinion,  the  causes  of 
both  diseases — beri-beri  and  ankylostomiasis — are  produced  simultaneously 
outside  the  organism,  the  conditions  favoring  the  development  of  the  anky- 
lostomum (uncleanliness  and  stagnant  water)  being  also  eminently  favorable 
to  the  evolution  of  the  germ  of  beri-beri. 

Careful  researches  on  the  etiology  of  beri-beri  leave  no  doubt  of  the 
propagation  of  this  disease  by  water,  a  fact  which  makes  the  boiling  and 
filtering  of  drinking-water  a  necessity  in  regions  where  beri-beri  prevails. 
With  regard  to  treatment,  the  first  thing  to  do  is  to  examine  the  stools  of  all 
patients  suffering  from  beri-beri,  in  order  to  institute  measures  for  the  expul- 
sion of  the  entozoa  which  may  be  present. 

Symptoms.  The  symptoms  are  the  same  as  those  of  other  forms  of  mul- 
tiple neuritis,  with  the  addition  of  oedema  and  a  tendency  to  effusion  into  the 
serous  cavities.     There  is  also  greater  liability  to  cardiac  disturbance. 

Cases  of  beri-beri  are  mild  or  severe  in  character.  In  the  mild  cases  the 
onset  is  gradual,  and  the  patient  complains  of  weakness  in  the  legs,  so  that 
he  cannot  walk  as  much  as  usual.  Soon  numbness  and  pain  occur.  There 
is  palpitation,  epigastric  oppression,  loss  of  appetite,  and  general  ill  feeling. 
Qi)dema  of  the  extremities  occurs,  and  the  pulse  is  irregular  and  dicrotic. 
The  anaesthesia  is  slight  and  irregularly  distributed.  In  these  cases,  under 
appropriate  treatment,  recovery  takes  place  in  a  few  days,  or  occasionally  the 
convalescence  may  be  slower. 

The  severe  cases  have  been  divided  into  three  types :  The  atrophic  or  dry 
type,  in  which  the  attack  begins  like  a  mild  case,  but  the  intensity  of  the 
symptoms  increase  with  greater  rapidity,  paralysis  becomes  complete  and  ex- 
tends to  almost  all  of  the  musQles  of  the  body,  including  the  face.     Muscular 

1  Brit.  Med.  Journ.,  Sept.  24,  1892.  2  Medical  Week,  September  21,  1894. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  735 

wasting  is  excessive,  and  the  pain  and  parsesthesia  are  intolerable  ;  in  fact, 
the  pain  in  the  extremities  is  a  prominent  feature  of  the  disease.  The 
anaesthesia  is  not  complete.  There  are  some  trophic  changes,  such  as  glossy 
skin,  but  in  this  form  there  are  no  gastric  symptoms  and  no  oedema.  The 
attack  may  terminate  fatally,  but  most  cases  recover  after  prolonged  con- 
valescence. 

The  second  form  is  the  hydropic,  or  wet  type.  In  this  form  oedema  occurs 
early,  and  the  entire  body  is  swollen  with  the  subcutaneous  effusion.  There 
is  also  effusion  into  the  cavities  of  the  body.  The  atrophy  in  the  muscles  is 
masked  by  the  oedema,  and  is  as  great  as  in  other  forms. 

There  is  also  a  pernicious  type  of  the  affection,  in  which  the  symptoms  of 
the  other  forms  are  present,  but  occur  in  more  rapid  succession,  and,  in  addi- 
tion, gastric  symptoms  are  prominent.  There  may  be  also  suppression  of 
urine.  The  heart  is  weak  and  irregular,  and  death  usually  results  from 
paralysis  of  this  organ. 

Leprous  Neuritis.  This  is  met  with  in  cases  of  leprosy,  the  so-called 
ansesthetic  leprosy,  and  resembles  beri-beri  in  its  infectious  nature,  although 
differing  from  it  in  the  fact  that  the  specific  bacillus  of  leprous  neuritis 
acts  directly  ujjon  the  nerve-tissue  instead  of  being  found  in  the  blood. 
Leprous  neuritis  differs  from  other  forms  of  neuritis  in  the  irregular  distribu- 
tion of  the  anaesthesia  and  in  the  discoloration  of  the  skin  in  dark  maculje. 
The  disease  is  gradual  in  its  invasion,  but  occasionally  the  ansesthesia  is  de- 
veloped suddenly  without  previous  evidences  of  leprosy.  Muscular  weakness 
and  wasting  are  not  conspicuous  features. 

The  form  of  neuritis  met  with  is  perineuritis  and  interstitial  neuritis. 
When  the  ultimate  fibres  themselves  are  diseased  it  is  of  secondaiy  occur- 
rence.    This  is  another  point  of  distinction  from  other  forms  of  neuritis. 

In  recent  cases  the  characteristic  bacilli  are  found  in  the  interstitial  con- 
nective tissue  of  the  nerves  in  large  numbers,  bu,t  with  the  increasing  devel- 
opment of  the  fibrous  tissue  in  the  nerve-bundles  the  bacilli  disappear. 

Leprous  ansesthesia  may  be  mistaken  for  syringomyelia,  but  in  the  latter 
affection  there  is  generally  involvement  of  the  legs,  with  exaggerated  knee- 
jerks,  and  the  dissociation  of  the  thermal  sense  is  a  characteristic  feature 
of  syringomelia.  Some  cases  of  Morvan's  disease  have  proved  to  be  lep- 
rous neuritis. 

Pathology.  The  pathological  changes  in  multiple  neuritis  are  much  like 
those  in  simple  neuritis.  The  peripheral  branches  of  the  nerves  are  involved 
throughout,  and  degenerative  changes  in  them  are  much  greater  than  in  the 
nerve-trunks  proper.  The  latter  are  usually  affected  in  but  a  limited  de- 
gree, and  it  frequently  happens  that  the  fibres  in  the  nerve-trunks  show 
no  evidences  of  disease,  even  in  cases  in  which  there  has  been  tenderness 
over  the  nerves.  The  neuritis  is  of  the  parenchymatous  type,  showing  all  the 
features  of  Wallerian  degeneration  similar  to  that  met  with  after  injury  of  a 
nerve.  In  recent  cases  the  nerve  may  appear  red  and  swollen  to  the  naked 
eye,  and  in  cases  of  long  standing  the  nerve  is  soft  and  may  be  even  pulpy. 
In  some  cases  the  connective  tissue  appears  principally  involved,  and  then 
the  sheaths  of  Schwann  are  found  under  the  microscope  to  be  infiltrated 
with  leucocytes.  In  the  septa,  between  the  fasciculi  and  in  the  secondary 
sheaths  surrounding  these,  lymphoid  cells  are  also  found  in  large  numbers. 
After  a  time  regeneration  begins  in  the  nerve-fibres,  and  the  process  is  the 
same  as  that  which  occurs  after  neuritis  from  injury.  The  period  of  improve- 
ment in  a  case  begins  with  the  regeneration. 

In  the  muscles  the  same  changes  occur  as  in  simple  neuritis.  The  mus- 
cular fibres  are  reduced  in  bulk  and  may  lose  their  striations  and  become 
granular,  and  in  bad  cases  fatty  degeneration  occurs.    In  some  cases  changes 


736  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

in  the  ganglion  cells  of  the  cord  are  met  with.  In  alcoholic  neuritis 
changes  in  the  cord  are  quite  frequent.  Chronic  myelitis  in  irregular 
areas  is  the  principal  lesion,  and  sometimes  chronic  inflammation  of  the 
spinal  meninges  has  been  found.  Various  other  organs  are  also  found  dis- 
eased, more  especially  the  liver  and  kidneys.  The  liver  is  enlarged  and  cir- 
rhotic or,  it  may  be,  fatty  ;  the  kidneys  are  large  and  white,  or  are  contracted. 
Phthisical  changes  are  frequently  met  with  in  the  lungs,  the  heart  is  usually 
flabby,  and  the  muscular  fibres  have  undergone  degeneration. 

Diagnosis.  The  history  of  the  case  and  the  combination  of  motor  symp- 
toms which  have  been  preceded  by  decided  sensory  disturbances  make  it 
almost  necessary  to  arrive  at  a  diagnosis  of  multiple  neuritis.  The  tender- 
ness of  the  muscles  and  nerve-trunks  is  also  an  important  diagnostic  feature 
in  the  disease.  The  diseases  most  likely  to  be  confounded  with  multiple 
neuritis  are  anterior  poliomyelitis  and  locomotor  ataxia.  The  differential 
diagnosis  of  multiple  neuritis  from  the  latter  has  been  considered  under  the 
head  of  Alcoholic  Neuritis.  The  following  summary  from  Starr^  shows  the 
prominent  differences  between  anterior  poliomyelitis  and  multiple  neuritis  : 

Anterior  Poliomyelitis.  Multiple  Neuritis. 

Sudden  onset  with  fever  and  development  of  Fatigue  for  some  weeks,  then  sudden  onset  and 

paralysis  in  all  limbs,  followed  in  from  three  to  progress  for  two  weeks  with  or  without  fever, 

five  days  by  subsidence  of  paralysis,  which  re-  Legs  first  affected,  then  arms,  then  body,  and 

mains  in  a  few  muscles  of  one  limb;  or,  if  two  paralysis   has   no  tendency-  to    subside   for   a 

are  affected,  the  paralysis  is  very  rarely  sym-  month  ;  limbs  are  affected  symmetrically,  and 

metrical.    If  onset  is  subacute,  four  weeks  is  the  the  muscles  affected  are  very  tender, 
duration  of  onset.    Muscles  not  tender. 

Sensory  symptoms  are  rare,  and  when  present  Sensory  symptoms  are  constant  and  severe,  and 

soon  subside.  increase ;  anaesthesia  becoming  well  developed. 

Acute  ascending  myelitis  resembles  multiple  neuritis  in  some  respects,  but 
cases  of  this  kind  are  uncommon.  In  myelitis  the  loss  of  sensation  is  com- 
plete, and  involves  the  trunk  as  well  as  the  extremities,  beginning  at  a  well- 
defined  line  around  the  body  at  the  level  of  the  lesion  in  the  cord.  Girdle- 
pains  are  common,  and  bed-sores  and  incontinence  of  urine  are  also  constant 
symptoms  of  myelitis.  In  myelitis  there  is  no  tenderness  of  the  muscles 
and  nerve-trunks.  Occasionally  hysterical  cases  are  seen  with  symptoms 
which  simulate  those  of  multiple  neuritis.  The  distribution  of  the  symp- 
toms, however,  is  irregular,  and  there  is  no  loss  of  the  reflexes.  If  there  is 
any  change  at  all  in  these,  they  are  exaggerated. 

Prognosis.  This  depends  largely  upon  the  general  condition  of  the 
patient,  whether  he  is  broken  down  by  dissipation  or  disease,  or  if  he  is  of 
good  constitution.  The  acuteness  of  the  attack  also  increases  the  risk  of 
death.  If  there  is  a  progressive  increase  in  all  of  the  symptoms  for  two  or 
three  weeks,  the  case  is  unfavorable ;  but  cases  of  alcoholic  neuritis  are  seen 
in  which  the  symptoms  grow  progressively  worse  for  five  or  six  weeks,  and 
yet  eventually  recover.  When  the  muscles  of  the  trunk  are  enfeebled,  in 
addition  to  paralysis  of  the  extensors  of  the  hands  and  feet,  the  case  is  more 
grave,  because  then  respiratory  difficulties  are  liable  to  arise.  Paralysis  of 
the  diaphragm  has  been  mentioned  already  as  an  unfavorable  symptom,  and 
one  should  be  on  the  lookout  for  diaphragmatic  paralysis,  which  may  come 
on  unexpectedly.  When  the  disease  has  become  stationary,  that  is,  when 
there  is  no  further  increase  in  the  degree  and  extension  of  paralysis,  then  the 
danger  of  life  is  lessened  and  recovery  becomes  probable.  In  cases  in  which 
there  is  evidence  of  involvement  of  the  spinal  cord,  as  shown  by  bed-sores, 
paralysis  of  the  bladder,  etc.,  the  prognosis  is  more  serious.  The  prognosis 
is  most  serious  in  cases  which  are  dependent  upon  alcohol  or  some  toxsemic 
state  of  the  blood,  and  in  acute  cases  resembling  Landry's  paralysis. 

1  "  Familiar  Forms  of  Nervous  Disease,"  page  216. 


DISEASES  OF  THE  NERVES  IN  OENEBAL.  737 

In  cases  which  tend  to  recovery  the  full  development  of  the  symptoms  is 
followed  either  by  improvement  or  a  stationary  period  which  may  last  for 
one  or  two  months.  The  course  of  convalescence  is  slow,  and  muscles  which 
have  been  only  partially  affected  take  from  three  to  four  months  to  recover 
their  power.  The  sensory  symptoms  improve  more  rapidly.  There  is  an 
impression  prevalent  that  in  cases  which  do  not  terminate  fatally  there  is  in  the 
course  of  time  complete  restoration  of  power,  but  this  is  not  always  the  case. 
In  a  patient  now  at  the  Philadelphia  Hospital  there  was  extensive  paralysis 
from  alcoholic  neuritis,  followed  by  great  atrophy  and  contractures  of  the 
flexors  of  the  feet  and  hands.  These  contractures  still  remain,  although  the 
acute  attack  occurred  five  years  ago. 

In  some  cases,  especially  those  of  alcoholic  origin,  death  may  occvir  within 
a  few  days  from  heart  failure  or  congestion  of  the  lungs,  due  to  involvement 
of  the  vagus.  If  the  patient  has  vitality  enough  to  live  until  regeneration  of 
the  nerves  begins,  he  will  probably  recover.  In  young  subjects  recovery  is  the 
rule,  and  in  cases  of  moderate  intensity  the  restoration  of  power  is  gener- 
ally complete. 

Treatment.  In  the  treatment  of  multiple  neuritis  the  first  consideration 
is  to  eliminate  the  cause  of  the  disease,  if  possible.  In  alcoholic  and  tox- 
semic  cases  this  is,  of  course,  clearly  the  indication.  It  is  frequently  exceed- 
ingly difficult  to  prevent  alcoholic  patients  from  taking  stimulants,  and  it 
requires  the  utmost  Avatchfulness  on  the  part  of  the  nurse  and  the  physician 
to  prevent  liquor  being  furnished  them.  It  is  important  in  alcoholic  neuritis 
to  stop  stimulants  entirely,  but  it  is  necessary  to  do  this  with  caution,  as  many 
patients  are  in  such  a  condition  of  weakness  that  the  alcohol  cannot  be  com- 
pletely withdrawn  without  risk  of  heart  failure  and  general  collapse.  In 
these  cases  strychnine,  together  with  strophanthus  or  digitalis,  is  of  great 
importance.  When  neuritis  can  be  traced  to  lead,  arsenic,  or  other  metallic 
poisoning,  means  must  be  taken  for  the  elimination  of  these — i.  e.,  the  admin- 
istration of  iodides,  baths,  etc.     (See  p.  196  et  seq.) 

Absolute  rest  in  bed  is  of  the  first  and  utmost  importance  in  all  forms  of 
neuritis.  The  treatment  can  be  more  readily  carried  out,  especially  in  regard 
to  applications  to  the  painful  and  sensitive  limbs,  and  the  patient's  strength 
is  economized.  One  of  the  earliest  indications  requiring  treatment  is  the 
pains  in  the  extremities.  Hot  fomentations  and  poultices  applied  over  the 
tender  nerves  and  muscles  often  afford  relief,  but  care  must  be  exercised  that 
the  applications  are  not  made  too  hot,  as  the  skin  readily  blisters  and  trouble- 
some sores  may  remain.  Warm  baths  often  give  great  relief  to  these 
pains. 

The  salicylates  have  been  recommended  for  the  relief  of  the  acute  symp- 
toms, but  their  depressing  influences  should  be  remembered  and  counteracted 
if  necessary  by  the  administration  of  digitalis  or  other  cardiac  stimulant. 
The  coal-tar  derivatives,  such  as  acetanilid,  antipyrin,  and  j)henacetin,  are 
also  useful  in  allaying  pain,  but  must  always  be  used  with  caution  on 
account  of  the  feeble  heart.  The  compound  tincture  of  cinchona  or  the 
tincture  of  gentian  may  be  used  with  advantage  in  cases  of  alcoholic  neuritis, 
where  it  is  not  advisable  to  withdraw  the  stimulants  altogether.  In  these 
cases  cocaine  in  doses  of  one-eighth  to  one-quarter  of  a  grain  may  be  given. 
It  acts  as  a  stimulant  and  as  an  analgesic  as  well.  It  may  be  given  hypo- 
dermatically  for  the  nerve-pains.  Strychnine  is  indicated  in  all  forms  of 
neuritis,  and  the  nitrate  of  strychnine  seems  specially  applicable  in  cases 
of  alcoholic  neuritis,  on  account  of  its  alleged  power  of  reducing  the  craving 
for  stimulants.  Cannabis  indica  also  may  be  given  continuously  to  relieve 
pain,  but  if  this  and  the  remedies  mentioned  above  fail,  morphine  should  be 
given  hypodermatically.     If  the  patient  is  wakeful,  one  of  the  bromides  or 

47 


738  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

cHoralamid  may  be  given,  but  if  there  is  much  excitement  a  hypodermatic 
injection  of  hyoscin  hydrobromate,  one-one-hundredth  of  a  grain,  is  preferable. 

Massage  is  of  great  importance,  and  may  be  employed  from  the  beginning 
of  the  attack  if  a  skilful  masseur  can  be  obtained.  The  movements  should 
be  made  with  the  utmost  gentleness,  and  effleurage  is  the  form  of  massage  to 
be  selected.  When  the  acute  symptoms  are  subsiding  deeper  massage  may 
be  employed,  and  thorough  kneading  of  the  muscles  may  be  resorted  to. 

Electricity  should  not  be  used  early  in  the  disease,  except  in  the  form  of 
the  galvanic  current  passed  continuously  down  the  limbs,  with  the  view  of 
allaying  j^ain.  When  the  active  progress  of  the  disease  is  arrested  the  faradic 
current  may  be  used  to  stimulate  muscular  contractions  and  prevent  wasting. 

Care  should  be  taken  to  prevent  contractions  of  the  muscles  during  the 
course  of  the  disease.  It  will  be  found  necessary  to  use  frames  to  keep  the 
bed-clothes  from  resting  upon  the  limbs  of  the  patient,  as  even  the  weight 
of  a  sheet  often  causes  suffering,  and  sand-bags  and  other  appliances  should 
be  used  to  keep  the  limbs  in  proper  position.  The  tendency  to  foot-drop, 
which  occurs  almost  universally,  must  be  overcome  by  pads  and  other  appli- 
ances, and  particular  care  is  necessary  to  prevent  contraction  of  the  ham- 
string muscles,  as  there  is  a  natural  tendency  of  the  patient  to  lie  with  his 
knees  flexed.  The  painful  extremities  may  be  wrapped  in  absorbent  cotton 
with  advantage,  and  sometimes  a  covering  of  oiled  silk  to  retain  heat  and 
moisture  adds  to  the  patient's  comfort. 

Iodide  of  potassium  may  be  given  during  the  stage  of  convalescence,  and 
arsenic  is  also  usefiil  as  a  nerve  tonic.  The  latter  is  a  remedy,  however, 
which  should  be  given  with  caution,  as  it  is  known  to  have  produced  neuritis 
even  in  small  doses.  Tonics  are  indicated,  and  cod-liver  oil,  when  it  can  be 
borne  by  the  stomach,  is  one  of  the  most  useful  tonics  which  can  be  adminis- 
tered. 

The  diet  of  the  patient  demands  especial  attention.  During  the  acute 
stages  light  and  easily  assimilated  food,  like  milk,  oysters,  fish,  meat  broths, 
and  eggs,  should  be  given  freely.  The  patient  often  has  an  abnormal  appe- 
tite, and  it  becomes  necessary  to  see  that  no  indiscretions  in  diet  are  committed. 


ERYTHBOMELALGIA. 

This  affection  was  first  accurately  described  by  Dr.  S.  Weir  Mitchel?  in  1878, 
and  since  then  many  cases  have  been  recorded  by  other  writers.  It  is  a  disease 
which  affects  the  feet  principally,  and  is  distinguished  by  intense  burning  pains 
and  redness  of  the  parts  affected.  The  disease  usually  attacks  men,  but  may 
be  met  with  in  women  as  well.  It  begins  in  the  ball  of  the  foot  or  heel,  and 
the  pain  comes  on  when  the  patient  attempts  to  walk,  or  when  the  foot  is 
hanging  down.  The  affected  part  becomes  swollen  and  intensely  red,  of  a 
bright  scarlet  hue.  The  disease  is  usually  symmetrical,  but  one  leg  alone  may 
be  involved.  The  pain  at  first  is  of  an  aching  kind,  but  afterward  it  assumes 
an  intensely  burning  character,  which  is  increased  by  warmth,  and  relieved 
by  the  application  of  cold  or  by  the  recumbent  position.  The  flushing  of  the 
painflil  areas  is  the  most  characteristic  feature.  The  feet,  according  to  Dr. 
Mitchell's  original  description,  "get  redder  and  redder,  the  veins  stand  out 
in  a  few  minutes  as  if  a  ligature  had  been  tied  about  the  limb,  and  the 
arteries  throb  violently  for  a  time,  until  at  length  the  extremities  become  of 
a  dark  purplish  tint."  The  parts  involved  may  perspire  profusely.  In  the 
worst  cases,  when  the  patient  is  at  rest,  the  limbs  are  cold  and  even  pale.    The 

1  American  Journal  of  the  Medical  Sciences,  July,  1878. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  739 

disease  increases  until  finally  all  of  the  branches  of  the  plantar  nerve  are 
involved.  The  pain  is  generally  worse  at  night,  and  is  much  increased  by 
exercise  of  any  kind.  The  feet  become  so  tender  that  standing  or  walking 
is  excessively  painful,  in  some  cases  the  patient  is  unable  to  stand  upon  his 
feet,  and  one  of  Dr.  Mitchell's  patients,  whom  I  saw,  "was  compelled  to  go  on 
his  knees  when  he  wished  to  go  across  the  room.  The  hands  also  may  be 
affected.^  Blisters  and  ulcerations  are  liable  to  arise  from  slight  injuries. 
All  of  the  symptoms  become  worse  in  warm  weather. 

In  some  cases  the  disease  is  progressive  and  may  be  associated  with  some 
evidences  of  spinal  disease,  such  as  girdle  pains,  partial  paralysis,  and  atrophy 
of  some  of  the  leg  muscles.  In  the  case  described  by  Ross'^  there  was  a  ten- 
der spot  in  the  centre  of  the  heel,  and  the  whole  course  of  the  external  plan- 
tar nerves  was  tender  to  pressure.  The  feet  were  bathed  in  a  sour-smelling 
sweat,  and  the  skin  of  the  sole  had  a  sodden  appearance,  becoming  somewhat 
glazed  during  the  paroxysm  of  pain  and  redness. 

Pathology.  The  disease  was  considered  by  Mitchell  in  his  original  paper 
as  a  vasomotor  neurosis,  but  it  is,  no  doubt,  a  peripheral  neuritis  involving 
the  branches  of  the  plantar  nerve. 

Diagnosis.  The  diagnosis  is  to  be  made  from  plantar  neuralgia  or  podal- 
gia  and  alcoholic  neuritis.  In  podalgia  there  is  no  redness  or  swelling,  and 
in  alcoholic  neuritis  the  tendereess  of  the  feet  is  not  accompanied  by  redness, 
and  there  are  also  present  other  peculiar  symptoms  of  the  disease. 

Treatment.  Elevation  of  the  feet  gives  temporary  relief.  Electricity  and 
massage  have  been  used,  and  in  some  cases  with  benefit.  Prolonged  rest  in 
bed,  with  general  tonic  treatment,  has  relieved  the  disease  in  some  cases. 
Dr.  Weir  Mitchell  has  recently  suggested  excision  of  the  posterior  tibial 
nerve  as  a  means  of  relief,  and  in  one  case  at  least  the  operation  has  been 
entirely  successful. 

TUMORS  OP  NERVES. 

Hypertrophy  of  nerve-trunks  is  rarely  met  with.  In  ausesthetic  leprosy 
there  is  found  an  increase  in  the  size  of  the  nerve-trunks  due  to  hyperplasia 
of  the  connective  tissue.  The  enlargement  of  the  nerves  in  this  disease  is 
a  cirrhotic  enlargement  rather  than  a  hypertrophy. 

Neuroma.  This  term  is  applied  to  a  tumor  growing  in  or  upon  a  nerve- 
trunk.  Neuromata  have  been  divided  into  true  and  false.  True  neuro- 
mata are  composed  of  nerve-tissue,  and  are  met  with  almost  exclusively  upon 
sj)inal  nerves.  They  consist  of  medullary  nerve-fibres  in  some  cases,  and 
in  others  of  fibres  of  the  non-medullary  variety,  the  axis-cylinders  exist- 
ing in  increased  numbers.  A  neuroma  may  also  consist  of  true  ganglion 
cells,  with  a  surrounding  network  of  fibres.  In  most  neuromata  the  nerve- 
tubes  are  not  continuous  with  those  of  the  nerve-trunk,  but  are  found  in  an 
irregular  network  mixed  up  with  loose  connective  tissue. 

Neuromata  are  met  with  either  singly  or  in  considerable  numbers.  They 
vary  in  size  from  1  c.cm.  to  6  c.cm.  in  diameter.  The  button-like  growth  at 
the  end  of  a  nerve  in  the  stump  of  a  limb  which  has  been  amputated  is  a 
good  example  of  a  neuroma. 

Multiple  neuromata  are  generally  neuro-fibromatous  in  composition.  They 
are  frequently  very  numerous,  many  thousands  having  been  found  in  a  single 

1  Gerhardt  (Annual  Med.  Sciences,  vol.  ii.  C.  58)  reports  a  case  in  a  needlewoman  of  forty-four 
years  who  suffered  from  erythromelalgia  in  the  hands  as  well  as  the  feet.  There  were  swelling  and 
redness  in  the  affected  parts. 

2  Diseases  of  the  Nervous  System,  vol.  i.  p.  518. 


740  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

case.  Thev  exist  under  the  skin  and  form  i:)ainful  nodular  bodies.  Duhring^ 
has  described  a  case  in  Avhich  a  great  number  of  neuro-fibromata  "were  found 
scattered  over  the  entire  surface  of  the  body.  Some  of  these  were  excised 
and  found  to  consist  principally  of  non-medullated  nerve-fibres,  with  con- 
nective tissue  interwoven  among  them.  The  pain  which  the  patient  suffered 
was  excessive. 

False  neuromata  are  tumors  of  nerves  containing  no  nerve  fibres  or  nerve 
cells,  such  as  fibromata,  gliomata,  myxomata,  carcinomata,  sarcomata,  and 
syphilomata.  These  growths  are  generally  secondary.  The  most  common 
form  of  false  neuroma  is  carcinoma.  The  small  neuromata,  which  are  found 
situated  just  under  the  skin  on  the  ends  of  the  sensory  ner^^es,  are  known  as 
tubercula  dolorosa. 

Etiology.  The  causes  of  neuromata  are  frequently  obscure,  the  principal 
being  some  hereditary  predisposition  which  tends  to  the  production  of  the 
multiple  variety.  Injuries  and  surgical  operations  are  common  causes  of 
neuromata.  This  is  more  particularly  the  case  in  stumps,  where  there  is 
almost  invariably  found  a  neuroma  at  the  end  of  the  divided  nerve.  The 
tubercular  and  cancerous  diatheses  have  also  an  influence  in  the  production 
,of  false  neuromata.  Multiple  neuromata  may  be  developed  early  in  life  or 
may  be  congenital. 

Symptoms.  In  many  cases  of  neuromata,  no  symptoms  are  present,  espe- 
ciallv  in  the  case  of  multiple  neuromata.  The  latter  are  sometimes  not  dis- 
covered until  after  the  death  of  the  patient.  Frequently,  however,  there  is 
excessive  pain  as  the  result  of  the  nerve-growths.  The  character  of  the  pain 
is  generally  acute  and  burning,  and  is  usually  referred  to  the  distribution  of 
the  nerve."  The  neuromata  themselves  are  tender  on  pressure.  When  the 
nerve-fibres  suffer  to  any  great  extent  there  are  parsesthesia  and  other  dis- 
turbances of  sensation.  Occasionally  paralysis  of  the  muscles  supplied  by 
the  nerve  occurs,  but  this  is  only  where  the  nerve-trunk  is  compressed  by 
the  tumor. 

In  the  case  of  neuromata  in  stumps  there  is  often  excessive  tenderness, 
which  may  prevent  the  use  of  an  artificial  limb.  There  is  also  occasionally 
some  reflex  disturbance  as  the  result  of  these  growths.  I  recall  a  case  seen 
manv  years  ago,  in  which  the  neuroma  in  a  stump  of  an  arm,  which  had 
been  amputated  many  years  before,  gave  rise  to  intense  neuralgia,  which  was 
relieved  as  soon  as  the  growth  had  been  removed. 

Neuromata  grow  with  greater  or  less  rapidity,  but,  as  a  rule,  the  symp- 
toms come  on  gradually  and  continue  for  a  length  of  time. 

Diagnosis.  The  diagnosis  of  neuromata  can  only  be  made  when  they  are 
in  superficial  positions.  The  symptoms  to  which  they  give  rise  may  merely 
lead  one  to  suspect  the  presence  of  these  growths.  In  the  case  of  subcu- 
taneous multiple  neuromata  they  are  to  be  distinguished  fi'om  fibromata  and 
carcinomata  bv  the  difference  in  their  size.  Neuromata  are  always  quite 
small,  seldom  exceeding  an  inch  in  diameter  at  the  utmost.  False  neuromata 
are  usuallv  secondary,  and  depend  on  the  existence  of  some  other  morbid 
growths. 

Treatment.  The  treatment  of  nerve-tumors  is  almost  purely  surgical. 
Except  in  the  syphilitic  varieties,  medical  treatment  is  of  no  value.  Extir- 
pation is  easily  effected  if  the  growth  is  superficial,  and  involves  little  or  no 
risk.  If  the  whole  nerve-trunk  is  infiltrated  by  the  growth,  the  affected  part 
must  be  excised  and  the  ends  brought  together.  The  risk  of  loss  of  function 
in  the  nerve  after  this  operation  is  comparatively  small  with  the  antiseptic 
precautions  which  are  now  taken  in  surgery.    There  is  a  tendency  to  relapse, 

1  American  Journal  of  the  Medical  Sciences,  vol.  Ixxiii.  p.  413. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  741 

however,  in  the  case  of  neuromata ;  and  in  multiple  neuromata  surgical 
treatment  is  almost  hopeless  on  account  of  the  continual  recurrence  of  new 
growths. 

When  there  is  a  painful  neuroma  in  a  stump  the  nerve-tumor  is  easily 
reinoved  by  operation,  and  recurrence  is  not  usual.  In  cases  in  which 
"amputation  neuromata"  cause  great  pain  and  reflex  spasms,  nerve- 
stretching  has  been  found  to  give  relief  when  excision  has  not  been  success- 
ful. Cocaine,  hypodermatically,  also  gives  temporary  relief,  although  the 
danger  of  the  cocaine  habit  is  great.  In  many  cases  of  amputation  neuro- 
mata, however,  the  paroxysms  of  pain  usually  occur  with  the  change  of  the 
weather  and  the  approach  of  storms,  so  that  palliatives,  like  cocaine  and 
morphine,  may  be  used  with  less  risk  of  a  drug-habit  being  formed. 


MECHANICAL  INJURIES  OP  NERVES. 

Nerves  may  be  injured  in  a  variety  of  ways,  either  from  blows  or  contu- 
sions, which  do  not  divide  the  overlying  skin,  and  they  may  also  be  severed 
by  cuts  or  injuries  which  lay  open  the  tissues  above  them.  The  results  of 
contusions  and  compressions  are  more  or  less  laceration  and  inflammation  at 
the  seat  of  the  injury,  together  with  neuritis  extending  upward  from  this 
point.  The  symptoms  connected  with  this  form  of  injury  have  been 
described  under  the  head  of  neuritis. 

Open  wounds  may  be  caused  by  cutting  instruments  or  by  bullets,  giving 
rise  to  difierent  symptoms  dependent  upon  the  extent  of  the  lesion.  The 
nerve-trunk  may  be  either  completely  severed  or  only  partially  divided,  or, 
possibly,  injured  by  being  merely  grazed  by  a  ball.  The  most  common 
causes  in  everyday  life  of  incised  wounds  of  nerves  are  from  glass,  either 
through  the  accidental  thrusting  of  the  hand  through  a  window-pane,  or  by 
bottles  which  break  while  being  filled  or  cleaned.  Injuries  are  not  uncom- 
mon in  bottling  establishments,  where  a  bottle  often  bursts  from  the  pressure 
of  carbonic-acid  gas  while  being  corked.  Knife  wounds  from  accident  and 
from  stabs  also  occur  quite  frequently. 

Wounds  of  the  sciatic  nerve  may  be  inflicted  by  tools  or  sharp  instru- 
ments, on  which  a  person  may  fall  or  sit.  I  have  seen  one  case  of  division 
of  the  sciatic  nerve  in  the  case  of  a  ship-carpenter,  who  fell  upon  an  adz,  and 
cases  have  been  reported  in  which  the  sciatic  was  divided  by  a  fall  upon  a 
scythe. 

The  nerves  which  are  most  frequently  injured  are  those  which  lie  super- 
ficially in  the  upper  extremities.  The  musculo-spiral  nerve,  from  the  posi- 
tion in  which  it  lies  as  it  turns  around  the  humerus  just  above  the  elbow,  is 
quite  frequently  the  seat  of  injuries.  I  have  seen  two  men  who  received 
stabs  in  this  position  which  completely  divided  the  nerve.  It  is  probable 
that  the  arm  was  thrown  up  to  ward  off  the  blow,  and  it  was,  therefore,  struck 
at  this  point.  In  one  case  the  wound  must  have  been  made  by  a  pocket- 
knife  with  a  narrow  blade,  as  the  scar  at  the  wound  of  entrance  was  not 
more  than  three-eighths  of  an  inch  in  length,  l)ut  the  nerve  was  completely 
divided. 

The  median  nerve  is  more  liable  to  injury  than  any  other  nerve  from  its 
exposed  position  at  the  wrist,  and  in  this  situation  it  is  frequently  severed 
by  cuts  inflicted  by  shai-p  weapons  or  by  glass.  I  know  of  an  instance  of  a 
patient  who,  during  an  attack  of  melancholia,  attempted  suicide  by  cutting 
herself  across  the  wrist.  The  median  nerve  was  divided  l)y  the  incision.  The 
ulnar  nerve  is  also  occasionally  injured  at  the  inner  condyle  of  the  humerus. 

The  extent  to  which  a  nerve  has  been  injured  can  only  be  determined  1)y 


742  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

careful  examination  of  the  parts  to  which  the  nerve  is  distributed,  in  order 
to  determine  the  loss  of  motion  and  sensation. 

Puncture  wounds  of  nerves  are  rare,  but  those  cases  which  have  been  re- 
ported, as,  for  example,  when  a  nerve  has  been  punctured  by  a  hypodermatic 
needle,  or  when  in  the  operation  of  phlebotomy  the  nerve  has  been  acci- 
dentally struck,  inflammation  of  the  nerve  is  likely  to  follow,  accompanied 
by  the  usual  symptoms  of  j)ain,  parsesthesia,  etc.,  and  possibly  by  reflex  dis- 
turbances. Mitchell  ^  mentions  the  case  of  a  man  who  had  driven  an  awl 
through  the  ulnar  nerve.  In  this  patient  there  was  excruciating  pain,  fol- 
lowed by  choreic  twitchings  and  finally  by  spasm  in  the  flexors  of  the  fingers. 

During  the  late  war  a  large  number  of  gunshot  wounds  of  nerves  were 
treated  in  the  United  States  Army  Hospital  at  Philadelphia  for  Injuries  and 
Diseases  of  the  Nervous  System,  and  the  classical  treatise  on  the  subject  by 
Mitchell,  Morehouse,  and  Keen,  which  was  published  in  1864,  has  been  a 
source  of  information  since  that  time. 

A  nerve-trunk  may  be  completely  severed  by  a  bullet,  or  it  may  be 
partly  divided,  or  only  contused.  The  results  and  symptoms  of  gunshot 
wounds  differ  little  from  injuries  inflicted  in  other  ways.  The  immediate 
effect,  however,  of  a  gunshot  wound  through  a  nerve-trunk  is  rather  differ- 
ent from  injuries  received  from  blows  and  cuts.  According  to  Mitchell,'* 
the  flrst  effect  of  a  gunshot  wound  of  a  nerve  varies  in  different  individ- 
uals ;  in  some  cases,  the  man  feels  as  if  he  had  been  struck  with  a  stick  or 
stone;  in  other  cases,  instant  and  intense  pain  is  felt  in  the  wound  and 
down  the  nerve-trunk ;  and  in  some  cases  there  is  little  or  no  pain  or  dis- 
comfort. In  91  cases  analyzed  by  Dr.  Mitchell,  one-third  had  no  pain,  and 
many  did  not  know  that  they  Avere  shot  until  weakness  or  the  sight  of 
their  blood  showed  that  they  had  received  a  wound.  If  the  nerve  is  com- 
pletely divided,  of  course,  paralysis  of  motion  in  the  parts  supplied  by  it 
immediately  occurs ;  but  in  some  cases,  even  when  the  nerve  is  only  grazed 
by  the  bullet,  its  function  may  be  completely  abolished  at  once.  A  case 
recorded  by  Mitchell,  a  soldier  who  was  injured  in  the  brachial  plexus  by  a 
bullet,  had  sudden  and  violent  muscular  contraction  of  the  muscles  of  his 
hand,  so  that  he  was  obliged  to  ask  a  comrade  to  unclasp  his  fingers  from 
their  hold  on  the  musket.  Shock  is  a  frequent  consequence  of  grave  nerve 
injuries.  The  patient  becomes  faint  and  cold,  and  passes  into  a  condition  of 
general  depression. 

The  secondary  effects  of  injuries  of  nerves  are  practically  those  of  intense 
neuritis.  All  of  the  evidences  of  degenerative  changes  are  present,  whether 
the  nerve  be  completely  divided  or  only  partially  so.  These  symptoms  have 
been  ftilly  described  in  the  section  on  Neuritis.  I  will  here  refer  only  to 
the  fact  that  trophic  changes  are  much  more  common  after  wounds  of 
nerves  than  as  a  consequence  of  simple  neuritis.  There  is  marked  atrophy 
of  the  muscles  supplied  by  the  injured  nerve,  and  also  anaesthesia  and  hyper- 
sesthesia,  with  greater  or  less  pain  in  the  distribution  of  the  nerve.  One  of 
the  characteristic  forms  of  suffering  is  the  violent,  burning  pain  which  has 
been  called  by  Mitchell  causalgia. 

The  condition  of  the  skin  and  its  appendages  is  greatly  changed.  Cuta- 
neous disturbances,  in  the  form  of  herpetic  and  vesicular  eruptions  and 
ulcerations  as  the  result  of  bullae,  are  often  present.  These  heal  slowly. 
The  peculiar  shining,  glossy  state  of  the  skin  described  by  Paget  is  a  well- 
known  result  of  nerve-wounds.  Mitchell  speaks  of  excessive  growth  of  hair 
in  the  skin  to  which  the  injured  nerve  is  distributed.  Deformities  of  the 
nails  are  common.     They  are- frequently  clubbed,  and  have  marked  furrows 

1  Injuries  of  Nerves,  p.  92.  2  loc.  cit.,  p.  135. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  743 

and  ridges  upon  them.  In  many  cases  they  are  thin,  atrophied,  and  fragile. 
Loss  of  hair  sometimes  occurs  as  well  as  increased  growth  of  hair.  Some- 
times there  is  an  excess  of  perspiration,  which  may  also  be  acid  and  of 
disagreeable  odor. 

Changes  in  Nerves  after  Complete  Division.  When  the  nerve 
has  been  severed  there  occurs  within  a  short  time  degeneration  in  the  divided 
ends.  The  degenerative  changes  differ  materially  in  the  upper  and  lower 
ends  of  the  nerve.  The  alterations  which  take  place  in  the  lower  end  have 
been  well  understood  for  many  years,  but  it  has  only  been  within  the  past 
few  years  that  a  more  thorough  knowledge  of  the  changes  which  occur  in 
the  proximal  end  has  been  attained. 

On  examining  a  nerve  which  has  been  divided  it  is  found  that  at  the 
proximal  end  there  is  a  bulbous  enlargement,  a  neuroma,  which  varies  in  size 
according  to  the  length  of  time  after  injury  that  the  examination  is  made. 

At  the  lower  or  peripheral  end  there  is  only  slight  enlargement  with  flat- 
tening, and  sometimes,  instead  of  enlargement,  there  is  shrinkage  of  the  end 
of  the  nerve.  From  the  cases  which  I  have  seen  I  believe  that  there  is  gen- 
erally a  slight  enlargement  of  the  distal  end  up  to  a  year  after  the  injury. 
Many  experiments  have  been  made  upon  the  lower  animals  as  to  the  degen- 
erative processes  which  take  place  in  nerves  after  section,  but  most  writers 
are  agreed  that  the  results  of  experiments  upon  animals  cannot  be  altogether 
applied  to  man,  as  in  the  former  changes  of  degeneration  and  repair  take 
place  much  more  rapidly  than  in  human  beings.  However,  most  of  the  ex- 
aminations which  have  been  made  in  man  after  injuries  have  given  practi- 
cally the  same  results  as  those  experimentally  produced  in  animals.  Of  late 
years  so  many  opportunities  for  examinations  have  occurred  in  man  after 
accidents  and  injuries  that  sufiicient  data  have  been  obtained  for  reliable 
conclusions. 

The  degeneration  of  the  fibres  in  the  peripheral  end  begins  almost  immedi- 
ately after  section,  the  degeneration  taking  place  according  to  the  well- 
known  laws  established  by  Waller  in  1862.  From  the  fourth  to  the  sixth 
day,  according  to  Mitchell,^  there  begins  to  be  a  change  in  the  nerve-fibres. 
The  white  substance  of  Schwann  undergoes  irregular  segmentation,  then 
becomes  granular,  and  finally  disappears.  The  axis-cylinder  also  undergoes 
degeneration.  The  process  extends  through  the  whole  of  the  peripheral  end 
of  the  divided  nerve,  so  that  complete  degeneration  takes  place  through  its 
entire  extent. 

Changes  in  the  medullary  sheath  have  been  found  to  begin  as  early  as 
the  fifth  day,  and  by  the  twelfth  day  the  axis-cylinder  has  been  found  to 
have  disappeared.  Bowlby'^  mentions  two  cases  which  he  had  examined, 
one  fifteen  days  and  the  other  thirty  days  after  nerve-section,  when  opera- 
tions for  secondary  suture  were  undertaken.  In  the  case  of  the  nerve 
which  had  been  divided  fifteen  days  previously,  there  was  found  much 
segmentation  of  the  myelin  sheaths,  and  there  was  still  some  myelin  pres- 
ent, but  in  a  few  tubules  it  was  completely  absent.  The  nuclei  of  the 
sheaths  had  increased  in  number.  The  axis-cylinders  had  disappeared  in 
most  of  the  sections  which  he  examined.  In  the  case  of  longer  standing  all 
of  the  changes  were  more  pronounced.  Only  a  few  drops  of  myelin  remained, 
the  axis-cylinder  had  entirely  disappeared,  and  the  nuclei  in  the  sheaths 
were  slightly  more  increased.  In  a  case  which  the  same  author  examined 
three  months  after  section  no  nerve-tubules  could  be  discovered,  and  the 
spaces  formerly  occupied  by  nerve-bundles  were  filled  with  connective  tissue. 

Changes  in  the  Proximal  End.     The  fibres  of  the  central  end  undergo 

1  Injuries  of  Nerves.  ^  injuries  and  Diseases  of  the  Nerves,  p.  18. 


744  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

but  sliglit  changes  after  nem^e-section.  There  may  be  some  changes  extend- 
ing to  one,  or,  at  the  most,  two  of  the  internodal  segments,  according  to 
Ranvier,  who  says  that  the  myelin  instead  of  becoming  broken  into  large 
fragments  which  subsequently  become  smaller,  as  in  the  peripheral  end,  is 
rapidly  reduced  to  tine  granules,  the  nuclei  multiply  and  increase  in  size, 
but  the  axis-cylinders  remain  intact. 

The  bulbous  enlargement  at  the  proximate  end  was  formerly  regarded  as 
mainly  consisting  of  fibrous  tissue.  MitchelP  speaks  of  neuromata  of  stumps 
being  composed  of  fibrous  tissue,  with  a  layer  of  nerve-fibres  spread  over 
them.  Microscopic  examinations  of  these  bulbs  show  very  clearly  that  they 
consist  almost  exclusively  of  nerve-fibres.  There  is  also  an  increase  in  the 
connective-tissue  element,  with  some  infiltration  of  leucocytes.  Sections  of 
the  nerve  above  the  bulb  show  none  of  the  degenerative  changes  which  are 
met  wdth  in  the  peripheral  end.  In  cases  wdiich  are  examined  years  after 
the  injury  there  are  some  atrophy  and  degeneration  in  the  nerve-fibres. 
Bowlby  says  he  has  examined  the  nerves  from  limbs  in  which  amputation 
had  been  done  many  years  before,  and  he  found  that  in  them  many  of  the 
nerve-fibres  are  diminished  in  size,  with  the  myelin  sheath  greatly  shrunken. 

Regeneeatiox  and  Uxiox.  Regeneration  of  the  proximal  end  of  a 
divided  nerve  folloW'S  the  process  of  degeneration,  and  begins  frequently 
within  a  short  time  after  the  injury.  There  has  been  a  difierence  of  opinion 
among  pathologists  as  to  the  process  by  which  the  new  nerve-fibres  are 
formed,  some  believing  that  they  are  developed  from  the  nuclei  of  the  sheath, 
and  others,  among  them  Neumann  and  Ranvier,  holding  that  the  new  fibres 
are  formed  by  a  longitudinal  division  of  the  axis- cylinders,  which  split  up 
like  a  brush,  and  which  are  subsequently  covered  by  myelin.  The  gener- 
ally accepted  view  at  the  present  time  appears  to  be  that  the  new  fibres  de- 
velop in  the  nuclei  of  the  sheath  of  Schwann.  As  soon  as  the  new  fibres 
begin  to  form  they  bud  out  from  the  proximal  end  of  the  nerve  and  extend 
toward  the  peripheral  extremity.  Regeneration  also  takes  place  from  the 
peripheral  end,  beginning  at  a  later  period,  and  the  process  takes  place 
more  slowly.  After  a  time  the  ends  become  united.  If  union  does  not  take 
place  the  peripheral  extremity  again  undergoes  degeneration. 

The  length  of  time  which  is  required  for  union  to  take  place  varies  in  dif- 
ferent cases,  and  depends  to  a  great  degree  upon  the  width  of  the  space  be- 
tween the  ends  of  the  divided  nerve.  In  a  case  recorded  by  Mitchell,^  in 
which  the  musculo-sj)iral  nerve  was  excised  for  an  excessively  painful  neu- 
ritis, six  months  after  the  operation  evidences  of  regeneration  were  observed 
in  return  of  sensation  in  the  area  supplied  by  the  nerve.  Fifteen  months 
after  the  operation  muscular  power  had  been  restored  to  such  a  degree  that 
the  patient  could  extend  the  wrist,  and  a  year  later  the  functions  of  the 
whole  extensor  group  had  returned.  A  second  operation  was  performed 
about  two  and  a  half  years  after  the  first,  and  one  inch  of  regenerated  nerve- 
tissue  was  found.  In  another  case  reported  by  the  same  writer,  complete 
union  was  found  after  eighteen  months  in  one  of  the  digital  nerves,  of  which 
an  inch  had  been  excised ;  and  in  a  third  case  a  radial  nerve  was  united 
w^ithin  ten  months  of  excision  of  two  inches  of  its  trunk. 

We  have  frequent  evidences  of  degeneration  and  union  of  nerves  in  cases 
where  excision  has  been  performed  for  neuralgia,  and  even  wdiere  an  effoi't 
has  been  made  to  prevent  reunion  by  turning  back  the  proximal  end  of  the 
nerve,  recurrence  of  pain  in  the  distribution  of  the  nerve  has  followed  after 
a  year  or  two.  In  many  cases,  if  the  separation  between  the  two  ends  of  the 
nerve  is  only  slight,  union  takes  place  wdthin  a  few  days,  but  restoration  of 

1  Injuries  of  Nerves.  -  American  Journal  of  the  Medical  Sciences,  April,  1876. 


DISEASES  OF  THE  NERVES  IN  GENERAL.  745 

the  function  does  not  occur  until  some  weeks  later.  If  the  ends  of  a  divided 
nerve  are  immediately  brought  into  apposition  and  sutured,  union  generally 
takes  place,  and  in  some  cases,  if  the  suturing  has  been  done  within  a  short 
time  of  the  accident,  there  is  no  apparent  loss  of  function.  In  a  case  which 
I  saw,  in  which  the  sciatic  nerve  was  divided  in  the  popliteal  space  in  mis- 
take for  one  of  the  hamstring  muscles  in  an  operation  for  division  of  those 
tendons,  the  divided  ends  of  the  nerve  were  immediately  sutured,  and,  with 
the  exception  of  some  numbness  and  pain  in  the  foot  for  a  few  days,  there 
was  no  impairment  of  sensation  or  motion,  and  no  ill  effects  followed. 

Treatment  of  Wouxds  of  Xerves,  When  there  is  no  evidence  that 
the  nerve  has  been  completely  divided  the  treatment  of  an  injured  or  par- 
tially divided  nerve  should  be  on  the  same  principles  that  would  govern  the 
treatment  of  neuritis  from  any  other  cause.  The  limb  should  be  kept  abso- 
lutely at  rest,  and  the  wound  should  be  treated  on  the  strictest  antiseptic 
principles.  If  the  external  wound  has  healed  and  evidences  of  neuritis 
remain,  it  will  be  necessary  to  use  counter-irritation  and  maintain  the  part  at 
rest.  Should  severe  pain  be  experienced  in  the  nerve-trunk,  application  of 
ice-bags  will  frequently  afford  relief.  Should  we  have  reason  to  believe  that 
the  ner^^e  has  been  completely  divided,  it  is  imperative  to  immediately  bring 
the  severed  ends  into  apposition.  The  result  of  immediate  operation  in  such 
cases  is  generally  satisfactory,  and  occasionally,  though  in  rare  instances, 
there  is  union  by  first  intention.  Bowlby^  records  several  cases  in  which 
immediate  suturing  of  divided  nerves  was  made  with  excellent  results.  In 
one  case  the  patient  was  brought  into  the  hospital  a  fcAV  minutes  after  a 
lacerated  wound  of  the  wi'ist  by  glass  had  divided  the  median  nerve  in  two 
places,  so  that  nearly  an  inch  of  the  trunk  lay  loose  in  the  wound.  The  ends 
of  the  nerve  were  brought  into  apposition  and  sutured  with  catgut.  Ten 
days  after  the  operation  sensation  began  to  return,  and  eventually  there 
was  complete  restoration  of  motion  and  sensation. 

The  operation  of  suturing  is  considered  a  perfectly  safe  one,  provided 
thorough  cleanliness  is  observed.  Bowlby^  and  Willard^  say  that  aseptic 
catgut  or  sterilized  silk  sutures  should  be  used  in  bringing  the  ends  of  the 
nen^e  together.  AVillard  advises  that  two  sutures  should  be  used ;  one 
should  pass  directly  through  the  body  of  the  nerve,  and  a  second  at  right 
angles  to  the  first. 

XVillard  records  117  cases  of  primary  suture  in  which  the  nerves  united 
were  as  follows :  In  41  cases,  the  median  nerve ;  38,  the  ulnar  ;  30,  the  me- 
dian and  ulnar ;  3,  the  median,  ulnar,  and  radial ;  4,  the  radial ;  3,  the 
musculo-spiral ;  1,  the  sciatic;  1,  the  external  popliteal;  1,  the  posterior 
tibial;  1,  the  anterior  tibial.  The  degree  of  separation  varied  from  1  cm. 
to  5  cm. 

The  results  of  primary  suture  are  thoroughly  satisfactory.  Bowlby*  records 
the  results  of  primary  suture  in  81  cases,  as  follows : 

Successful 32 

Doubtfully  successful 12 

Partially  successful 22 

Failures 14 

Results  not  stated 1 

—    81 

The  details  of  the  operation  will  be  found  in  Chapter  XXXIII.  Several 
methods  have  been  suggested,  but  that  of  bringing  the  ends  in  apposition 
with  sutures  at  right  angles  is  apparently  the  most  desirable. 

Secondary  Suture.     If  the  nerve  has  been  divided  for  a  length  of  time, 

1  Loc.  cit.  -  Loc.  cit.  3  Med.  News,  October  6, 1894.  *  Loc.  cit. 


746  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

varying  from  several  months  to  several  years,  and  no  restoration  of  function 
has  occurred,  the  success  of  operation  is  uncertain ;  nevertheless,  a  number 
of  cases  have  been  recorded  in  which  excellent  results  have  been  obtained 
after  an  interval  of  many  months.  FavelP  records  a  case  in  which  the 
sciatic  nerve  was  cut  across  by  the  point  of  a  scythe.  Nine  montlis  after- 
ward the  nerve  was  exposed,  and  it  was  found  that  the  ends  were  an  inch 
and  a  half  apart,  the  upper  end  was  bulbous  and  the  lower  was  flattened, 
no  attempt  at  union  having  taken  place.  The  two  extremities  were  cut  off, 
and  by  traction  the  nerve  was  stretched  sufiiciently  to  unite  the  two  extrem- 
ities. Steady  improvement  took  place,  and  in  time  a  good  result  was 
obtained. 

In  the  cases  in  which  the  sej)aration  of  the  ends  of  a  divided  nerve  is  so 
great  that  they  cannot  be  brought  into  apposition,  the  operation  of  nerve- 
grafting  has  been  employed  with  more  or  less  success.  In  a  case  of  Tille- 
mann's  a  section  4  J  cms.  long  from  a  nerve  of  a  rabbit  was  inserted  in  the 
median  and  ulnar  nerves.  Sensation  returned  in  four  weeks,  and  motion  in 
nine.  In  a  case  reported  by  Robson,^  2  \  inches  of  a  posterior  tibial  nerve, 
which  was  obtained  from  a  fi'esh  amputation,  was  implanted  in  the  gap  in  a 
median  ner^^e  forty-eight  hours  after  division  by  injury.  Four  months  later 
sensation  was  almost  entirely  restored.  A  number  of  other  cases  have  been 
reported  in  which  nerve  transplantation  has  been  successfully  performed. 

►Secondary  suture  of  nerves  has  been  made  at  intervals,  varying  fi'om  sev- 
eral months  to  many  years  after  the  original  injury.  In  a  case  reported  by 
Marsh,  at  St.  Bartholomew's  Hospital,  he  united  the  ulnar  nerve  twelve  years 
after  the  injury,  and  decided  improvement  in  motion  and  sensation  took 
place.  As  a  rule,  however,  secondary  operations,  after  a  year,  are  not  prom- 
ising as  to  the  results. 

The  period  at  which  improvement  begins  after  operation  varies,  and  many 
circumstances  influence  the  rate  of  nerve-regeneration  ;  usually  improvement 
begins  to  show  itself  after  a  few  days  in  partial  return  of  sensation.  Motor 
gain  begins  later.  In  some  cases,  however,  there  is  no  marked  improvement 
seen  until  after  several  months  have  elapsed,  and  all  hope  of  improvement 
should  not  be  given  up  until  after  a  year. 

The  results  following  secondary  suture  given  by  Willard'^  in  130  cases  are 
as  follows : 

Total  number  of  cases  slightly  improved 10 

Greatly  improved  in  motion  and  sensation,  or  absolutely  cured       .  102 

Slightly  improved  or  not  improved  at  end  of  a  year      ....  15 

Death  resulting  from  hydatias 1 

With  such  results  as  these,  giving  80  j)er  cent,  of  improvement  by  opera- 
tion, we  should  feel  encouraged  to  operate  in  every  case,  no  matter  how  great 
an  interval  of  time  has  elapsed  after  the  injury. 

The  conditions  which  mainly  influence  recovery  from  secondary  suture  are 
the  general  state  and  habits  of  the  patient  and  the  season  of  the  year.  Res- 
toration is  more  rapid  and  perfect  in  young  subjects  than  in  old,  and  is  said 
to  be  more  raj)id  in  warm  weather  than  in  cold.*  Certain  nerves  unite  more 
readily  than  others ;  the  musculo-spiral,  for  instance,  seems  especially  prone 
to  unite  after  section.  In  patients  who  are  intemperate,  or  who  insist  upon 
using  the  member  in  which  nerve-suture  has  been  performed,  recovery  takes 
place  more  slowly,  and  there  is  greater  risk  of  failure.  The  use  of  electricity 
and  massage  is  of  great  importance  after  nerve-suture.  As  soon  as  the  ex- 
ternal wound  is  healed  a  mild  galvanic  current  should  be  apphed  to  the  para- 

i  Brit.  Med.  Journ.,  Aug.  5, 1876. 

2  Trans.  Clinical  Society,  London,  1889.  s  Loc.  cit. 

*  Mitchell:  "Injuries  of  Nerves,"  and  Bowlby,  loc.  cit. 


DISEASES  OF  THE  NERVES  IN  GENERAL. 


747 


lyzed  muscles,  and  in  three  or  four  weeks  it  is  well  to  begin  massage  to  the 
affected  limb.  It  is  necessary  to  avoid  active  massage  immediately  over  the 
wound,  but,  after  an  interval  of  six  weeks,  gentle  massage  may  be  applied 
directly  over  the  sutured  nerve.  The  faradic  current  should  be  substituted 
for  the  galvanic  as  soon  as  the  muscles  begin  to  respond  to  the  former.  The 
strength  of  the  current  should  never  be  greater  than  just  sutficient  to  cause 
decided  muscular  contractions,  and  the  application  should  not  be  too  long  at 
a  sitting,  but  it  is  important  that  there  should  be  a  treatment  at  least  every 
alternate  day  for  months. 

Injuries  of  Special  Xerves.  The  nerves  most  frequently  injured  are 
the  median,  ulnar,  radial,  musculo-spiral,  and  sciatic,  in  the  order  given. 

The  median  nerve  supj)lies  the  pronators  of  the  wrist,  the  flexor  carpi 
radialis,  the  suj)erficial  and  deep  flexors  of  the  fingers,  except  the  ulnar  half 
of  the  deep  flexor,  the  flexor  longus  pollicis  and  abductor  pollicis,  and  the 
two  radial  lumbricales.  It  also  supplies  the  skin  on  the  radial  side  of  the 
palm,  the  anterior  surface  of  the  thumb,  the  first  two  fingers  and  half  of  the 
third.  The  posterior  aspect  of  the  distal  phalanges  of  the  fore  and  middle 
fingers  are  also  supplied  by  this  nerve.  The  cutaneous  distribution  varies 
greatly  in  individuals ;  in  some  it  is  much  more  limited  than  in  others.  In 
some  cases  of  injury  of  the  median  nerve  there  is  but  little  loss  of  sensation  ; 


Fig.  241. 


Fig.  242. 


Showing  areas  of  sensory  loss  in  injuries  of  the  median  nerve.    (Bowlby.) 


but,  as  a  rule,  loss  of  sensation  on  the  palmar  surface  of  the  thumb  and  fore- 
finger is  complete,  and  on  the  same  surface  of  the  middle-finger  it  is  partial. 
The  patient  is  unable  to  flex  the  last  phalanges  of  the  thumb,  forefinger,  and 
middle-finger.  The  third  and  fourth  fingers  can  be  flexed  through  the  part 
of  the  flexor  profundus  which  is  supplied  by  the  ulnar  nerve,  and  flexion  of 
the  proximal  phalanges  of  the  fore-  and  middle-fingers  is  accomplished  by 
the  interossei.  In  some  cases,  however,  the  loss  of  power  of  flexion  is  con- 
fined to  the  thumb  and  forefinger.  The  patient  is  unable  to  abduct  the 
thumb,  and  it  remains  in  a  position  of  extension  and  adduction,  resembling, 
as  Gowers  remarks,  the  thumb  of  an  ape. 


748 


^^ERVOUS  DISEASES  AND  THEIR  TREATMENT. 


The  ulnar  nerve  supplies  the  flexor  carpi  uhiaris  and  the  inner  half  of  the 
flexor  profundus  digitorum,  the  muscles  of  the  little  finger,  the  interossei, 
some  of  the  lumbricales,  and  the  adductor  poUicis  and  inner  head  of  the  flexor 
brevis  polHcis.  The  sensory  distribution  of  the  ulnar  nerve  is  to  the  little 
finger  and  inner  half  of  the  third  finger.  After  division  of  the  ulnar  nerve 
there  is  distinct  anaesthesia  in  the  little  and  third  fingers,  both  on  the  palmar 
and  dorsal  surfaces,  but  more  markedly  upon  the  latter.  Adduction  of  the 
thumb  is  lost,  and  so  are  all  of  the  movements  of  the  little  finger.  None  of 
the  fingers  can  be  flexed  in  their  proximal  phalanges,  but  in  the  first  two 
fingei-s  the  loss  of  power  is  not  so  great,  because  the  median  nerve  sends 
branches  to  the  first  two  lumbricales.  Atrophy  takes  place  in  the  muscles, 
giving  rise  to  great  wasting  of  the  hypothenar  eminence,  the  palm  becomes 
hollow,  and  contraction  of  the  little  finger  occurs.  After  several  months 
have  elapsed  great  contraction  of  the  common  extensors  and  long  flexors 
of  the  flngers  and  thumbs  takes  place  in  consequence  of  the  paralysis  of  the 
lumbricales  and  interossei,  giving  rise  to  the  claw-like  hand. 


Fig.  243. 


Fig.  244. 


Showing  sensory  loss  in  injuries  of  the  ulnar  nerve.    (Bowlby.) 


The  radial  nerve  supplies  the  skin  on  the  radial  side  and  ball  of  the  thumb 
by  its  external  branch,  and  by  its  internal  branch  it  supplies  the  skin  on  the 
ulnar  side  of  the  thumb,  the  radial  side  of  the  index  finger  and  the  adjoining 
sides  of  the  index  and  middle  fingers,  and  also  the  adjacent  sides  of  the 
middle-  and  ring-fingers.  In  a  case  reported  by  Bowlby,  in  which  a  deep 
wound  on  the  back  of  the  radial  side  of  the  wrist  divided  the  radial  nerve, 
sensation  was  completely  lost  over  a  small  area,  including  the  back  of  the 
first  and  second  metacarpal  bones  of  the  thumb.  The  radial  nerve  gives  ofl 
no  muscular  branches. 

Division  of  the  mmeulo-spiral  nerve  gives  rise  to  characteristic  symptoms. 
This  nerve  supplies  the  extensor  muscles  of  the  fingers  and  wrist,  and  the 
supinators.  The  triceps  also  receive  branches  from  the  musculo-spiral ;  but,  as 
the  nerve  is  usually  injured  ne&v  the  middle  of  the  humerus,  the  branches  sup- 
plying these  muscles  escape.  There  is  little  or  no  anaesthesia  after  division  of 
this  nerve,  although  there  are  subjective  sensations  of  tingling  and  numbness 


DISEASES  OF  THE  NERVES  IN  GENERAL. 


749 


in  the  hand  and  fingers.  In  a  patient  in  whom  the  musculo-spiral  nerve  was 
divided  by  a  stab  there  was  an  area  of  lessened  sensation  on  the  back  of  the 
thumb.  The  paralysis  of  the  extensors  causes  the  typical  wrist-drop  and  loss 
of  power  of  extending  the  distal  phalanges  of  the  fingers  and  thumb.  There 
is  ability  to  extend  the  proximal  phalanges  which  are  supplied  by  the  inter- 
ossei  and  lumbricales.  The  patient  is  unable  to  flex  the  fingers  strongly  on 
account  of  the  loss  of  antagonism  of  the  extensors.  This  is  shown  when 
an  attempt  is  made  to  squeeze  the  djmamometer.  If  the  instrument  is  placed 
in  the  hand  and  the  patient  makes  an  eflTort  to  grasp  it,  the  wrist  is  flexed  and 
the  dynamometer  registers  only  a  few  degrees.  If  the  instrument  is  supported 
so  that  flexion  of  the  wrist  does  not  occur,  the  grasp  of  the  hand  shows  almost 
normal  strength.  There  is  marked  muscular  wasting  in  the  forearm.  It  is 
unusual  to  see  trophic  changes  after  division  of  this  nerve ;  but,  as  a  result 
of  the  overflexion  of  the  wrist  and  the  loss  of  support  by  the  extensor  tendons, 
there  is  frequently  a  prominence  of  the  back  of  the  hand,  due  to  an  enlarge- 
ment of  the  synovial  sacs,  giving  rise  to  a  characteristic  hump.  Although 
the  supinators  are  paralyzed,  the  patient  is  still  able  to  supinate  the  forearm 
by  the  aid  of  the  biceps  muscle. 

Fig.  245. 


Area  of  ansesthesia  from  division  of  sciatic  uerve. 

The  scirxtic  nerve  supplies  the  flexors  of  the  legs  and  all  of  the  muscles 
below  the  knee.  The  cutaneous  distribution  of  the  sciatic  nerve  is  to  the 
integument  of  nearly  the  whole  of  the  leg.  When  the  nerve  has  been 
divided  there  is  inability  to  flex  the  leg  and  to  flex  the  foot.  The  patient, 
however,  is  able  to  walk,  very  much  like  a  child  suffering  from  poliomyelitis, 
by  swinging  the  leg  around  so  as  to  make  the  toes  clear  the  ground,  and  by 
lifting  the  foot  by  the  aid  of  the  hip  muscles.  The  amount  of  anaesthesia 
met  with  after  division  of  the  sciatic  nerve  is  much  less  extensive  than  would 
be  supposed,  owing  to  the  distribution  of  the  small  sciatic,  the  long  saphenous, 
the  external,  middle,  and  internal  cutaneous  nerves.     There  seems  to   be 


750  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

great  want  of  accord  in  the  reports  of  different  writers  as  to  the  areas  of 
ansesthesia  after  division  of  the  sciatic.  Tlie  following  case  shows  quite  well 
the  area  of  anaesthesia  after  complete  division  of  the  ner\"e. 

John  B.  W.,  aged  nineteen  years,  ship  carpenter  by  occupation,  was  ad- 
mitted to  my  wards  at  the  Episcopal  Hospital,  Philadelphia,  April  26,  1877. 
On  December  25, 1876,  while  working  at  his  trade  of  sparmaking,  he  slipped 
and  fell  upon  an  adz,  receiving  a  severe  wound  in  the  upper  posterior  part 
of  his  left  thigh.  He  bled  pi'ofusely,  and  fainted.  About  a  week  after  the 
accident  he  began  to  feel  pain  in  the  back  of  the  feet  and  toes,  which  per- 
sisted for  nearly  two  months  and  then  disappeared.  About  a  month  after 
the  injury  small  vesicles  formed  upon  the  dorsum  of  the  toes,  which  gradually 
attained  the  size  of  a  three-cent  piece,  and,  after  breaking,  left  ulcers,  which 
healed  slowly.  The  original  wound  did  not  heal  for  about  four  weeks.  On 
admission  to  the  hospital  a  scar  three  inches  in  length  was  found  in  the  upper 
inner  posterior  surface  of  the  left  thigh  just  below  the  tuber  ischii.  There 
was  complete  loss  of  power  of  motion  below  the  knee.  The  left  calf  meas- 
ured 11  inches  in  circumference,  and  the  right  12?  inches.  A  shallow  ulcer 
li  inches  in  diameter  existed  over  the  external  malleolus,  and  there  was 
another  small  ulcer  on  the  anterior  portion  of  the  leg.  The  toe-nails  were 
marked  by  transverse  grooves  about  the  middle  of  each  nail.  The  muscles 
responded  to  a  very  strong  slowly  interrupted  faradic  current,  but  did  not 
respond  to  the  rapidly  interrupted  current.  The  galvanic  current  caused 
much  more  active  response  in  the  muscles  of  the  left  leg  than  in  those  of  the 
right.  The  accompanying  diagram,  made  by  Dr.  Robert  Meade  Smith,  the 
resident  physician,  shows  very  accurately  the  area  of  anaesthesia. 


NEURALGIA. 

Neuralgia  is  a  functional  disease  of  the  sensory  fibres  of  the  nerve-trunks, 
and  is  characterized  by  pain,  as  indicated  by  the  name.  This  definition  is 
not  as  universally  applicable  as  it  would  have  been  a  few  years  ago,  as  it  is 
now  recognized  that  certain  forms  of  neuralgia  are  due  to  neuritis ;  and  it 
is  a  cpiestion  as  to  whether  we  should  consider  any  form  of  neuralgia  as 
purely  functional,  as,  no  doubt,  during  the  attack  of  pain  there  are  distinct 
changes  in  the  nerve.  Neuralgias  are  either  idiopathic,  in  which  the  disease 
is  dependent  purely  upon  functional  disturbance,  or  symptomatic,  due  to 
some  organic  disease  affecting  the  neive,  such  as  a  tumor  or  toxic  influences. 
In  neuritis  we  have  an  example  of  a  symptomatic  neuralgia,  but  the  ordi- 
nary forms  of  neuralgia  in  which  the  pain  is  transient,  and  where  it  flies 
from  one  part  to  another,  the  symptoms  cannot  be  due  to  actual  organic 
changes. 

Neuralgias  are  classed  according  to  their  cause,  and  also  according  to  their 
location.  The  commonest  forms  of  neuralgia  are  :  trigeminal,  or  neuralgia  of 
fifth  nerve,  cervico-occipital,  brachial,  intercostal,  sciatic,  and  visceral.  Neu- 
ralgias may  depend  upon  some  toxic  cause,  as,  for  instance,  gout,  rheuma- 
tism, or  diabetes,  and  other  diseases  causing  dyscrasia.  The  most  common 
foi*m  of  neuralgia  is  that  affecting  the  fifth  nerve,  and  next  in  order  come 
sciatic  and  intercostal  neuralgias. 

Neuralgia  is  essentially  a  disease  of  adults ;  it  never  affects  young  chil- 
dren, except  in  the  form  of  migraine.  In  old  age  neuralgia  is  rare.  Women 
suffer  much  more  from  neuralgia  than  men,  in  the  proportion  of  five  to  three, 
according  to  Dana,^  who  made  an  analysis  of  887  cases.     More  cases  occur 

1  Diseases  of  the  Nervous  System,  p.  81. 


DISEASES  OF  THE  NERVES  IX  GENERAL.  751 

in  winter  and  autumn  than  in  warm  weather,  and  neuralg-ia  is  more  common 
in  damp  and  cold  climates  than  in  those  which  are  dry  and  temperate. 

Heredity  plays  a  decided  part  in  the  production  of  this  disease.  The 
gouty  and  rheumatic  diatheses  also  predispose  to  it.  Ansemia  is  one  of  the 
most  common  causes  of  neuralgia,  the  nerve-pain  in  these  cases  having  been 
termed  "  the  cry  of  the  nerve  for  more  blood."  In  some  cases  neuralgia 
seems  to  be  dependent  upon  reflex  irritation,  as  in  the  ca.se  of  caries  of  the 
teeth,  which  causes  neuralgia  of  the  fifth  nerve,  or  from  irritation  from  disease 
of  the  eye,  as  glaucoma,  in  which  the  ophthalmic  division  of  the  fifth  nerve 
is  the  seat  of  severe  pain.  Xeuralgias  are  recorded  as  being  produced  by 
reflex  irritation  in  various  organs,  as  the  ovaries,  stomach,  and  brain. 

The  pain  of  neuralgia  is  usually  sharp,  lancinating,  boring,  or  burning  in 
character,  or  it  may  be  merely  dull  and  gnawing.  In  certain  nei-ves  the 
pain  Ls  intensely  acute,  as,  for  example,  in  the  fifth  nerve,  where  it  seems  to 
dart  with  lightning-like  rapidity  into  every  filament.  The  pain  of  neuralgia 
is  not  steady,  but  is  intermittent  and  paroxysmal.  Sometimes  between  the 
paroxysms  a  dull  ache  remains.  The  pain  is  increased  by  cold  and  some- 
times by  pressure  on  the  aflfected  part,  although  often  this  relieves  it.  In 
some  cases  the  skin  in  the  distribution  of  the  affected  ner\^e  is  excessively 
tender.  The  inter^'als  between  the  paroxysms  of  pain  are  greater  or  less  in 
length,  sometimes  being  only  a  few  minutes,  and  in  other  cases  hours  inter- 
vene between  the  attacks.  Frequently  the  paroxysms  recur  at  the  same 
hour  of  the  day,  giving  rise  in  many  cases  to  the  suspicion  that  the  disease 
is  malarial.  In  sciatic  neuralgia  the  most  common  time  of  the  day  for  the 
attack  of  pain  is  about  6  p.  m.  An  attack  of  neuralgia  may  last  only  a  few 
days  or  it  may  continue  for  years,  with  but  brief  periods  of  relief.  The  pain 
in  neuralgia  is  sometimes  of  such  an  explosive  character  as  to  give  rise  to  the 
name  of  epileptiform  neuralgia,  as  seen  in  tic  douloureux. 

Xeuralgias  are  sometimes  met  with  in  neurasthenic  and  hysterical  jDatients, 
in  whom  a  painful  impression  remains  after  the  true  paroxysm  has  passed 
away.  In  patients  who  are  addicted  to  morphine,  this  form  of  "  reminiscent" 
or  "  hallucinatory  "  neuralgia  Ls  frequently  seen,  and  the  pain  seems  to  be 
due  to  the  craving  of  the  patient  for  the  narcotic. 

Pathology.  In  many  cases  of  neuralgia  there  is  neuritis  to  a  greater  or 
less  extent.  This  is  especially  the  case  in  sciatica  and  in  neui'algias  of  the 
b]"achial  plexus.  In  cases  of  neuralgia  of  the  fifth  nerve  of  long  standing 
there  Ls  almost  always  found  an  inflammatory  condition  of  the  nerve-trunk  ; 
even  in  short  attacks  of  neuralgia,  as  in  the  supra-orbital  nerve,  where  the 
attack  is  of  but  a  few  hours'  duration,  the  nerve  can  be  felt  swollen  under 
the  finger  in  the  supra-orbital  notch.  In  some  cases  neuralgia  seems  to  be 
due  to  some  irritant  poison  in  the  blood,  as  in  gout,  rheumatism,  or  diabetes, 
and  in  other  cases  to  some  of  the  metallic  poisons,  like  lead,  arsenic,  and 
mercury.  There  are  other  cases  in  which  no  diathetic  or  local  cause  can  be 
traced,  and  in  these  it  is  supposed  that  the  pathogenic  focus  is  in  the  spinal 
ganglia  or  in  the  sensory  cells  of  the  posterior  horns  of  the  cord.  This, 
however,  is  not  an  explanation  of  the  cause,  as  we  do  not  know  what  is  the 
condition  of  the  cells  in  the  spinal  cord  or  the  sj^inal  ganglia  which  produces 
the  attack  of  neuralgia. 

Diagnosis.  The  diagnosis  between  neuralgia  and  neuritis  depends  on  the 
fact  that  in  the  former  the  pains  are  paroxysmal  and  shift  from  one  point  to 
another,  taking  the  course  of  the  nerves  in  some  cases,  and  in  others  flying 
from  one  nerve  to  another.  In  neuralgia  there  is  no  anaesthesia  in  the 
distril)ution  of  the  nerve-trunks,  and  motor  paralysis  does  not  occur.  (See 
Chapter  XXVII.  for  detailed  consideration  of  treatment.) 


CHAPTER  XXYI. 

DISEASES  OF  THE  CRANIAL  NERVES. 

By  GEORGE  E.  de  SCHWEINITZ,  M.D. 

DISEASES   OF   THE    OPTIC,    OCULOMOTOR,   PATHETIC 
AND   ABDUCENS   NERVES. 

The  nerves  designated  in  the  title  represent  two  of  the  four  groups  into 
which,  according  to  their  physiological  actions,  it  is  customary  to  divide  the 
cranial  nerves.  Their  intimate  association  with  the  comjDlex  problems  of 
intra-cranial  physiology,  as  well  as  their  anatomical  relations  to  the  struc- 
tures at  the  base  of  the  brain,  and,  through  their  nuclei  and  centres  of  origin, 
with  its  deeper  tissues,  render  changes  at  the  intra-ocular  end  of  the  optic 
nerve,  disturbances  of  the  equilibrium  of  the  external  ocular  muscles,  and 
anomalies  of  the  pupillary  reflex  of  the  utmost  importance  in  the  study  of 
many  problems  of  nervous  disease. 

DISEASES  OF  THE  OPTIC  NERVE. 

Normal  Relations.  The  optic  nerves,  second  in  the  list  of  nerves  of  special 
sense,  arise  from  the  anterior  part  of  the  commissure,  pass  through  the  optic 
foramina,  traverse  the  orbits,  and  enter  the  sclerotic  and  choroid  coats  to 
expand  in  the  retinas.  Each  nerve  is  invested  with  an  inner  (pial)  and  an 
outer  (arachnoid-dural)  sheath,  between  which  is  a  space — the  inter-vaginal 
space — which  is  derived  from  the  subdural  and  subarachnoid  spaces. 

The  optic  nerve  is  usually  regarded  as  exclusively  concerned  with  the 
sense  of  sight,  but  it  also  contains  the  afferent  fibres  of  the  pupil-reflex, 
which,  according  to  von  Gudden,  may  be  histologically  differentiated  from 
those  which  are  designed  for  vision.  The  total  number  of  fibres  in  the  optic 
nerve  has  been  estimated  at  400,000. 

The  smallest  branch  of  the  ophthalmic  artery,  arising  from  the  cavernous 
portion  of  the  internal  carotid,  is  the  central  artery  of  the  retina,  which 
pierces  the  optic  nerve  obliquely  and  reaches  the  retina,  upon  which  its 
branches  are  distributed.  It  is  accompanied  by  a  vein  which  collects  the 
blood  from  the  retinal  veins  and  empties  into  the  ophthalmic  vein,  which,  in 
its  turn,  pours  its  blood  into  the  cavernous  sinus.  There  is  free  anastomosis 
between  the  ophthalmic  vein  and  the  branches  of  the  facial  vein. 

Visual  Path.^  The  deeper  relations  of  the  oj)tic  nerves  are  best  appre- 
ciated by  tracing  the  visual  pathway.  The  peripheral  percipient  elements 
are  the  rods  and  cones  of  the  retina,  and  the  macular  fibres,  constituting 
about  one-fourth  of  the  nerve,  enter  the  papilla  at  its  infero-temporal  side, 

1  According  to  Noyes :  N.  Y.  Med.   Record,  April  4,  1891,  and  Wilbrand  ;  Die  Hemianopischen 
Gesichtsfeld-Formen  und  das  optische  Wahrnehmungszentrum. 


DISEASES  OF  THE  CRANIAL  NERVES.  753 

forming  the  so-called  papillo-macidar  bundle  Avhich  gradually  approaches 
the  axis  of  the  optic  nerve,  reaching  it  in  the  optical  canal.  In  the  front  of 
the  chiasm  it  occupies  the  upper  and  inner  portion,  being  divided  into  cross- 
ing and  direct  fibres,  but  in  the  tractus  it  sinks  to  the  central  portion  and 
passes  along  the  tract  on  its  way  to  the  cortex  in  the  cuneal  region. 

The  remaining  fibres  (intermedianj  and  peripheral)  are  so  arranged  that 
the  remaining  right  temporal  and  all  of  the  left  nasal,  on  the  one  hand,  and 
the  remaining  left  temporal  and  all  of  the  right  nasal  on  the  other,  by  com- 
mingling in  the  chiasm,  join  respectively  at  the  beginning  of  each  optic 
tract  and  proceed,  the  one  set  to  the  right  and  the  other  to  the  left  cuneus. 

The  chiasm  is  the  flattened  body,  resting  upon  the  sphenoid,  in  which  the 
fibres  undergo  a  semi-decussatiou,'  and  which  lies  betAveen  the  optic  nerves 
and  their  continuations — the  optic  tracts.  Each  tract  winds  around  the  cor- 
responding cms  cerebri  and  terminates  in  two  roots  upon  the  corpora  genicu- 
lata  externa  and  interna,  and  upon  the  posterior  part  of  the  opMc  thalamus, 
called  the  pulvinar.  Fibres  also  go  to  the  anterior  part  of  the  corpora  quad- 
rigemina ;  but  these  organs  are  not  regarded  as  concerned  in  vision,  but  in  the 
activity  of  the  pupil.  The  parts  just  referred  to  are  called  the  primary  visual 
ganglia  or  primary  optic  centres. 

In  them  are  found  innumerable  ganglion  cells  in  which  the  fibres  of  the 
tractus  lose  themselves,  and  thereafter  a  new  set  of  fibres  proceeds  backward 
through  the  posterior  part  of  the  internal  capsule  to  the  cortex,  under  the 
name  of  the  visual  radiation,  or  fibres  of  Gratiolet  or  of  Wernicke.  Passing 
through  the  internal  capsule  they  cross  the  sensitive  fibres  coming  down  from 
the  hemisphere,  and  then,  spreading  out  like  a  fan,  rise  upward,  wind  outside 
the  tip  of  the  lateral  ventricle  to  reach  their  destination  at  the  lower  part  of 
the  median  surface  of  the  occipital  lobe.     (See  Fig.  136,  p.  491.) 

Hyperemia  of  the  Optic  Nerve  ;   Congestion. 

Etiology,  (a)  Refractive  error,  especiallj^  hypermetropia  and  hyperme- 
tropic astigmatism. 

(b)  Occupations  which  expose  their  subjects  to  intense  glare  and  heat. 

(c)  Toxic  agents,  for  example,  tobacco,  alcohol,  and  lead. 

(d)  Diseases  of  the  eye,  e.  g.,  inflammation  of  the  iris. 

(e)  Disorders  of  the  brain  and  spinal  cord,  the  former  including  various 
types  of  insanity  and  general  paralysis  of  the  insane,  and  the  latter  chronic 
lesions  of  the  posterior  columns  of  the  spinal  cord,  particularly  locomotor 
ataxia.  In  mania  Albutt  has  found  the  disks  hypersemic  and  sometimes  pale  ; 
Noyes  has  observed  both  ansemia  and  hypersemia,  but  in  only  one  case  could 
Gowers  distinctly  determine  a  pathological  congestion.  Melancholia  is 
usually  unassociated  with  ophthalmoscopic  changes,  although  hypersemia  has 
been  recorded.  In  chronic  dementia  Allbutt  noted  changes  twenty-three 
times  out  of  thirty-eight — sometimes  atrophy  and  sometimes  hypergemia. 
Lautenbach^  examined  707  insane  patients,  including  mania,  dementia,  melan- 
cholia, and  other  cases  not  exclusive  of  epilepsy,  and  records  frequent  retinal 
hyperaemia  and  congestion,  amounting  to  40  per  cent,  in  the  acute  cases. 
There  is,  however,  no  fundus-lesion  characteristic  of  insanity. 

In  general  paralysis  of  the  insane,  hyperjemia  has  also  been  observed  by 
UhthoflT  and  Growers,  while  Albutt  believes  that  the  atrophy  is  ushered  in  by 
a  stage  of  hypersemia,  and  he  has  made  a  similar  observation  in  locomotor 
ataxia.  In  cases  examined  by  the  author  no  true  congestion  of  the  disk  has 
been  observed,  although  not  infrequently  there  is  a  dull  red  appearance,  with 
marked  grayness  of  the  deeper  layers,  folloAved  later  by  undue  broadening 

1  This  semi-decussation  is  denied  by  some  observers. 

-  Ophthalmic  Studies  of  Acute  Mania,  Journal  of  Nervous  and  Mental  Disease,  1886,  vol.  xiii.  p.  337. 

48 


754  NERVOUS  DISEASES  AND  THEIR  TREAT2IENT. 

of  tlie  scleral  ring  and  ultimately  by  atrophy  of  the  nerve.  Focal  brain  lesion 
may  be  accomi^anied  by  hyperaemia,  for  example,  cerebral  embolism  associ- 
ated with  secondary  brain  irritation.^ 

(/)  Heart  disease,  violent  cough,  etc.,  or  any  cause  which  produces 
engorgement  of  the  veins  of  the  head  and  neck,  for  example,  convulsive  seiz- 
ures, may  occasion  retinal  h^-perseniia.  It  is  not  uncommon  to  find  conges- 
tion of  the  nerve-tip  and  undue  fulness  of  the  venous  retinal  circulation  in 
general  epilepsy,  but  nothing  characteristic  of  the  disease  is  visible  in  the 
fundus  oculi,  and  even  the  hypersemia  which  has  been  described  may  not 
always  be  due  to  the  disease  in  which  it  occurs.  In  epilepsy  of  sufiicient 
moment  and  standing,  however,  Oliver-  considers  low  and  chronic  forms  of 
retinitis  associated  with  a  dirty  red-gray  incipient  degeneration  of  the  optic 
disk  to  constitute  the  type  of  ophthalmoscopic  findings. 

The  difiiculty  of  deciding  whether  congestion  of  the  nerve-tip  or  retina  is 
caused  by  a  cerebral  condition  depends  upon  the  fact,  as  Gowers  has  ex- 
pressed it,  that  increased  vascularity  of  the  paj)illa  is  not  an  index  of  hyper- 
gemia  of  the  cerebral  vessels,  and  hyperaemia  of  the  retina  is  inferred  by 
the  undue  redness  of  the  disk,  rather  than  by  an  altered  appearance  of  the 
membrane  itself,  although  we  may  speak  of  a  hyperaemia  of  the  central  ves- 
sels, meaning,  if  it  is  active,  that  the  arteries  are  distended,  tortuous  or 
lengthened ;  if  it  is  passive,  that  the  veins  are  large,  twisted,  and  filled  with 
dark  blood. 

Symptomatology,  (a)  General  Considerations.  In  order  to  appreciate 
morbid  changes  at  the  intra-ocular  end  of  the  optic  nerve,  familiarity  ^-ith 
its  natural  condition  is  necessary. 

Normal  Fu^-Dus  Oculi.  When  viewed  with  the  ophthalmoscope  the  optic 
nerve  appears  as  a  nearly  round  or  slightly  oval  disk,  with  distinct  margins, 
especially  on  the  temporal  side,  varying  in  color  from  a  grayish  pink  to  more 
decided  red,  the  tint  being  most  marked  upon  the  nasal  side.  The  centre  is 
occupied  by  a  whiter  patch,  marking  the  position  of  the  emergence  and  en- 
trance of  the  retinal  bloodvessels,  or  by  an  actual  excavation  shelving  toward 
the  temporal  border  {the  physiological  cup).  The  dLsk  is  surrounded  by  two 
rings :  the  outer,  often  incomplete  and  frequently  wanting,  is  dark-colored, 
and  represents  the  margins  of  the  choroidal  opening  through  which  the  nerve 
passes  (hence  the  choroid  ring),  the  other  a  faintly  marked  whitish  circle, 
indicates  the  rim  of  the  sclerotic  coat  (hence  the  scleral  ring)."  From  the 
central  spot  the  principal  retinal  arteries  emerge,  and  into  it  the  chief  ven- 
ous trunks  empty.  The  arteries  divide  dichotomously,  and  usually  spring 
from  one  stem,  which  separates  into  two  principal  divisions,  which  sj^read 
over  the  retina  and  are  accompanied  by  the  veins  which  pass  in  the  same 
general  direction.  The  veins  are  larger  than  the  arteries  in  the  proportion 
of  three  to  two,  and  dark  red  in  color  ;  the  arteries  assume  the  natural  blood 
red  tint,  formally  the  arteries  do  not  pulsate,  but  spontaneous  pulsation  in 
the  veins  is  frequent.*     (Fig.  1,  Plate  V.)   . 

(b)  Ophthalmoscopic  Appearances  of  Congestion.  Mere  redness  of  the 
intra-ocular  end  of  the  optic  nerve  is  not  congestion.  This  term  is  appli- 
cable only,  according  to  Gowers,  when  the  color  of  the  disk  is  dull  red  or 
brick-dust,  when  it  is  diflacult  to  diiferentiate  the  margin  from  the  general 
red  color  of  the  eyeground,  when  one  eye  is  more  affected  than  the  other,  so 
that  the  second  may  be  taken  as  a  point  of  comparison,  and  especially  when 

1  Consult  Gowers's  Medical  Ophthalmoscopy,  second  edition,  p.  46. 

-  Universitv  Medical  Magazine,  March,  1894. 

a  Called  bvLoring  the  "  connective  tissue  ring." 

■»  Lang  and  Barrett  found  venous  pulse  in  73.S  per  cent,  of  the  cases  examined,  and  the  author  in 
62.1  per  cent.,  and  Dr.  Veasey,  one  of  his  assistants,  in  58.3  per  cent.,  making  a  general  average  of 
61.7  per  cent. 


PLATE  V, 


Fiq.    I, 


NonT[al   eye-ground   (average  tiqt).      (Norris   &  Oliver.) 

Fiq,    2. 


Opl-ithalmoscopic    appearances   in    early    stage   of    papillitis. 
(Norris  &.  Oliver.) 


DISEASES  OF  THE  CRANIAL  NERVES.  755 

previous  ophthalmoscopic  examination  has  demonstrated  that  the  color  is 
now  an  unnatural  one.  The  disk  is  not  swollen  and  the  borders  are  not 
hidden,  but  obscured,  and  there  are  no  hemorrhages.  There  may  be  a  dis- 
proportion between  the  size  of  the  veins,  which  are  unduly  dark  and  tortu- 
ous (the  normal  proportion  being  as  3  to  2),  and  the  arteries,  remembering 
that  the  diameter  of  the  veins  is  much  more  frequently  increased  than  that 
of  the  arteries,  while  it  is  more  common  to  find  small  arteries  than  those 
which  are  distended.  ^STormally,  the  veins  are  slightly  tortuous  in  many 
eyegrounds ;  but  in  cases  of  true  hypereemia,  or  rather,  exaggerated  filling  of 
the  central  vascular  system,  this  becomes  a  marked  feature.  It  is  often  diffi- 
cult to  interpret  the  significance  of  hypersemia,  and  much  undue  prominence 
has  been  ascril^ed  to  hypereemic  nerve-heads  in  connection  with  cerebral 
symjDtoms  when  their  existence  was  but  a  coincidence. 

Prognosis.  The  prognosis  depends  entirely  upon  the  cause.  If  it  is 
removable,  the  intra-ocular  health  may  be  restored  to  normal.  Lautenbach 
beheves  that  congestion  itself  may  be  utilized  as  a  prognostic  point  in  acute 
manias  as  compared  with  more  serious  lesions.  Thus,  h}"pereemia  which 
tends  to  disappear  occurs  in  cases  which  recover ;  hypereemia  which  goes  on 
to  neuritis  and  subsequent  atrophy  is  seen  in  those  which  do  not  recover. 

Treatment.  This,  independently  of  those  cases  which  belong  strictly  to 
ophthalmic  work,  Ls  the  same  as  that  indicated  for  the  case  in  which  the 
symptom  occurs.  Rest  for  the  eyes  should  be  prescribed,  and,  although 
rarely  accompanied  with  subjective  symptoms,  if  there  should  be  dread  of 
light,  tinted  glasses  Avould  be  indicated,  and,  internally,  bromide  of  potas- 
sium and  ergot. 

Optic  ^K^euritis.  This  may  be  divided  into  those  cases  exhibiting  dis- 
tinct lesions  at  the  intra-ocular  end  of  the  nerve  {intra-ocular  optic  neuritis'), 
and  into  those  unassociated  with  such  lesions,  or  at  most  ajDparent  only  in  an 
indistinct  manner  (orbited  optic  neuritis). 

Varieties  of  Intra-ocular  Optic  Neuritis.  Various  types  of  inflammation, 
either  with  or  without  the  appearances  of  engorgement,  are  seen  at  the  intra- 
ocular end  of  the  optic  nerve.  Systematic  writers  in  former  davs,  and  occasion- 
ally at  the  present  time,  describe  two  chief  types,  called  respectivly  choked  disk 
(Stauung's  papille),  and  descending  neuritis  (interstitial  neuritis),  to  Avhich  a 
third  is  sometimes  added,  namely,  neuro-retinitis.  To  avoid  conflision  in 
nomenclature,  and  at  the  same  time  to  escape  unproven  theories  in  pathol- 
ogy, Leber  proposed  the  general  term  papillitis,  and  this  word  will  be  used 
in  the  following  pages  to  describe  the  various  tjpea  of  optic  neuritis  which 
chiefly  manifest  themselves  to  the  ophthalmoscope  at  the  nerve-tij). 

Theories  Concerning  the  Mechanism  of  Papjillitis.  As  is  well-known,  Von 
Graefe  at  one  time  sharply  distinguished  between  descending  neuritis  and 
so-called  choked  disk.  The  former,  as  its  name  implies,  indicated  a  descent 
of  inflammation  from  the  seat  of  disease  along  the  optic  nerve,  which  then 
became  manifest  at  the  intra-ocular  tip.  The  latter  was  reserved  for  a 
condition  which  was  supposed  to  indicate,  by  its  appearance,  engorgement, 
oedema  and  mechanical  obstruction,  and  to  rejDresent  a  mechanism  and 
pathology  quite  different  from  that  ascribed  to  the  former.  Inasmuch  as 
ophthalmoscopically  it  is  frequently  impossible  to  tell  one  from  the  other, 
and  as  the  conditions  may  be  mixed,  it  is  wise  to  coincide  with  the  opinion 
of  Hughliugs  Jackson,  that  there  is  one  kind  of  optic  neuritis  from  intra- 
cranial disease  which  may  manifest  itself  under  difierent  appearances,  some- 
times with  and  sometimes  without  "  swelling  of  the  disk."  The  following- 
are  the  most  important  theories  of  the  mechanism  of  papillitis : 

(a)  The  Back  Water  Theory,  propounded  by  Von  Graefe,  taught  that 
through  increased  intx-a-cranial  pressure  there  was  compression  upon  the  cav- 


756  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ernous  sinus,  which  induced  venous  congestion  in  the  central  vessel  of  the 
optic  nerve,  because  the  passage  of  blood  returning  from  the  eye  was  hin- 
dered, and  that  this  congestion  was  increased  by  the  rigid  scleral  ring  which 
acted  as  a  multiplier.  This  theory  ceased  to  be  tenable  when  Sesemann 
demonstrated  the  anastamosis  between  the  ophthalmic  vein  and  the  anterior 
facial  vein.     (See  Fig.  79,  p.  367.) 

(6)  The  Lymph-space  Theory  arose  after  the  demonstration  by  Schwalbe 
and  Retzius  of  the  lymphatic  circulation  of  the  eyeball  and  the  communica- 
tion between  the  subarachnoid  space  and  the  inter-vaginal  sheath  of  the  optic 
nerve.  First  Schmidt-Rimpler,  and  later  Manz,  ascribed  to  the  dropsy  of 
the  inter-sheath  space  of  the  optic  nerve,  which  is  caused  by  the  increased 
subarachnoid  fluid  being  forced  into  this  situation  under  the  influence  of 
elevated  intra-crauial  pressure,  a  mechanical  or  compressing  action,  or  to 
the  fluid  which  found  its  way  into  the  lymphatic  spaces  of  the  optic  disk, 
an  action  causing  oedema,  congestion  and  inflammatory  symptoms. 

(c)  The  Vasomotor  Theory  was  first  suggested  by  Schneller,  and  has  been 
advocated  by  Benedict  and  Hughlings  Jackson.  To  use  Jackson's  words,^ 
"  Optic  neuritis  may  be  a  doubly  indirect  result  of  local  gross  organic 
disease ;  that  first  there  are  changes  of  instabihty  about  the  tumor ;  that 
next  these  lead  on  to  discharges,  by  intermediation  of  vasomotor  nerves,  to 
repeated  contractions,  with  subsequent  paralyses,  of  vessels  of  the  optic 
nerves  or  centres,  and  thus,  at  length,  to  that  trouble  of  nutrition  which  is 
optic  neuritis."  This  hypothesis  has  few  followers  on  account  of  the  lack 
of  anatomical  demonstration  of  the  possibility  of  such  a  mechanism. 

(d)  The  Inflammatory  Theory,  with  various  modifications,  assumes,  as 
Leber  suggested,  and  Deutschmann  afterward  experimentally  showed,  that 
papillitis  was  not  a  product  of  oedema,  but  an  inflammatory  afiection,  the 
fluid  which  distends  the  sheath  of  the  nerve  possessing  an  irritative  quality ; 
or,  in  other  words,  that  the  subarachnoid  fluid  is  infected  by  products  from 
the  intra-cranial  disease  or  lesion  which  is  the  prime  cause  of  the  trouble. 
Microscopic  investigation  has  shown  that  not  only  in  basilar  meningitis  may 
an  inflammation  be  traced  from  the  source  of  the  disease  to  the  intra-ocular 
end  of  the  nerve,  but  also  in  many  cases  of  tumor,  the  focus  of  inflamma- 
tion being,  perhaps,  a  localized  meningitis  or  a  surrounding  cerebritis.  Dr. 
Gowers  points  out  the  frequenc}''  of  such  direct  inflammatory  connection, 
while  he  does  not  deny  the  well-known  ophthalmoscopic  appearances  of  me- 
chanical congestion,  or  swelling  of  the  disk,  which  have  given  rise  to  so 
much  confiision  in  nomenclature.  He  further  states,  papillitis  may  continue 
slight  and  without  such  appearances  throughout  the  course  of  its  existence, 
or  they  may  arise  for  reasons  not  now  definitely  known,  but  not  on  account 
of  a  compression  by  the  scleral  ring,  but  from  the  deposition  of  inflamma- 
matory  products  within  the  inflamed  nerve-head.  The  intensity  of  the  pro- 
cess may  also  be  added  to  by  the  distention  of  the  nerve-sheath,  and  per- 
haps, although  not  yet  proven,  by  the  admission  of  the  cerebro-spinal  fluid, 
possessing  an  irritative  quality,  within  the  lymph  spaces  of  the  papilla. 
This,  in  the  author's  opinion,  best  describes,  so  far  as  our  knowledge  goes, 
the  mechanism  of  optic  neuritis,  and  corresponds  with  numerous  micro- 
scopical investigations  which  he  has  had  the  privilege  of  making. 

Elsching,^  in  a  research  based  upon  the  post-mortem  results  of  fifty-five 
cases  of  intra-cranial  disease,  shows  that  the  ophthalmoscopic  picture  to  which 
the  term  "choked  disk"  is  applicable  is  indicative  of  an  inflammation  of  the 
optic  papilla  characterized  by  a  high  degree  of  swelling  of  all  tissues  of  the 

1  Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  i.  p.  89. 

2  Wien.  klin.  Wochenschrift,  December  20,  1894. 


DISEASES  OF  THE  CRANIAL  NERVES. 


757 


papilla.  In  no  case  are  well-marked  evidences  of  inflammation  wanting, 
and  similar  changes  are  found  in  the  trunks  of  the  nerves. 

Etiology.  The  most  usual  intra-cranial  cause  of  papillitis  is  tumor  of  the 
brain.  According  to  the  statistics  of  Annuske'  and  Reich^,  88  cases  of  intra- 
cranial and,  for  the  most  part,  brain  tumors  were  accompanied  in  95.4  per 
cent,  with  optic  neuritis  or  neuritic  atrophy,  in  93.2  per  cent,  with  double 
optic  neuritis,  and  in  2.2  per  cent,  with  monocular  optic  neuritis.  In  4.5 
per  cent,  ophthalmoscopic  changes  were  absent.  Oppenheim^  found  that  in 
82  per  cent,  of  his  23  cases  there  was  neuritis  of  one  or  both  sides,  and  accepts 
Annuske's  views  as  to  the  frequency  of  papillitis.  Gowers  believes  that  optic 
neuritis  is  present  in  |-  or  80  per  cent,  of  all  cases  of  cerebral  tumor. 

A  very  important  analysis  by  Edmunds  and  Lawford,*  of  cases  of  intra- 
cranial tumor,  throws  light,  not  only  upon  the  frequency  of  optic  neuritis, 
but  upon  its  relative  frequency,  according  to  the  situations  of  the  neoplasms. 
(See  table.) 


Locality  of  Tumor. 


1.  Anterior  frontal  convolutions 

2.  Motor  convolutions 

3.  Occipital  lobes 

4.  In  hemispheres 

5.  Ganglia  at  base 

6.  Tempero-sphenoidal  lobes 

7.  Cerebellum 

8.  Medulla  and  pons 

9.  Meningeal  growths  at  motor  convolutions 
10.  Meningeal  growths  elsewhere 


Total 


Optic 

No  optic 

Total. 

Per  cent, 
of  ODtic 
neuritis. 

Per  cent, 
without 

neuritis. 

neuritis. 

optic 
neuritis. 

8 

2 

10 

80 

20 

12 

12 

100 

5 

4 

9 

55.5 

44.5 

6 

4 

10 

60 

4') 

17 

3 

20 

85 

15 

1 

2 

3 

33.3 

66.6 

20 

3 

23 

86.9 

13.1 

3 

6 

9 

33.3 

66.6 

4 

1 

65 

80 

20 

4 

2 

6 

66.6 

33.3 

68 

39 

107 

From  this  analysis  these  authors  point  to  the  comparative  immunity  from 
optic  neuritis  of  the  cases  of  tumor  in  the  cortical  motor  area,  and  the  fre- 
quency and  severity  of  papillitis  in  cerebellar  tumors.  If  all  cases  toward 
the  convexity  of  the  brain  (groups  1,  2,  3,  4,  and  9)  be  added  together,  there 
is  a  yield  of  50  per  cent,  of  optic  neuritis,  while  those  toward  the  base  (groups 
5,  G,  7,  8,  and  10)  constitute  61  cases,  with  a  percentage  of  74  of  optic  neu- 
ritis. Hence  it  may  be  safely  stated,  on  the  basis  of  these  statistics,  as 
Gowers  declares  that  fully  80  per  cent,  of  cases  of  intra-cranial  tumor  at 
one  time  or  another  of  their  existence  develop  optic  neuritis.^  Perhaps  this 
percentage  would  rise  even  higher  if  investigations  were  more  thorough  and 
frequently  repeated,  because  a  tumor  may  exist  for  a  long  time  without  caus- 
ing papillitis,  but  later  this  symptom  appears.  Growths  in  two  regions  of 
the  brain  seldom  produce  papillitis,  namely,  the  medulla,  and,  according  to 
Rath,®  the  hypophysis.  True,  tumors  involving  the  medulla  and  pons  may 
have  this  association,  but  when  the  growth  is  strictly  localized  in  the  me- 
dulla, optic  neuritis,  if  it  occurs  at  all,  must  be  extremely  rare. 

Of  the  four  varieties  of  meningitis — simple,  tubercular,  traumatic,  and 


1  Archiv.  f.  Ophthalmologic,  1873,  Bd,  sis.  Abth,  iii.  p.  165. 

-  Monatsbl.  f.  klin.  Augenheilk.,  Jahrgang  xii.  p  274. 

3  Quoted  by  Philip  Coombs  Knapp  :  "  Pathology,  Diagnosis,  and  Treatment  of  Intra-cranial 
Growths." 

*  Trans,  of  the  Ophthal.  See.  of  the  United  Kingdom,  vol.  iv.  p.  172. 

5  Examinations  by  the  author  in  the  Philadelphia  Hospital  and  Infirmary  for  Nervous  Diseases 
yield  a  percentage  fully  equal  to  this. 

0  Quoted  by  Vossius,  Lehrbuch  der  Augenheilkunde,  p.  592.  This  is  not  according  to  the  author's 
experience  in  two  cases ;  there  was  no  autopsy. 


758  NERVOUS  DISEASES  AND  THEIR  TREATMENT       . 

cerebro-spinal — tubercular  disease  of  the  base  is  most  frequently  the  cause 
of  optic  neuritis,  the  percentage  varying  from  76  per  cent.  (Allbutt)  to  81  per 
cent.  (Heinzel)  of  the  cases.  In  simple  meningitis  of  the  convexity,  ophthal- 
moscopic changes  usually  fail,  unless  it  has  lasted  for  a  long  time,  but  neu- 
ritis by  propagation  may  be  the  result  of  this  disease  at  the  base  of  the  brain. 
Optic  neuritis  has  been  described  in  hemorrhagic  pachymeningitis,  and  may 
be  present  in  high  degree  in  purulent  meningitis ;  for  example,  in  septic  con- 
ditions. 

"With  cerebral  abscess  papillitis  occurs,  differing  in  no  wise  from  that  pro- 
voked by  cerebral  tumor,  but  it  is  less  frequently  observ^ed  with  cerebral 
hemorrhage,  softening  from  vascular  disease  of  the  brain,  meningeal  hemor- 
rhage, and  chi'onic  cerebritis.  In  the  cases  of  cerebral  hemorrhage  it  is  diffi- 
cult to  decide  whether  the  hemorrhage  or  the  disease — for  example,  gout, 
syphilis,  or  nephritis,  which  caused  the  intra-cranial  extravasation — is  the 
etiological  factor.  Hemorrhages  into  the  substance  of  soft  intra-cranial 
neoplasms  would  be  accompanied  by  neuritis,  which  then  should  be  ascribed 
to  the  tumor,  and  not  to  the  hemorrhage.  Other  intra-cranial  causes,  also 
uncommon,  are  thrombosis  of  the  cavernous  sinus,  chi'onic  hydrocephalus 
(unassociated  with  tumor),  and  aneurism  of  the  internal  carotid. 

In  rare  instances  myelitis  is  associated  with  optic  neuritis,  and  slight  forms 
are  seen  in  general  paresis  (Uhthofl),  and  in  some  cases  of  chronic  insanity, 
epilepsy,  and  disseminated  sclerosis. 

The  non-intra-cranial  causes  of  papillitis  are :  Acute  febrile  affections,  syph- 
ilis, toxic  agents  (lead,  alcohol),  anaemia,  menstrual  disorders,  exposure  to 
cold,  rheumatism,  injuries,  diseases  of  the  orbital  region,  and  perhaps  intra- 
nasal lesions.  Occasionally  papillitis  is  a  congenital  afiection,  and  may  occur 
as  an  idiopathic  disease  without  evident  cause.  The  shght  grades  of  neuritis 
which  are  so  frequent  with  refractive  error  have  been  mentioned. 

SiGXiFiCANCE  OF  Optic  Neuritis.  Double  papillitis  is  highly  signifi- 
cant of  intra-cranial  disease,  especially  tumor  or  basilar  meningitis,  but  is 
not  a  pathognomonic  sign.  Other  causes  which  have  been  mentioned,  promi- 
nently Bright's  disease,  gout,  and  certain  poisons,  which,  indeed,  may  or  may 
not  be  associated  with  the  intra-cranial  lesion,  must  be  excluded.  Con- 
versely, brain  tumor  (usually  cerebellar)  may  cause  "  choked  disk,"  with  a 
star-shaped  figure  of  whitish  color  in  the  macular  region,  exactly  simulating 
the  appearances  usually  considered  characteristic  of  a  type  of  albuminuric 
retinitis.  The  author  has  seen  this  in  a  number  of  cases  at  the  Philadelphia. 
Hospital  and  at  the  Infirmary  for  Xervous  Diseases.     (Fig.  246.) 

Oj)tic  neuritis  gives  no  information  of  the  nature  of  the  tumor  which  may 
cause  it,  although  sometimes  it  is  the  only  positive  sign  of  its  presence,  be- 
cause it  occurs  with  all  forms  of  neoplasm  found  in  the  brain — fibroma,  sar- 
coma, glioma,  carcinoma,  solitary  tubercle,  gummata,  cysts  (entozoic  and 
otherwise),  and  hgematoma  of  the  dura  mater.  Neither  does  neuritis  afford 
evidence  as  to  the  size  of  the  growth,  as  it  may  be  intense  with  a  small  lesion 
and  practically  absent  with  a  large  one ;  but  unusual  swelling  of  the  nerve- 
head  is  more  significant  of  tumor  than  slight  papillitis  (interstitial  neuritis 
or  descending  neuritis),  Avhich  is  rather  indicative  of  meningitis.  The  subsi- 
dence of  a  neuritis  which  has  not  greatly  developed  points  to  subsidence  of 
its  intra-cranial  cause ;  but  it  must  be  remembered  that  neuritis  under  all 
circumstances  is  a  transient  phenomenon,  although  it  may  be  long-continued. 
Again,  sudden  increase  in  papillitis,  particularly  associated  with  the  symp- 
toms of  mechanical  obstruction,  is  not  without  indication  of  increase,  if  not 
of  the  size,  of  the  irritative  quality  of  the  intra-cranial  lesion.  Finally,  it 
should  be  remembered,  in  searching  with  the  ophthalmoscope  for  evidences 


DISEASES  OF  THE  CRANIAL  XERVES. 


759 


of  brain  disease,  that  the  neuritis  may  have  entirely  passed  away,  except 
traces  in  the  form  of  spots  of  degeneration  in  the  retina,  filling  in  of  the 
centre  of  the  disk,  or  white  tissue  surroundinsr  the  vessels. 


Fig.  246. 


Right  fundus  oculi  of  a  woman  aged  twenty-five  years  ;  optic  neuritis  and  star-shaped  macular  figure 
simulating  appearances  seen  in  albuminuric  retinitis.    Kidneys  normal. 

Symptomatology.  There  is  increased  redness  of  the  nerve-head  and  ob- 
scuration of  the  borders,  followed  by  a  swelling,  which  gradually  increases 
and  assumes  a  mound-shape  of  mixed  grayish  color,  so  that  the  form  of  the 
disk  is  lost,  and  can  be  inferred  only  by  the  convergence  of  the  vessels.  The 
arteries,  often  smaller  than  normal,  are  partly  concealed,  while  the  veins  are 

Fig.  247. 


Concentric  contraction  of  the  fields  of  vision.  The  outer  boundary  marks  the  limits  of  the  nor- 
mal fields  ;  the  shading  indicates  where  the  vision  was  lost.  (From  a  case  of  optic  neuritis,  caused 
by  tumor  of  the  temporal  lobe,  studied  by  the  author  while  under  the  care  of  Dr.  H.  C.  Wood.) 

dark,  tortuous,  distended,  and  dip  into  the  infiltrated  tissue.  In  many  cases 
hemorrhages  are  found  upon  the  swollen  papilla  or  in  its  immediate  neigh- 
borhood ;  they  may  be  narrow  and  flame-shaped,  or  large,  elongated  patches 
of  lilood.     This  swelling  of  the  disk,  according  to  the  variety  of  papillitis 


760  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

which  is  present,  varies  from  2  to  9  dioptres,  or  in  other  words,  an  elevation 
of  0.5  to  3  mm.  (Fig.  2,  Plate  V.). 

Vision  may  be  entirely  unaffected — a  most  important  point,  and,  more- 
over, may  remain  unaffected  until  late  in  the  disease.  Occasionally  it  is 
lost  with  suddenness.  Early  blindness  is  more  common  in  tumors  of  the 
cerebellum  than  with  other  intra-cranial  causes  of  optic  neuritis.^ 

The  field  of  vision  may  be  normal  in  its  periphery,  concentrically  con- 
tracted, or  there  may  be  hemianopsia,  if  the  cause  of  the  papillitis  is  so  situ- 
ated as  to  produce  this  phenomenon.     (Fig.  247  and  248.) 

Fig.  248. 


Left  hemianopsia,  with  marked  reduction  of  the  remaining  half  fields,  greatest  upon  the  right 
side,  caused  by  hemorrhagic  softening  the  right  cuneus  from  the  same  case  as  Fig.  241 — a  later  con- 
dition of  the  visual  fields. 

Color  perception  is  often  defective,  and  that  of  red  and  green  is  usually 
lost  before  the  others.  There  are  no  external  appearances  indicative  of  papil- 
litis, and  no  pupillary  phenomena  suggestive  of  its  presence,  unless  there  is 
blindness,  when  the  light  reaction  of  the  iris  is  lost. 

The  Diagnosis  depends  upon  ophthalmoscopic  examination.  Neuritis  may 
be  the  result  of  hypermetropic  astigmatism,  and  often  amounts  to  a  swelling 
of  IJ  dioptres;  if  the  prominence  is  2  dioptres  or  over,  it  betokens  intra- 
orbital or  intra-cranial  disease  (Norris). 

Course  and  Prognosis,  Papillitis  may  begin  as  an  ordinary  congestion 
associated  with  oedema,  and  gradually  go  on  to  a  fully  developed  condition, 
or  subside  before  this  stage  is  reached ;  sometimes  it  originates  with  great 
rapidity ;  it  may  be  slow  in  its  progress  and  development. 

During  the  stage  of  subsidence  the  elevation  decreases,  the  veins  grow  less 
distended,  the  grayish-red  tint  becomes  uniformly  gray,  and  gradually  the 
margins  of  the  disk  appear.  Finally,  both  sets  of  vessels  contract,  and  often 
much  white  tissue  appears  along  their  margins,  while  spots  of  degeneration 
in  the  ftindus  indicate  the  position  of  former  hemorhages.  An  uncommon 
phenomenon  is  a  second  attack  of  optic  neuritis,  implanted  upon  a  nerve- 
head  which  has  been  in  the  state  of  post-papillitic  atrophy  for  many  months. 
The  author  has  observed  and  reported,  with  Dr.  A.  G.  Thomson,  one  such 
case.^ 

The  prognosis  depends  entirely  upon  the  cause.  It  may  be  good  when 
the  neuritis  has  arisen  under  the  influence  of  a  removable  intra-cranial  de- 
posit, for  example,  a  gumma ;  or  perfectly  hopeless,  the  nerve  passing  into 
atrophy,  for  instance,  in  a  sarcoma  or  glioma  of  the  cerebellum. 

1  For  the  cause  of  this,  consult  Dercum,  Journ.  of  Nervous  and  Mental  Diseases,  Oct.  1893,  p.  675. 

2  Archives  of  Ophthalmology,  1895,  vol.  xxiv.  No.  2. 


DISEASES  OF  THE  CRANIAL  NERVES.  761 

James  Taylor/  after  alluding  to  the  observations  of  Horsley,  Bruns,  and 
Erb,  that  there  may  be  subsidence  of  optic  neuritis  after  operation  under- 
taken with  a  view  to  the  removal  of  cerebral  tumor,  even  when  the  tumor 
was  not  removed,  describes  additional  cases  of  decrease  and  disappearance  of 
papillitis.  Under  exactly  similar  circumstances,  in  two  instances  no  opera- 
tion except  the  trephining  had  been  performed.  W.  W.  Keen  has  seen  optic 
neuritis  subside  after  removal  of  brain  tumors,  and  the  author  has  made  the 
same  observation.  He  has  also,  however,  noted  marked  increase  of  neuritis 
subsequent  to  trephining. 

Pathology  and  Pathological  Anatomy.  The  swelling  of  the  disk  is  often 
visible  when  the  backs  of  the  eyes  which  have  been  removed  are  examined. 
So,  also,  a  pear-shaped  distention  of  the  optic  nerve-sheath  is  not  infrequently 
present. 

Microscopic  changes  in  the  nerve-head  vary  according  to  the  stage  at 
which  the  examination  is  made,  from  oedematous  nerve-fibres  to  marked 
degeneration  of  these  tissues,  with  aggregations  of  fatty  change,  granular 
corpuscles,  and  colloid  changes.  The  nerve  and  its  head  are  crowded  wdth 
inflammatory  corpuscles  which  are  deeply  stained  with  carmine,  and,  as  has 
been  pointed  out,  these  changes,  both  within  the  nerve  and  its  sheath,  may 
often  be  traced  through  the  entire  length  of  the  nerve.  The  bloodvessels, 
large  and  small,  in  the  nerve-head  itself  are  distended,  but  do  not  show 
signs  of  compression  at  the  lamina.     (Gowers.) 

Treatment.  This  should  consist  of  remedies  suited  to  the  disease  which 
has  caused  the  neuritis,  especially  mercury,  iodide  and  bromide  of  potassium, 
salicylic  acid,  pilocarj)ine,  and,  during  the  stages  of  atrophy,  strychnine. 
Incision  of  the  swollen  sheath  has  been  practised. 

Orbital  Optic  Neuritis.  Although  not  strictly  pertinent  to  the  neuro- 
logical aspects  of  the  diseases  of  the  optic  nerve,  it  seems  proper  that  a  few 
words  should  be  said  in  regard  to  that  form  of  optic  neuritis  in  which  the 
inflammation  occurs  in  the  orbital  part  of  the  optic  nerve,  and  which  is 
therefore  known  as  orbital  optic  neuritis,  or  retro-bulbar  neuritis. 

Varieties  of  Orbital  Optic  Neuritis.  Two  varieties  are  described  by  syste- 
matic writers : 

1.  Acute  Retro-hulhar  Neuritis,  in  which  the  appearances  are  not  unlike 
those  described  with  hypersemia  of  the  nerve-head.  Direct  vision  is  greatly 
impaired  owing  to  the  presence  of  a  large  central  scotoma,  which  may  be 
either  positive  or  negative,  that  is,  a  defect  appreciated  by  the  patient  or 
one  of  which  he  is  unconscious,  the  latter  usually  being  a  color  scotoma  in 
which  red  and  green  are  not  recognized  as  such.  There  may  be  complete 
restoration  of  vision  after  this  affection,  which  is  either  monocular  or  binoc- 
ular, a  long  interval  sometimes  occurring  between  the  involvement  of  the 
first  and  the  second  eye. 

Etiology.  The  disease  is  usually  attributed  to  certain  toxic  agents,  for 
example,  lead,  alcohol,  nicotine,  etc.,  to  menstrual  disturbances,  rheumatism, 
the  exanthemata,  diphtheria,  and  other  acute  infectious  diseases,  and  to  over- 
work. 

2.  Chronic  Retro-bulbar  Neuritis.  This  variety  is  generally  known  under 
the  name  of  tobacco  amblyopia  or  toxic  amblyopia.  The  ophthalmoscopic 
lesions  may  be  absent  or  the  disk  is  discolored,  and  in  the  latter  stages  a 
triangular-shaped  patch  of  atrophy  appears  in  its  lower  and  outer  part. 
Occasionally  general  atrophy  supervenes. 

There  is  diminution  of  direct  vision,  particulai'ly  in  bright  light.  The 
peripheral  boundaries  of  the  field  of  vision  are  normal,  but  there  is  a  cen- 

1  Ophthalmic  Review,  June,  1894. 


762  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tral  scotoma,  usually  oval  in  shape,  situated  between  the  fixation  point  and 
the  blind  spot,  in  which  area  the  perception  of  red  and  green  is  lost.  Some- 
times the  recognition  of  other  colors  also  fails,  and  in  bad  cases  the  scotoma 
may  become  absolute.^ 

Etiology.  Most  of  the  cases  of  chronic  retro-bulbar  neuritis  are  the  result 
of  the  abuse  of  tobacco.  Generally  the  patients  have  also  consumed  alcohol 
in  one  form  or  another,  but  there  is  sufiicient  evidence  to  show  that  pure 
tobacco  amblyopia  exists.  The  disease  is  nearly  always  bilateral  and  uncom- 
mon before  the  thirty-fifth  year  of  life.  The  same  character  of  scotoma, 
may  be  caused  by  poisoning  with  lead,  carbon  bisulphide,  iodoform,  canna- 
bis indica,  quinine,  opium,  and  has  been  attributed  to  syphilis,  diabetes, 
rheumatism,  gout,  and  influenza.  Analogous  scotomas  are  occasionally 
seen  in  patients  with  locomotor  ataxia  (progressive  atrophy,  with  scotoma), 
but  it  is  difiicult  in  all  of  these  cases  to  separate  the  influence  of  tobacco 
and  alcohol,'*  and  also  in  disseminated  sclerosis.    (Uhthoff.)    (See  Fig.  252.) 

Pathology.  Retro-bulbar  neuritis  is  a  form  of  peripheral  neuritis,  and  is 
caused  by  an  interstitial  inflammation  of  the  papillo-macular  fibres  of  the 
optic  nerve  (see  page  752).  Therefore,  the  quadrant-shaped  patch  of 
atrophy  which  is  visible  in  the  latter  stages  represents  the  area  of  degener- 
ation which  has  attacked  this  bundle,  which  in  the  nerve-head  consists  of 
a  triangle  with  its  base  in  the  lower  and  outer  part  and  its  apex  in  the  cen- 
tral vessels. 

Treatment.  Both  acute  and  chronic  retro-bulbar  neuritis  must  be  treated 
by  removing  the  cause — toxic  agent  or  general  disease — and  this  alone  will 
suflice  to  cure  many  of  the  cases.  Other  remedies  that  suggest  themselves  are 
free  diaphoresis,  inhalation  of  nitrite  of  amyl,  iodide  of  potassium,  and  parti- 
cularly the  free  exhibition  of  strychnine,  suitably  administered  by  hypoder- 
matic injections. 

Atrophy  of  the  Optic  Nerve.  The  general  term  atrophy  of  the  optic 
nerve,  usually  abbreviated  into  optic  atrophy,  includes  various  types  and 
grades  of  degeneration  of  the  fibres  of  the  optic  nerve. 

Varieties  of  Atrophy  of  thf  Optic  Nerve,  (a)  Primary  atrophy, 
usually  designated  gray,  progressive,  spinal,  or  tabetic  atrophy;  (b)  secondary 
atrophy,  or  that  form  which  results  from  pressure  more  or  less  directly  ap- 
plied to  the  chiasm  or  optic  nerve  itself;  and  (c)  consecutive  atrophy,  also 
called  neuritic  or  post-papillitic  atrophy,  because  it  follows  an  inflammation 
of  the  nerve.  Retinal  and  choroiditic  atrophy  are  forms  of  consecutive  optic 
nerve  degeneration,  caused,  as  their  names  imply,  by  pre-existing  disease  of 
the  retina  and  choroid. 

Etiology  of  Primary  Atrophy  of  the  Optic  Nerve.  The  causes  of  primary 
atrophy  may  be  divided  as  follows  : 

(1.)  Spinal  Lesions,  (a)  Locomotor  Ataxia.  It  is  difiicult  exactly  to 
state  the  frequency  of  essential  optic  nerve  atrophy  in  locomotor  ataxia. 
The  average  of  a  number  of  observations  gathered  by  Berger^  gives  33.7  per 
cent,  of  atrophies.  Among  his  own  106  carefully  studied  cases  there  was 
marked  atrophy  in  44,  and  7  cases  of  amblyopia  without  ophthalmoscopic 
changes,  or,  in  other  words,  46.7  per  cent,  of  disturbance  of  the  optic  nerve.* 

1  For  the  detection  of  scotomata  or  blind  spots  in  tbe  field  of  vision,  the  patient  is  placed  before 
the  perimeter,  or  a  blackboard,  precisely  as  if  the  visual  field  was  to  be  mapped  out.  Small  test- 
objects,  white  or  colored,  }4of  &  centimetre  square,  are  employed,  which  are  moved  in  different  di- 
rections from  the  spot  which  the  eye  under  observation  attentively  fixes,  aiid  the  point  marked 
where  the  object  begins  to  disappear  or  change  its  color. 

"  There  is  also  stationary  atrophy  with  scotoma  seen  in  men;  after  thirty  years  of  age,  and  of 
hereditary  tendency. 

3  Archives  of  Ophthalmology,  vol.  six.  p.  429. 

^  The  following  figures,  showing  the  diversity  of  opinion  as  to  this  point,  may  be  quoted,  and  are 
taken  partly  from  Berger's  paper :  Erb,  3  cases  of  optic  atrophy  in  60  patients  ;  Topinard,  49  to  102  ; 


DISEASES  OF  THE  CRANIAL  NERVES.  763 

The  differences  depend  largely  upon  the  point  of  view.  Careful  examina- 
tions— such,  for  example,  as  William  F.  Norris  has  made — would  probably 
show  that  Berger's  average  is  by  no  means  too  high.  In  a  certain  number 
of  cases  one  eye  is  affected  before  and  more  than  its  fellow. 

(b)  Friedreich's  Ataxia.  According  to  Griffith,'  atrophy  of  the  optic 
nerve  is  very  rare  in  this  disease.  In  38  cases  in  which  ophthalmoscopic 
examinations  were  recorded,  white  disks  were  noted  in  one  (Power)  and  par- 
tial atrophy  in  another  (Seguin).  Sinkler  and  Oliver,  however,  who  have 
made  really  careful  investigations  of  the  optic  nerves  under  these  circum- 
stances, have  found  similar  changes  to  those  which  occur  in  the  earlier  stages 
of  tabes,  and  this  has  been  the  experience  of  the  author  in  one  or  two  exam- 
inations, although  the  degeneration,  if  present,  was  incipient. 

(c)  Lateral  Sclerosis.  Atrophy  of  the  optic  nerve  is  uncommon,  Gowers 
having  seen  it  only  once  in  an  uncomplicated  case.  This  corresponds  with 
the  experience  of  the  author  in  the  Infirmary  for  Nervous  Diseases  and  the 
Philadelphia  Hos^iital,  but  it  is  desirable  that  more  accurate  ocular  examina- 
tions in  this  disease  should  be  made  than  those  which  are  recorded. 

In  amyotrophic  lateral  sclerosis  some  changes  in  the  optic  nerve  have 
occasionally  been  observed.  Petelsohu,^  for  example,  reports  a  case  of  optic 
nerve  atrophy. 

Optic  atrophy  has  also  been  noted  in  chronic  myelitis,  paralysis  agitans, 
spastic  spinal  palsy  and  bulbar  palsy ;  but  Gowers'^  has  not  observed  it  in 
progressive  muscular  atrophy. 

(d)  Insular  Sclerosis.  The  most  complete  investigation  of  the  ocular  dis- 
turbances which  accompany  multiple  sclerosis  has  been  made  by  Uhthoff.* 
The  analysis  includes  67  males  and  33  females,  between  the  ages  of  ten  and 
seventy  years.  Pronounced  atrophy  was  present  in  3  per  cent.,  incomplete 
atrophy  of  the  whole  disk  in  19  per  cent.,  and  partial  atrophy  of  the  tem- 
poral half  of  the  disk,  the  inner  half  being  normal,  or,  in  other  words, 
appearances  similar  to  those  seen  in  toxic  amblyopia,  was  present  in  18  per 
cent.  Forty-eight  of  the  100  cases  had  normal  ophthalmoscopic  appearances, 
but  in  5  of  these  there  were  disturbances  of  vision.  Central  scotomas  were 
found  in  15  cases.  Therefore,  the  amblyopia  of  multiple  sclerosis,  as 
compared  with  other  diseases  of  the  optic  nerve,  most  resembles  non-toxic 
retro-bulbar  neuritis.  The  difference,  however,  consists  in  the  fact  that  the 
pallor  of  the  disk  in  multiple  sclerosis  does  not  necessarily  imply  the  pres- 
ence of  a  central  scotoma,  while  in  ordinary  retro-bulbar  neuritis  the  quad- 
rant-shaped patch  of  atrophy  practically  always  means  a  scotoma,  usually 
between  the  fixing  point  and  the  blind  spot.  The  difference  in  the  path- 
ology of  the  two  affections  accounts  for  this  state  of  affairs ;  the  degene- 
ration is  probably  irregularly  scattered  through  the  nerve  in  sclerosis,  while 
there  is  a  regular  degeneration  of  the  axial  fibres  in  retro-bulbar  neuritis. 
Buzzard^  agrees  with  Uhthoff,  that,  excepting  tumors  and  tubercular  men- 
ingitis, there  is  no  disease  of  the  nervous  system  so  frequently  accompanied 
by  ophthalmoscopic  changes  as  disseminated  sclerosis,  and  finds  pallor  of  the 
disks  in  43  per  cent,  of  his  cases. 

Cyon,  60  to  203  ;  Leber's  estimate  is  26  per  cent. ;  Michel,  12  to  13  per  cent. ;  Alttiaus,  one-sixth  of 
the  cases  :  Moeli,  13.5  per  cent.  ;  and  Gowers,  20  per  cent. 

Buzzard  finds  optic  atrophy  in  1.5.3  per  cent,  of  his  cases,  and  Nettleship  (Trans.  Oph.  Soc.  United 
Kingdom,  vol.  iii.  p.  2.51),  among  76  cases  of  progressive  atrophy,  found  3S  the  subjects  of  locomotor 
ataxia,  whilst  20  others  suffered  from  mixed  symptoms  of  spinal  and  cerebral  disease  and  from  other 
forms  of  chronic  spinal-cord  disease,  not  ataxia. 

1  "  A  Contribution  to  theStudv  of  Friedreich's  Ataxia."  Transactions  of  the  College  of  Physicians 
of  Philadelphia,  February  1, 1888. 

-  Centralblatt  f.  praktische  Augenheilkunde,  1886,  p.  108. 

3  Trans.  Oph.  Soc.  United  Kingdom,  vol.  iii.  p.  197. 

*  For  a  valuable  abstract  of  this  elaborate  work,  consult  the  Ophthalmic  Review,  vol.  ix.,  1890. 

6  Brit.  Med.  Journ.,  Oct.  7. 1893. 


764  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

(e)  Injuries  of  the  Spinal  Cord.  In  ordinary  injuries  of  the  spine  there 
are  no  lesions  in  the  optic  disks,  and  in  injuries  below  the  level  of  the  third 
dorsal  nerve-roots  the  ophthalmosopic  changes  do  not  arise  (Thorburn).  As 
is  well  known,  Clifford  Allbutt  has  noted  changes  in  chronic  cases,  an  obser- 
vation that  has  been  challenged,  and  properly,  by  Thorburn,'  who,  in  7  cases 
among  21  severe  injuries  above  the  second  dorsal  nerve,  found  that  3  of  them 
showed  want  of  definition  of  the  disk  and  slight  distention  of  the  retinal 
veins,  while  in  6  cases,  which  survived  the  accident  for  long  periods,  no  sub- 
jective symptoms  arose,  so  that  atrophy  of  the  optic  nerve  probably  never 
took  place. 

(2.)  Paretic  Dementia.  Changes  analogous  to  those  seen  in  locomotor 
ataxia  are  common,  not  only  in  the  form  of  essential  atrophy  of  the  disks,  but 
as  a  discoloration  of  the  papilla  and  surrounding  fibre  layer  of  the  retina.  The 
latter  phenomenon  has  been  observed  by  Uhthoff^  32  times  among  150 
cases,  i.  e.,  in  28  per  cent,  of  the  cases.  The  same  observer  noted  ati'ophy  of 
the  disk  in  8.04  per  cent,  of  the  cases,  and  abnormal  color  of  its  surface  in  14 
per  cent.  In  the  third  stage,  Oliver  reports  decided  and  unequal  semi-atrophy, 
especially  on  the  temporal  side,  and  in  the  earlier  stages  dirty,  gray-red  de- 
generation of  the  disks.  The  percentage  of  atrophy  among  167  cases  recorded 
by  various  observers  (Galezowski,  Boy,  Yehn)  is  7.2,  while  Klein  found  the 
same  condition  in  5  per  cent.,  and  Siemerling  in  6  per  cent,  of  his  cases. 
Atrophy,  preceded  by  scotoma,  has  been  recorded  by  Hirschberg. 

(3. )  MiscELLAXEOUs  Causes.  Among  the  miscellaneous  causes  of  essential 
atrophy  of  the  optic  nerve,  the  following  are  usually  enumerated :  Cold, 
depraved  nutrition,  syphilis,  menstrual  disturbances,  venereal  excesses,  ma- 
laria, diabetes,  the  abuse  of  the  narcotics,  (preceded  by  inflammation  of  the 
axial  fibres  of  the  optic  nei-ve),  toxic  doses  of  quinine,  and  probably  of  other 
drugs,  e.  g.,  iodoform. 

Etiology  of  Secondary  Atrophy  of  the  Optic  Nerve.  As  Gowers  points  out, 
secondary  atrophy  of  the  optic  nerve  may  result  from  a  lesion  of  the  optic 
centres  or  of  the  fibres  of  the  nerve  itself.  Quoting  Ferrier,  he  shows  that 
a  cortical  lesion  in  the  brain  about  the  supra-marginal  gyrus  may  entail 
loss  of  sight  of  the  opposite  eye. 

AtrojDhy  without  precedent  neuritis,  however,  usually  results  from  direct 
pressure,  for  example,  on  the  chiasm,  the  tracts,  or  the  nerve  itself.  In  the 
first  two  situations  this  may  be  produced  by  tumors,  aneurisms,  exostoses,  or 
by  the  distention  of  the  third  ventricle,  as  in  chronic  hydrocephalus.  It  is 
said  that  a  meningitis  occasionally  produces  a  secondary  atrophy ;  that  is, 
one  without  pre-existing  papillitis. 

A  not  uncommon  cause  is  injury  to  the  optic  foramen,  or  pressure  due  to 
periostosis,  syphilitic  deposits,  caries,  and  necrosis.  A  blow  on  the  head, 
especially  in  the  neighborhood  of  the  supra-orbital  foramen,  may,  it  is  said, 
occasion  atrophy,  but  there  is  good  reason  to  believe  that  the  degeneration  is 
the  result  of  periostitis,  rather  than  of  an  uncomplicated  injury. 

Etiology  of  Consecutive  Atrophy  of  the  Optic  Nerve  is  chiefly  of  ophthalmo- 
logical  interest,  except  in  so  far  as  it  is  of  post-neuritic  origin.  The  relation 
of  papillitis  to  the  production  of  atrophy  has  been  referred  to  in  the  section 
on  Prognosis. 

Significance  of  Atrophy  of  the  Optic  Nerve.  Probably  one-half 
of  the  cases  of  primary  atrophy  of  the  optic  nerve  are  associated  with  spinal 
lesions,  and  certainly  a  very  large  proportion  of  the  cases  are  forerunners  of 
locomotor  ataxia.    Buzzard,  however,  finds  atrophy  most  frequently  associated 

1  "  a  Contribution  to  the  Study  of  the  Spinal  Cord,"  1SS9. 

-  Berichtder  Ophthalmologischen  Gesellschafc.  Heideloerg,  1883,  p.  139. 


DISEASES  OF  THE  CRANIAL  NERVES. 


765 


with  insular  or  disseminated  sclerosis ;  next  frequently  with  fasciculated  scle- 
rosis of  the  posterior  columns  of  the  spinal  cord  (tabes  and  general  paralysis  of 
the  insane),  and  least  often  with  fasciculated  sclerosis  of  the  lateral  columns. 

Practically  all  authors  are  in  accord  that  optic  nerve  atrophy  usually  de- 
velops in  the  beginning  of  tabes,  often  in  the  pre-ataxic  stage,  although  it 
may  also  arise  late  in  the  course  of  the  disease.  Berger  points  out  that  cases 
with  palsy  of  the  ocular  muscles  are  more  disposed  to  atrophy  than  those 
without  such  association. 

Sometimes  the  interval  between  the  development  of  the  ocular  and  spinal 
symptoms  is  a  long  one.  Thus,  Forster  has  seen  optic  atrophy  precede 
the  development  of  other  symptoms  by  a  period  of  three  years,  Charcot  by 
ten  years,  and  Gowers  fifteen  and  twenty  years.  Buzzard  also  has  observed 
blindness  and  lightning  pains  fifteen  years  before  the  ataxic  symptoms  devel- 
oped. Norris^  calls  particular  attention  to  early  gray  degeneration  of  the 
nerve,  while  there  is  full  acuity  of  central  vision  and  only  slight  contraction 
of  the  field  for  form  and  color,  as  a  forerunner  of  spinal  cord  degeneration. 
These  cases,  moreover,  had  both  diminished,  lost  and  increased  knee-jerks. 

The  following  chart  from  Berger  gives  a  good  idea  of  the  frequency  of 
tabes  at  the  various  periods  of  life,  of  severe  ocular  symptoms  and  of  atrophy 
of  the  optic  nerve : 

Fig.  249. 


35 

A 

A 

/\ 

30 

/  \ 

/  \ 

/   \ 

/    \ 

/     ' 

25 

'        ' 

A 

/\ 

/  \ 

\ 

20 

/ 

/    \ 

\ 

/ 

/      \ 

\ 

/ 

'  A  \ 

\ 

A 

/ 

/\ 

,    \ 

/  \ 

// 

/  \ 

\  \ 

15 

/     \ 

// 

/   \ 

\\ 

/   .. 

^       // 

/     \ 

w 

'    /\ 

\     // 

/ 

kW 

/ 

/  ^ 

\// 

/ 

/. 

v//  / 

\  \  \ 

10 

/ 

/A 

^  / 

\  \ 

\ 

/ 

'/  ^ 

/ 

\  \ 

\ 

/     / 

/ 

\  / 

\  \ 

\ 

/    / 

/ 

\/ 

\ 

>     \ 

^    / ! 

\ 

\     \ 

5 

/ 

J  / 

\ 

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^>^ 

y 

y 

v\ 

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y  y 

'  / 

\^— 

--^'^^ 

. 

^  /^ 

^ 

\    . 

/^ 

~ 

l^^^ 

y 

\y 

~^^^ 

^ 

- — 

' 

~ — ^^ 

15-20 

21-25 

26-30 

31-35 

36-40 

41-45 

46-50 

51  -  55 

56-60 

61-65 

00-70 

71-75 

Upper  curve,  frequency  of  tabes  ;  middle  curve,  frequency  of  severe  ocular  symptoms  ;  lower  curve, 
frequency  of  atrophy  of  the  optic  nerve. 

As  a  localizing  symptom,  optic  nerve  atrophy  is  often  of  little  value  in  the 
absence  of  other  phenomena,  particularly  changes  in  the  visual  field,  but, 
taken  into  consideration  with  these,  with  pupillary  changes,  and  with  the 


1  "On  the  Association  of  Gray  Degeneration  of  the  Optic  Nerves  with  Abnormal  Patellar  Tendon 
Reflexes."    Transactions  of  the  American  Ophthalmological  Society,  July,  1885. 


766 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


general  symptoms,  it  assumes  great  importance,  while  its  presence,  even  in 
incipient  degree,  may  often  decide  between  organic  and  so-called  functional 
disorders ;  for  example,  hysteria  and  disseminated  sclerosis.  The  gray  de- 
generation of  paretic  dementia,  frequent  late  in  the  disease,  may  also  precede 
the  mental  symptoms  by  a  long  period  of  time. 

The  significence  of  secondary  and  post-papillitic  atrophy  has  been  referred 
to  on  page  762. 

Symptomatology.  The  clinical  types  of  optic  nerve  atrophy  present  differ- 
ent ophthalmoscopic  appearances.  In  general  the  color  of  the  nerve-head 
varies  from  a  slight  gray  to  an  entirely  white  hue,  with  intermediate  pure 
gray  and  greenish-gray  tints.  Often  the  disk  is  grayish-red  on  its  surface, 
but  decidedly  gray  in  its  deeper  layers.  The  clinical  types  of  optic  nerve 
atrophy  present  a  variety  of  ophthalmoscopic  appearances.  (See  section  on 
Diagnosis,  p.  768.) 

The  acuity  of  central  vision  varies  from  a  slight  depreciation  to  complete 
blindness. 

The  changes  in  the  field  of  vision  consist  of  contraction,  irregular  limita- 
tions in  the  form  of  re-entering  angles  (Fig.  251),  quadrant-shaped  defects, 
loss  of  one-half  of  the  field  (hemianopsia)  (Fig.  250),  and  abnormal  blind 
spots,  or  scotomas  (Fig.  252).     In  disseminated  sclerosis  with  ocular  dis- 


FlG.  250. 


Fjg.  251. 


Visual  field  ot  a  case  of  ataxia  with  atrophy  of 
the  disks,  showing  loss  of  temporal  half.  Percep- 
tion of  red  and  green  was  lost. 


Right  visual  field  from  a  case  of  ataxia  with 
atrophy  of  disk,  showing  contraction  and  re- 
entering angles. 


turbances,  Uhthoff  describes  four  varieties  of  the  visual  field — central 
scotoma,  with  un  contracted  field,  central  scotoma  with  contraction ;  irreg- 
ular peripheral  contraction,  with  relatively  good  central  vision ;  and  con- 
centric contraction  analogous  to  hysteric  cases.  Normally,  in  the  visual 
field,  between  the  outer  limit  of  white  perception  and  the  outer  limit  of 
color  perception,  colors  appear  as  light  gray,  white,  or  black.  The  same 
condition  obtains  in  the  contracted  fields  of  tabes  and  disseminated  sclerosis. 
Head  has  found  the  same  phenomenon  in  the  hysterical  type  of  disseminated 
sclerosis,  but  it  is  not  present  in  the  true  hysteric  field  (Fig.  25-1:). 

In  tabes  there  may  be  ophthalmoscopic  atrophy  of  the  disk,  with  good  color 
perception  and  with  normal  fields,  or  with  normal  central  vision  and  color 
percei^tion,  but  with  contracted  color-fields,  especially  green  (Fig.  253),  or  with 
both  form  and  color-fields  restricted.  Usually  vision,  color  perception  and 
fields  of  vision  are  affected  simultaneously.    A  variety  of  forms  of  contraction 


DISEASES  OF  THE  CRANIAL  NERVES. 

Fig.  252. 


767 


y 

\ 

^ 

~ 

~~" 

-V      ■*• 

\ 

/' 

< 

'    ./ 

isQ> 

V 

/ 

\ 

\ 

N 

^^^' 

.^-~ 

/ 

\ 

\ 

\ 

\ 

-^ 

Visual  fields  of  a  case  of  ataxia  (mapped  on  board),  showing  central  scotomas.    Patient  also  smoked. 

Fig.  253. 


105°  90 


Tabes,  central  vision  normal,  optic  disk  slightly  discolored,  form  and  blue  field  normal,  red 

slightly  contracted,  green  markedly  restricted.    White .    Blue Red  —  •  —  • — •  — 

Green 

Fig.  254. 


From  a  case  of  disseminated  sclerosis  with  optic  atrophy  after  hysterical  symptoms  for  many  years. 
A,  the  white  field.  B,  the  shaded  patch,  represents  the  area  over  which  red  is  seen  as  such  ;  the 
outer  line  represents  the  limit,  within  which  red  on  a  white  ground  appears  as  black.  C,  the  shaded 
patch,  represents  the  area,  over  which  green  is  seen  as  such  ;  the  outer  line  represents  the  limit 
within  which  green  on  a  back  ground  appears  as  white.    (After  Buzzard.) 


768  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

of  the  field  are  seen.  Berger  concludes  that,  although  contraction  of  the  outer 
part  of  the  visual  field  is  most  frequent,  it  does  not  occur  in  this  position  in 
more  than  half  of  the  cases.  Sector-formed  defects  are  common.  Defect  in  color 
vision  may  be  marked  before  the  form-field  is  at  all  afiected.  The  apprecia- 
tion of  green  is  first  diminished,  then  that  of  red,  and  later  blue  and  yellow ; 
finally  there  may  be  complete  achromatopsia.  The  color  fields  are  afiected 
in  the  same  order.     Sometimes  the  red  field  is  the  first  to  contract. 

Pathology  and  Pathological  Anatomy.  The  anatomical  changes  in  the 
optic  nerve  which  has  undergone  atrophy  depend  upon  the  stage  and  the 
cause.  If  it  follows  an  interstitial  inflammation  or  pressure,  the  fibrous  tissue 
of  the  septa  is  thickened,  the  fibres  reduced  in  number,  atrophied,  and  de- 
stroyed. This  atrophy  may  be  so  great  that  the  whole  nerve  is  reduced  to  a 
fibrous  cord. 

When  there  is  gray  degeneration  the  nerve  is  rather  gelatinous  in  appear- 
ance and  shrunken.  The  fibres  first  lose  their  medullary  sheath,  later  be- 
come granular,  and  often  in  the  later  stages  fatty  j)articles,  compound  gran- 
ular corpuscles,  and  amyloid  bodies  are  present. 

In  post-papillitic  atrophy,  in  addition  to  the  atrophic  changes,  nuclei  and 
nucleated  connective-tissue  fibres  may  be  found,  with  traces  of  the  nerve 
fasciculi.  In  certain  forms  of  atrophy — as,  for  example,  that  found  with 
multiple  sclerosis — according  to  Uhthoff",  the  changes  are  midway  between 
tabetic  atrophy  and  that  which  follows  interrupted  nerve  conduction  on  the 
one  hand  and  post-neuritic  atrophy  on  the  other,  the  changes  sometimes 
resembling  those  of  simple  atrophy  and  sometimes  those  of  interstitial 
neuritis.     (See  abstract,  loc.  cit.) 

Diagnosis.  It  is  essential  not  to  mistake  an  ordinary  pallor  of  the  optic 
disk  for  atrophy  ;  therefore,  the  importance  of  associating  with  ophthalmo- 
scopic examination  accurate  investigation  of  the  field  of  vision,  particularly 
the  field  for  colors,  and  the  direct  color-sense. 

In  primary  atrophy  the  outline  of  the  disk  is  sharp,  its  color  gray-red  or 
gray,  the  lamina  usually  visible  and  well  mottled,  and  the  vessels  in  the 
earlier  stages  uncontracted  and  free  from  white  lines  along  their  margins. 
(See  Plate  VI.,  Fig.  1.) 

In  consecutive  atrophy,  on  the  other  hand,  the  margin  of  the  disk  is  hazy, 
the  color  white,  the  white  spot  usually  filled  in,  the  arteries  contracted,  the 
veins  often  large  and  tortuous,  with  white  lines  bordering  their  margins. 
(See  Plate  VL,  Fig.  2.)  In  the  retinitic  and  choroiditic  atrophies  the  disk  is 
often  yellowish  and  waxy  in  appearance,  and  both  sets  of  vessels  markedly 
narrowed.     (See  Plate  VI.,  Fig.  3.) 

In  secondary  atrophy  the  color  of  the  disk  resembles  that  of  the  spinal 
form  of  the  disease,  but  more  often  is  distinctly  white ;  both  veins  and  arteries 
are  contracted,  the  veins  usually  proportionately  more  so  than  the  arteries. 

Prognosis.  Optic  nerve  atrophy  is  always  slow  in  its  course,  and  may  last 
for  months  or  years  before  total  blindness  is  reached.  The  prognosis  of  a 
post-papillitic  atrophy  depends  upon  the  amount  of  inflammation  and  the  con- 
sequent shrinking  of  the  tissues.  Tabetic,  or,  as  it  is  often  denominated,  pro- 
gressive atrophy,  afibrds  an  unfavorable  prognosis,  visual  acuity  and  the 
field  of  vision  gradually  deteriorating ;  but  much  difference  of  opinion  has 
been  expressed  in  regard  to  its  course.  Berger  states  that  Leber  believed, 
as  a  rule,  one  or  two  years  were  required  for  the  atrophy  to  result  in  total 
blindness,  and  quotes  Growers,  that  when  atrophy  develops  early  in  the  course 
of  the  tabes  blindness  follows  more  quickly  than  when  it  is  a  late  phenomenon. 
In  his  own  experience  the  quickest  development  of  blindness  was  two  months, 
and  the  slowest  fifteen  years  in  a  syphilitic  patient,  and  seventeen  in  a  non- 
syphilitic  patient.     The  average  development  of  blindness  in  cases  of  optic 


PLATE  VI, 


Prin-iary  Atrophy  of  Optic  Nerve 
(Spirial  Atrophy),  Modified  from 
Haab, 


Post-papiliitic  or  Consecutive  Atrophy 
of  the  Optic  Nerve,  Modified 
frorr[  Juler. 


Embolic  Atrophy  of   th^e  Optic  Nerve,      From  a  case   in  tl^e  Jefferson   Medical 

College   Hospital, 


DISEASES  OF  THE  CRANIAL  NERVES.  769 

atrophy  complicated  with  ocular  palsies  was  3.4  years ;  without  ocular  pal- 
sies, 3  years.  As  most  of  the  optic  atrophies  develop  in  the  pre-ataxic  stage, 
the  danger  of  this  complication  is  lessened  if  this  stage  is  passed.  Optic 
atrophy  is  usually  somewhat  slower  in  syphilitic  than  in  non-syphilitic  pa- 
tients ;  in  a  case  under  the  care  of  J.  K.  Mitchell  and  the  author  the  vision 
sank  during  twenty-eight  months  from  f  to  ^-^  of  normal. 

Treatment.  If  there  is  reason  to  suspect  syphilis  the  usual  remedies  are  in- 
dicated, especially  a  prolonged  course  of  bichloride  of  mercury  ;  but  it  is  worse 
than  useless  in  advanced  atrophy,  even  if  the  patient  is  syphilitic,  provided 
there  are  no  other  indications,  to  depress  his  nutrition  with  a  long  course 
of  mercury  which  can  have  no  possible  influence  on  nerve-fibres  long  since 
hopelessly  degenerated.  Nitrate  of  silver  has  sometimes  been  used  with 
advantage,  and  the  visual  field  of  tabetic  atrophy  is  said  to  have  been 
enlarged  by  suspension.'^  Other  remedies,  according  to  the  cause,  are  iron, 
arsenic,  phosphorus,  and,  if  a  recent  report  of  Valude's  may  be  credited,  anti- 
pyrine,  although  what  its  physiological  action  can  be  under  such  circum- 
stances it  is  difficult  to  conceive.  The  most  generally  useful  remedy,  for  the 
introduction  of  which  we  are  indebted  to  Nagel,  is  strychnine.  This  some- 
times has  a  very  remai'kable  influence.  It  should  be  pushed  to  its  full 
physiological  effect,  and  it  acts  usually  more  promptly  and  more  efficiently  by 
the  hypodermic  method.  It  is  well  to  associate  with  it  nitroglycerin,  which 
may  be  alternated  with  digitalis,  both  of  them  improving  the  nvitrition  of  the 
nerve  by  their  influence  upon  the  peripheral  capillaries.  Santonin  has  been 
used,  but,  there  is  no  goodlreason  to  believe,  with  any  value.  The  same  is  true 
of  injections  of  animal  extracts  after  the  manner  of  Brown-Sequard,  and  also, 
probably  of  suspension.'^  Competent  observers  have  reported  good  results 
after  the  use  of  galvanism,  and  particularly  after  the  method  of  voltaic 
alternatives.     The  author's  results  have  been  unsatisfactory.^ 

Hemianopsia.*  A  lesion  situated  at  the  optic  chiasm,  in  the  visual  tract, 
or  at  its  ultimate  destination  in  the  cuneus,  produces,  so  far  as  the  eyes  are 
concerned,  a  defect  of  vision  characterized  by  an  obscuration,  usually  in  each 
eye,  of  one-half  or  the  visual  field.  To  this  defect  the  name  hemianopsia  is 
applied. 

Varieties  of  Hemiano2)sia.  Hemianopsia  is  divided  into  horizontal,  in 
which  the  dividing  line  between  the  darkened  and  preserved  fields  is  hori- 
zontal ;  and  vertical,  in  which  the  dividing  line  is  vertical. 

1.,  Horizontal,  or  Altitudinal  Hemianopsia  may  be  inferior  or  superior,  both 
lower  or  both  upper  half  fields  being  wanting.  In  addition  to  diseases  of 
the  eye,  such  a  condition  could  arise  under  the  influence  of  a  lesion  so 
situated  as  to  press  upon  the  upper  or  lower  part  of  the  chiasm,  or  down- 
ward upon  one  optic  tract,  or  upon  the  lower  or  upper  part  of  both  optic 
nerves.  A  double  lesion  in  front  of  the  chiasm  may  produce  loss  of  the 
upper  half  of  the  field  in  one  eye  and  of  the  lower  half  of  the  field  in  the 
other. 

2.    Vertical  Hemianopsia.     This  is  subdivided  into  several  varieties  : 

(a)  Bitemporal  Hemianopsia  (peripheral),  in  which  both  temporal  fields 
are  wanting.  This  can  only  be  caused  by  a  lesion  (tumor,  aneurism  or  frac- 
ture, etc.)  involving  the  crossing  fibres  of  both  optic  tracts  in  the  middle  of 

1  University  Med.  Magazine,  vol.  ii.,  p.  39. 

2  See  an  article  by  the  author  on  "  Medicinal  Ocular  Therapeutics,"  Therapeutic  Gazette,  August, 
1894. 

3  For  a  review  of  the  literature  of  this  subject  and  the  results  obtained,  the  reader  is  referred  to 
an  editorial  by  the  author  in  the  Therapeutic  Gazette,  April,  1893. 

^  The  terms  hemiopia  and  hemianopsia  are  sometimes  used  synonymously.  Hemiopia,  however, 
as  Seguin  points  out,  signifies  loss  in  the  perceptive  power  of  one-half  of  the  retina,  while  hemi- 
anopsia means  obscuration  of  one-half  of  the  visual  field.  Other  names  which  are  used  are  hemianopia 
and  hemiablepsia. 

49 


770  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  chiasm,  and  is  a  symptom   perfectly  characteristic  of  disease  in   this 

region  (Fig.  255).  .   o  ^^ 

(b)  Binaml  Hemianopsia,  in  ^hich  both  nasal  fields  are  wanting,  is  ex- 
tremely rare.  It  necessitates  a  lesion  on  both  sides  of  the  chiasm,  or  one  on 
the  outer  side  of  each  optic  nerve,  which  disables  the  direct  fibres. 

Fig.   255. 


180    350 


210- 


270 


330 


270 


Bitemporal  hemianopsia  from  a  case  of  akromegaly  originally  under  the  care  of  Dr.  H.  C.  Wood 
and  later  studied  by  Dr.  F.  A.  Packard.  Eyes  examined  in  1885  by  the  author,  and  above  fields 
found. 

(e)  Homonymous  Hemianopsia  (central),  in  \vhich  the  corresponding  half 
of  the  visual  field  in  each  eye  is  wanting.  Thus,  both  right  or  both  left 
fields  are  darkened,  in  the  former  case  indicating  loss  of  the  function  of  the 

Fig.  256. 


Right  homonymous  hemianopsia  from  a  patient  under  the  care  of  Dr.  Wharton  Smkler. 

left  half  of  each  retina,  and  designated  right  homonymous  lateral  hemianopsia 
(Fig.  256),  and  in  the  latter  ca.se  indicating  loss  of  function  of  the  right  half 
of  each  retina,  and  designated  left  homonymous  lateral  hemianopsia  (Fig.  257). 


DISEASES  OF  THE  CRANIAL  NERVES. 


771 


This  form  of  hemianopsia  is  caused  by  a  lesion  situated  in  the  occipital  lobe, 
the  evidence  being  that  the  absolute  optical  centre  chiefly  occupies  the  cor- 
tex of  the  cuneus  and  of  the  superior  occipital  convolution,  and  also,  at 
least  so  far  as  color-sense  is  concerned,  the  posterior  part  of  the  superior  and 


Fig.  257. 


Left  homonymous  hemianopsia  from  a  case  of  gunshot  wound,  with  suspected  lesion  of  the  right 
cuneus,  from  a  case  under  the  care  of  S.  Weir  Mitchell,  at  the  Infirmary  for  Nervous  Diseases. 

inferior  occipito-temporal  convolutions.  It  is  fiirther  produced  by  a  lesion 
situated  in  the  optic  radiations,  the  internal  capsule,  primary  optic  centres, 
or  the  optic  tract ;  in  other  words,  by  any  lesion  which  breaks  the  continuity 
of  the  visual  tract  posterior  to  the  optic  chiasm. 

The  lesion  is  in  the  optic  tracts,  or  in  the  primary  optic  centres,  and  inter- 
feres with  the  sensory-motor  arc  of  the  pupil  if  AVernicke's  symptom  (page 
802)  is  present ;  it  is  further  on  in  the  visual  pathway  if  Wernicke's  symp- 
tom is  absent. 

Fig.  258. 


Quadrant  anopsia,  from  a  case  in  the  Phiiladelphia  Hospital.    Probably  softening  in  cuneus. 


Homonymous  lateral  hemianopsia  is  the  most  common  variety  of  hemian- 
opsia. It  may  be  complete,  that  is,  the  entire  half  of  each  field  is  wanting,  or 
incomplete,  that  is,  a  portion  of  each  half  field  is  wanting,  the  defect  usually 
being  in  the  form  of  a  quadrant  (Fig.  258).  The  hemianopsia  may  be 
absolute,  that  is  all  the  three  functions  of  sight,  perception  of  light,  of  form 


772 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


and  of  color,  are  wanting,  or  it  may  be  relative,  that  is,  perception  of  color, 
or  perception  of  color  and  form  is  wanting  in  the  deficient  area  of  the  field, 
but  light-sense  is  preserved.  In  rare  cases  the  half-defect  is  present  for 
colors  alone,  and  is  known  under  the  name  of  homonymous  hemiachromat- 
opsia.  Under  these  circumstances  the  defect  is  situated  in  the  cortex  of  the 
occipital  lobe  (Fig.  259). 

Fig.  259. 


Hemiachromatopsia  from  a  case  under  the  care  of  Dr.  J.  William  White,  and  examined  by  the 
author.    White, .    Blue, .    Red, Green, 

Given  a  case  of  homonymous  hemianopsia,  the  lesion  is  on  the  opposite 
side  of  the  darkened  fields.  If  the  preserved  fields  are  accompanied  by  a 
concentric  contraction,  the  smaller  half  field  will  be  in  the  eye  opposite 
the  lesion.  Contraction  of  the  preserved  half  field  is  most  common  with 
lesions  of  the  cortex,  but  it  may  also  occur  in  lesions  of  the  tract.  If  the 
hemianopsia  is  relative,  the  lesion  must  be  in  the  cortex ;  elsewhere  it  pro- 
duces absolute  hemianopsia.  However,  cortical  lesions  are  not  excluded  by 
absolute  hemianopsia. 

Fig.  260. 


Small  central  field  in  a  case  of  double  homonymous  hemianopsia  under  the  care  of 
Dr.  T.  D.  Dunn,  of  West  Chester. 

The  dividing  line  in  hemianopsia  may  exactly  cut  the  fixing  point,  but  it 
usually  passes  around  this  point,  leaving  it  in  the  area  of  preserved  vision. 


DISEASES  OF  THE  CRANIAL  NERVES.  773 

Again,  it  may  fail  to  correspond  with  the  perpendicular  for  some  distance,  or 
may  assume  an  oblique  or  irregular  direction.  These  peculiarities  are  ex- 
plained (Schmidt-Rimpler,  Gowers),  by  "  individual  variations  in  the  expan- 
sion of  the  retinal  fibres  of  the  tractus  opticus." 

That  the  macula  lutea  is  specially  represented  in  the  visual  centre  has 
been  j)roven  by  cases  of  double  homonymous  hemianopsia,  in  which  a  small 
central  field  is  preserved  in  each  eye,  indicating  that  the  region  in  the  cortical 
visual  centre  which  supplies  the  macula  lutea  has  not  been  destroyed.  (See 
Fig.  260.)  It  is  therefore  also  evident  that  destruction  of  this  centre  alone 
would  be  manifested  in  the  visual  field  by  a  central  scotoma. 

The  evidence  at  this  time  is  constantly  accumulating  to  show  that  there 
is  a  correlation  between  the  parts  of  the  retina  and  the  occipital  lobe ;  for 
example  in  Dr.  Hun's  case  of  left  quadrant  hemianopsia,  the  lesion  was 
strictly  limited  to  the  lower  half  of  the  cuneus,  indicating  that  the  upper 
right  quadrant  of  each  retina  terminates  in  the  lower  half  of  the  right  cuneus. 

For  the  more  particular  relations  of  hemianopsia  to  the  localization  of 
cerebral  disease  and  to  other  symptoms,  both  direct  and  distant,  the  reader 
is  referred  to  the  paragraphs  specially  devoted  to  these  topics. 


DISEASES  OP  THE  ABDUCENS,  PATHETIC,  AND  OCULO- 
MOTOR NERVES. 

Anatomical  and  Physiological  Considerations.  The  oculo-motor, 
pathetic,  and  abducens,  or  third,  fourth,  and  sixth  in  the  list  of  cranial  nerves, 
constitute  the  nerve-supply  of  the  external  ocular  muscles,  while  the  third 
division  of  the  oculo-moLor  sends  a  branch  to  the  ophthalmic  ganglion, 
forming  its  motor  root.^ 

The  deep  origin  of  the  third  nerve  has  been  traced  to  a  nucleus  about  10 
mm.  in  length  in  front  of  the  anterior  corpora  quadrigemina,  extending  from 
the  level  of  the  posterior  commissure  to  within  a  short  distance  of  the  nucleus 
of  the  fourth  nerve.  According  to  Alexander  Bruce,'^  the  following  groups 
of  cells  can  be  distinguished:  1.  An  anterior  or  ventral  group.  2.  A  poste- 
rior external  group  (dorsal  nucleus  of  Edinger  and  Siemerling ).  3.  A  median 
or  centra!  nucleus.  4.  A  posterior  median  or  pale  nucleus  (Edinger-West- 
phal  nucleus).  5.  Superior  nucleus  (antero-lateral  or  small-celled  nucleus  of 
Darkschewitsch).  All  the  segments  of  the  oculo-motor  nucleus  are  connected 
with  the  posterior  longitudinal  fasciculus.  Bruce  has  not  demonstrated  a 
decussation  of  the  root  fibres,  but  believes  that  this  is  present,  just  as  there  is 
free  commissural  connection  between  the  anterior  nuclei  of  both  sides.* 

Some  authors  have  attempted  to  bring  the  various  segments  of  the  nucleus  in 
connection  with  the  ocular  muscles,  for  example,  Hensen  and  Voelkers  place 
the  nuclei  in  the  following  order  from  above  downward  (before  backward)  : 
(1)  ciliary  muscle;  (2)  sphincter  iridis;  (3)  rectus  internus;  (4)  rectus 
superior ;  (5)  levator  paljDebrse  superioris ;  (6)  rectus  inferior  ;  (7)  obliquus 
inferior.  The  evidence  upon  which  this  arrangement  is  based  was  obtained 
by  experiments  in  animals.  An  analysis  of  twenty  cases  of  partial  third- 
nerve  palsy  has  caused  Allen  Starr*  to  locate  the  relative  situation  of  the 

1  For  its  relation  to  the  iris  and  ciliary  muscle,  see  p.  794. 

2  Illustrations  of  the  Nerve  Tracts  of  the  Mid  and  Hind  Brain,  p.  17. 

8  It  is  impossible  to  review  the  contradictory  evidence  of  examination  of  the  oculo-motor  nuclei. 
Perlla's  scheme  is  considered  more  useful  by  many  than  the  one  given.  A  recent  review  of  the 
subject  is  by  Bernheimer  in  a  monograph  entitled,  "Das  Wurzelgebiet  des  Oculo-motorius  beim 
Menschen,"  Wiesbaden,  1894. 

*  Familiar  Forms  of  Nervous  Disease,  p.  108 ;  also  Journal  of  Nervous  and  Mental  Disease,  vol. 
XV.  1888,  p.  301. 


774 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


groups  of  cells  governing  the  ocular  muscles,  and  the  following  table  con- 
structed by  Starr  gives  the  situation  of  these  groups.  It  practically  agrees 
with  the  scheme  of  Kahler  and  Pick.  In  this  he  has  named  each  group  for 
the  muscle  which  it  controls. 

Arrangement  of  the  Group  of  Cells  Governing  the  Ocular  Muscles. 


Eight. 


Sphincter  iridis. 
Levator  ralp.  sup. 
Rectus  superior. 
Obliquus  infer. 
Obliquus  super. 


1.  Ciliary  muscle. 

3.  Rectus  internus. 

4.  Rectus  inferior. 
9.  Rectus  externus. 


Lefi. 


1.  Ciliary  muscle. 

3.  Rectus  internus. 

4.  Rectus  inferior. 
9.  Rectus  externus. 


2.  Sphincter  iridis. 

5.  Levator  palp.  sup. 

6.  Rectus  superior. 

7.  Obliquus  infer. 

8.  Obliquus  super. 


The  nerve  pierces  the  dura  mater  below  the  j)osterior  clinoid  process,  passes 
along  the  outer  wall  of  the  cavernous  sinus,  and  divides  into  two  branches, 
which  enter  the  orbit  through  the  sphenoidal  fissure.  The  superior  division 
supplies  the  superior  rectus  and  levator  palpebrse  ;  the  inferior  division  sepa- 


FlG.  261. 


Scheme  of  the  segments  of  the  nucleus  of  the  third  nerve  and  their  relations  to  each  other  and  to 
the  nucleus  of  the  fourth  nerve,  iii.  r.  Third  nerve,  m.  Median  nucleus  a.  Anterior  nucleus, 
interior  part.  Ai.  Anterior  nucleus,  lower  part  of  main  nucleus.  Ao.  Anterior  nucleus,  intermediate 
portion.  A3.  Anterior  nucleus,  upper  portion,  p.i.  Postero-internal  nucleus,  p.e.  Postero-external 
nucleus,  e.  External  nucleus,  s.  Superior  nucleus.  Some  of  the  root  fibres  from  the  lower  and 
intermediate  parts  of  the  anterior  nucleus  are  represented  by  dotted  lines  as  crossing  to  the  opposite 
side.  IV.  The  nucleus  of  the  fourth  nerve.  iv.B.i,  IV.E.2,  IV.R.3.  The  first,  second,  and  third  portions 
of  the  root  respectively.     (Bruce.) 

rates  into  three  branches,  one  going  to  the  internal  rectus,  a  second  to  the 
inferior  rectus,  and  the  third,  and  largest,  to  the  inferior  oblique.  It  also 
receives  filaments  from  the  cavernous  plexus  of  the  sympathetic,  and  its 
superior  division  is  not  infrequently  connected  with  the  ganglionic  branch  of 
the  nasal  nerve  or  third  division  of  the  fifth  ophthalmic. 

The  fourth,  pathetic  or  trochlear  nerve  supplies  the  superior  oblique.      It 


DISEASES  OF  THE  CRANIAL  NERVES. 


775 


apparently  arises  on  the  outer  side  of  the  crus  just  in  front  of*  the  pons,  and 
can  be  traced  behind  the  corpora  quadrigemina  to  the  valve  of  Vieussens. 

Its  deep  origin  can  be  traced  to  the  nucleus  situated  at  the  level  of  the 
depression  midway  between  the  anterior  and  the  posterior  corpora  quadri- 
gemina in  front  of  the  gray  matter  which  surrounds  the  aqueduct  of  Sylvius. 
(Bruce.)  Its  connection  with  the  nucleus  of  the  sixth  nerve,  which  has  been 
described,  is  doubted  by  Bruce,  who  regards  it  as  more  probable  that  fibres 
may  go  to  that  division  of  the  opposite  oculo-motor  nucleus  which  supplies 
the  inferior  rectus. 

It  pierces  the  dura  near  the  posterior  clinoid  process,  passes  along  the  outer 
wall  of  the  cavernous  sinus,  and  enters  the  orbit  through  the  sphenoidal 
fissure,  being  the  highest  of  the  nerves  passing  through  the  orbit.     It  also 

Fig.  262. 


Cochlea 


Semicircular 
Canals 


Diagram  of  the  connections  of  the  nucleus  of  the  sixth  nerve.    (Bruce.) 

receives  filaments  from  the  cavernous  plexus  of  the  sympathetic  and  trans- 
mits a  twig  to  the  lachrymal,  the  first  branch  of  the  ophthalmic,  or  primary 
branch  of  the  tri-facial. 

The  sixth,  or  abducens,  nerve  supplies  the  external  rectus.  It  apparently 
arises  from  the  corpus  pyramidale  close  to  the  pons.  Its  deep  origin  is  from 
the  nucleus  situated  under  the  floor  of  the  fourth  ventricle,  on  which  its  posi- 
tion is  marked  by  a  slight  elevation,  the  eminentia  teres,  immediately  above 
the  acoustic  striae.  The  nucleus  is  covered  by  the  ependyma  of  the  fourth  ven- 
tricle. It  is  bordered  on  its  inferior,  inner,  and  upper  sides  by  the  first,  second, 
and  third  portions  of  the  facial  nerve.  The  root  fibres  leave  the  nucleus  and 
become  united  at  the  outer  side  of  the  posterior  longitudinal  fasciculus  into  a 
number  of  bundles  (Bruce).  The  connections  of  the  sixth  nucleus,  according 
to  Bruce,  are  somewhat  as  follows  :  With  the  second  part  of  the  root  of  the 
facial  nerve  and  the  segment  of  the  third  nerve  nucleus  supplying  the  in- 
ternal rectus,  with  the  superior  olive,  with  the  auditory  nucleus  and  with  the 
cortex  of  the  opposite  cerebral  hemisphere,  and  probably  also  with  that  of 


776 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


the  same  side.  Clinical  investigations  seem  to  show  that  the  sixth  nerve 
nucleus  is  the  centre  of  conjugate  'lateral  deviation.  (See  page  787.)  The 
olive  has  also  been  supposed  to  contain  this  centre. 

The  nerve  pierces  the  dura  mater  on  the  basilar  surface  of  the  sphenoid 
bone,  passes  through  the  posterior,  or  clinoid  process,  enters  the  cavernous 
sinus,  and  finally  reaches  the  orbit  through  the  sphenoidal  fissure  between 
the  two  heads  of  the  external  rectus.  It  receives  filaments  from  the  carotid 
and  cavernous  plexus  of  the  sympathetic,  from  Meckel's  ganglion,  and  from 
the  ophthalmic  nerve.^ 

Clinical,  experimental,  and  anatomical  data  seem  to  show  that,  although 
the  frontalis  and  orbicularis  palpebrarum  receive  their  peripheral  nerve  sup- 

PiG.  263. 


Sagittal  section  through  the  cerebral  axis,  to  show  the  nuclei  of  the  ocular  nerves  In  the  floor  of 
the  aqueduct  of  Sylvius  and  the  fourth  ventricle,  and  the  course  of  the  nerves  to  their  exit.  The 
various  groups  of  cells  from  which  the  third  nerve  arises  are  seen.  R  N,  red  nucleus  of  tegmentum  ; 
L,  lemniscus  (sensory  tract) ;  C  C,  motor  tract  in  the  crus  cerebri  seen  to  traverse  the  pons  and 
enter  the  anterior  pyramid  of  the  medulla.    (Starr.) 

ply  from  the  facial  nerve,  they  are  really  eye-muscles.  They  are  designated 
the  oculo-facial  group,  and  their  central  innervation,  according  to  Mendel,  is 
the  oculo-motor  nucleus,  connected  with  the  facial  through  the  posterior 
longitudinal  fasciculus. 

It  will  thus  be  seen  that,  in  general  terms,  the  cell  groups  constituting  the 
nuclei  of  the  nerves  governing  the  ocular  muscles  lie  in  the  gray  matter  of 
the  floor  of  the  aqueduct  of  Sylvius  and  of  the  fourth  ventricle,  the  major 
gathering  being  beneath  the  corpora  quadrigemina.     (Fig.  263.) 

Physiological  Action  of  the  Ocular  Muscles.  The  actions  of  the 
ocular  muscles  are  reckoned  from  what  is  known  as  the  primary  position 
of  the  globe.  The  eyes  occupy  this  position  when  they  are  directed  straight 
forward,  the  head  being  held  erect,  and  a  distant  object  situated  in  the  median 
line  of  the  visual  plane  is  observed  with  practically  parallel  visual  lines. 
Positions  of  the  eyes  other  than  these  are  called  secondary  positions. 

It  is  customary  to  separate  the  six  muscles  which  control  the  movements 
of  the  eyeballs  into  three  pairs,  namely,  the  internus  and  externus,  which 


1  The  course,  connections,  and  distributions  of  the  cranial  nerves  are  according  to  Gray's  Anat- 
omy, American  edition,  edited  by  Keen.  The  deen  origin  of  the  nerves  and  the  relation  of  the 
nuclei  are  taken  from  Alexander  Bruce,  "  Illustrations  of  the  Nerve  Tracts  in  the  Mid  and  Hind 
Brain." 


DISEASES  OF  THE  CRANIAL  NERVES.  777 

control  the  horizontal  movements  or  rotations  ;  the  superior  rectus  and  infe" 
rior  oblique,  which  control  the  upward  movements,  and  the  inferior  rectus 
and  superior  oblique,  which  control  the  downward  movements.  Movement 
of  the  eyeball  upward  and  inward  is  performed  by  the  superior  and  internal 
rectus  acting  with  the  inferior  oblique ;  downward  and  inward  by  the  inferior 
and  internal  rectus  acting  with  the  superior  oblique ;  upward  and  outward 
by  the  superior  rectus  and  external  rectus  acting  with  the  inferior  oblique  ; 
and  downward  and  outward  by  the  inferior  and  external  rectus  acting  with 
the  superior  oblique.  The  first  series  of  actions,  comprising  the  horizontal 
and  vertical  movements,  are  the  ones  of  chief  interest  in  the  ordinary  diag- 
nosis of  the  ocular  palsies,  and  it  has  not  been  considered  necessary  in  these 
pages  to  describe  the  obliquity  of  the  double  images,  which  is  also  present  in 
diagonal  movements  when  there  is  paralysis  of  one  or  more  muscles. 

Under  normal  conditions  there  is  co-ordination  in  the  movements  of  the 
eyes,  one  eyeball  being  associated  in  its  movements  with  those  of  its  fellow. 
If  these  associated  movements  regulated  by  equal  impulses  from  the  co-ordinat- 
ing centre  did  not  exist,  single  vision  would  not  be  possible,  for  the  two 
images  of  an  object  could  not  fall  upon  corresponding  parts  of  the  retinae. 

In  order  to  test  the  extent  of  the  movements  of  the  eyes  in  various  direc- 
tions, or  the  field  of  fixation,  the  limit  of  the  excursion  of  the  eye  in  four  chief 
directions  may  be  measured.  This  amounts  in  the  vertical  and  horizontal 
directions  to  90°. 

Pakalysis  of  the  External  Ocular  Muscles.  Certain  general 
symptoms  are  common  to  paralysis,  or  paresis,  of  the  external  ocular  muscles. 

G-eneral  Symptoms  of  Paralysis  of  the  External  Ocular  Muscles.  These 
may  be  summed  up  as  follows  : 

1.  Diplopia,  owing  to  the  failure  of  images  of  an  object  to  fall  upon  cor- 
responding points  of  the  retinae,  and  which  increases  as  the  object  is  moved  to 
the  side  of  the  paralyzed  muscle. 

2.  Strabismus,  which  may  be  manifest  only  in  complete  cases,  or  only 
appear  when  attempt  is  made  to  move  the  eye  in  the  direction  of  the  action 
of  the  palsied  muscle.     Sometimes  it  results  from  secondary  contractures. 

3.  Primary  deviation,  or  limitation  of  movement  of  the  eye  in  the  direc- 
tion of  the  action  of  the  affected  muscle.  Therefore  this  is  always  in  a 
direction  opposite  to  the  action  of  the  muscle. 

4.  Secondary  deviation,  or  the  deviation  of  the  sound  eye,  while  the  affected 
eye  attempts  to  regard  an  object.  This  secondary  deviation  is  always  greater 
than  the  primary  deviation,  because  the  same  degree  of  nervous  impulse 
passes  from  the  centre  to  the  muscles  of  the  affected  eye  and  to  those  of  the 
unaffected  associate ;  the  former  requires  an  abnormally  great  impulse  to 
stimulate  its  movement,  and  hence  the  latter  is  over-excited,  causing  an  ex- 
cessive movement. 

5.  False  projection  of  the  field  of  vision,  or,  in  other  words,  an  inaccurate 
estimation  of  the  position  of  an  object  which  is  situated  in  such  a  portion 
of  the  visual  field  that  it  requires  an  effort  on  the  part  of  the  affected  muscle 
to  turn  the  eye  toward  it. 

6.  Vertigo.  When  both  eyes  are  open  this  depends  upon  the  diplopia. 
If  the  unaffected  eye  is  closed,  it  depends  upon  an  erroneous  localization  of 
objects  in  the  field  of  vision. 

7.  Altered  carriage  of  the  head,  which  depends  upon  the  impulse  of  the 
patient  to  turn  his  head  in  that  direction  in  which  he  is  least  troubled  by  the 
double  images. 

Varieties  of  Diplopia.  According  to  the  relation  which  the  double  images 
bear  to  the  eyes,  there  are  two  varieties  of  diplopia,  simple  or  homonymotis, 
and  crossed  or  heteronymous^  diplopia.     The  former  is  present  if  the  right, 


778 


NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 


image  pertains  to  the  right  eye,  and  the  left  image  to  the  left  eye,  and  the 
latter,  if  the  reverse  is  true.  The  image  seen  by  the  unaffected  eye  is  termed 
the  t7me  image;  that  seen  by  the  affected  eye,  the  fake  image.  If  the 
two  images  are  on  a  horizontal  line,  there  is  lateral  diplopia;  if  there  is 
vertical  displacement  of  the  double  images,  vertical  dijolopia.  Certain  rules 
in  regard  to  diplopia  in  cases  of  recent  external  ocular  muscle  palsy  should 
be  remembered,  namely : 

1.  Diplopia  is  most  marked  and  sometimes  only  noticeable  when  the 
patient  turns  his  eyes  in  a  direction  which  requires  an  action  of  the  affected 
muscle,  while  if  the  eye  moves  in  such  direction  that  the  paralyzed  muscle 
is  not  concerned,  diplopia  is  absent. 

2.  The  image  which  belongs  to  the  affected  eye  is  projected  in  the  direc- 
tion toward  which  the  paralyzed  muscle  normally  rotates  the  eye. 

3.  The  relative  distance  of  the  double  images  increases  when  the  eyes  are 
turned  in  the  direction  of  the  action  of  the  paralyzed  muscle,  or,  in  other 
words,  that  image  is  false  and  belongs  to  the  affected  eye  which  in  the  region 
of  diplopia  moves  faster  than  a  moving  test-object,  for  example,  a  candle 
flame. 

Special  Symptoms.  The  most  important  symptoms  peculiar  to  paralysis 
of  the  ocular  muscles  are  summarized  in  the  following  paragraphs.  It  is 
supposed  that  the  right  eye  is  affected  and  that  the  signs  of  complete  or  nearly 
complete  palsy  are  present. 


Fig.  264. 


k 


6 


A,  position  of  images  in  paralysis  of  the  left  external  rectus,  and  B,  in  paralysis  of  the  right  ex- 
ternal rectus.    The  false  image  is  drawn  in  outline ;  the  true  image  shaded.    (Modified  from  Fuchs.) 

1.  External  Rectus.  Homonymous  diplopia,  the  images  being  side  by  side 
and  parallel  when  the  eyes  are  directed  on  a  horizontal  level,  the  distance 
between  them  widening  as  the  test-object  is  moved  to  the  right ;  convergent 
strabismus,  increasing  as  the  object  is  moved  to  the  right,  and  limitation  of 
movement  in  this  direction ;  inward  secondary  deviation  of  the  sound  eye ; 
false  projection  of  the  field  of  vision  to  the  right  side,  and  turning  of  the 
face  toward  the  right  or  affected  muscle.    (See  Fig.  264  b.) 


Fig.  265. 


A,  position  of  the  images  in  paralysis  of  the  left  internal  rectus,  and  B,  in  paralysis  of  the  right 

internal  rectus. 

2.  Internal  Rectus.  Crossed  diplopia,  the  images  being  side  by  side  and 
parallel  if  the  eyes  are  directed  on  a  horizontal  level,  the  distance  between  them 
widening  as  the  test-object  is  moved  to  the  left ;  divergent  strabismus,  which 
increases  as  the  eye  attempts  to  follow  an  object  moved  to  the  left,  and  limi- 
tation of  movement  in  this  direction ;  outward  secondary  deviation  of  the 
sound  eye ;  false  projection  of  the  visual  field  to  the  left,  and  rotation  of  the 
face  toward  the  left  or  affected  muscle.     (Fig.  265  b.) 


DISEASES  OF  THE  CRANIAL  NERVES. 


779 


3.  Superior  Rectus.     Crossed  diplopia  in  the  upper  field,  the  images  being 

one  above  the  other,  the  image  of  the  affected  eye  higher  than  its  fellow  and 

inclined  to  the  left,  and  the  distance  between  them  widening  as  the  test-object 

is  moved  upward  and  to  the  right ;  downward  strabismus,  which  increases 

when  the  eye  attempts  to  follow  an  object  moved  upward,  and  limitation  of 

movement  in  this  direction  ;  upward  secondary  deviation  of  the  sound  eye ; 

false  projection  of  the  visual  field  too  high,  and  upward  direction  of  the  face. 

(Fig.  266  B.) 

A  Fig.  266. 


A,  position  of  images  in  paralysis  of  left  superior  rectus,  and  B,  in  paralysis  of  right  superior  rectus. 

4.  Inferior  Oblique.  Homonymous  diplopia  in  the  upper  field,  the  images 
being  one  above  the  other,  the  image  of  the  afifected  eye  being  higher  than 
its  fellow  and  inclined  to  the  right,  the  vertical  distance  between  them  widen- 
ing as  the  test-object  is  moved  upward  and  to  the  left ;  downward  and  inward 
dii'ection  of  the  affected  eye,  most  marked  when  the  eyes  attempt  to  follow 
an  object  moved  upward  and  outward,  with  limitation  of  movement  in  this 
direction ;  upward  and  inward  secondary  deviation  of  the  sound  eye ;  false 
projection  of  the  visual  field  too  far  upward,  and  turning  of  the  face  upward 
and  toward  the  left.     (Fig.  267  b.) 

A  Fig.  267. 


A,  position  of  images  in  paralysis  of  left  inferior  oblique,  and  B,  in  paralysis  of  right  inferior 

oblique. 

5.  Inferior  Rectus.  Crossed  diplopia  in  the  lower  field,  the  images  being 
one  above  the  other,  the  image  of  the  affected  eye  being  lower  than  its  fel- 
low, and  inclined  to  the  right,  and  the  distance  between  them  widening  as  the 
test-object  is  moved  downward  and  to  the  right ;  upward  strabismus,  which 
increases  when  the  eye  attempts  to  follow  an  object  moved  downward,  with 

A  Fig.  268. 


A,  position  of  images  in  paralysis  of  left  inferior  rectus,  and  B,  in  paralysis  of  right  inferior  rectus. 

limitation  of  movement  in  this  direction  ;  downward  and  outward  secondary 
deviation  of  the  sound  eye ;  false  projection  of  the  visual  field  too  far  down- 
ward, and  turning  of  the  face  downward  and  to  the  right.     (Fig.  268  B.) 


780  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

6.  Superior  Oblique.  Homonymous  diplopia  in  the  lower  field,  the  images 
being  one  above  the  other,  the  image  of  the  affected  eye  being  lower  than  its 
fellow  and  inclined  to  the  left,  the  vertical  distance  between  them  widening 
as  the  test-object  is  moved  downward  and  to  the  left ;  upward  and  inward  direc- 
tion of  the  affected  eye,  especially  when  the  eye  attempts  to  follow  an  object 
moved  downward  and  outward,  and  limitation  of  movement  in  this  direction  ; 
downward  and  inward  secondary  deviation  of  the  sound  eye ;  false  projection 
of  the  visual  field  too  far  downward,  and  inclination  of  the  face  downward 
and  to  the  left.     (Fig.  269  b.) 

A  Fig.  269.  B 


A,  position  of  images  iu  paralysis  of  left  superior  oblique,  and  B,  in  paralysis  of  right  superior 

oblique. 

7.  Oculo-motor  (third  nerve)  Paralysis.  Crossed  diplopia  ;  divergent  stra- 
bismus and  limitation  of  movement  in  all  directions  except  outward  and 
sKghtly  downward ;  outward  secondary  deviation  of  the  sound  eye ;  false 
projection  of  the  visual  field  to  the  inner  side,  and  inclination  of  the  face  to 
the  right,  the  chin  being  tipped  upward ;  in  addition,  ptosis,  medium  dilata- 
tion of  the  pupil,  and  paralysis  of  accommodation. 

Method  of  Examination.  In  complete  paralysis  the  strabismus  and  the 
limitation  of  movement  of  the  paralyzed  muscle  are  sufficient  to  identify 
the  affected  organ.  In  paresis,  however,  a  diagnosis  must  be  based  upon  a 
study  of  the  double  images.  The  patient,  therefore,  is  seated  four  or  five 
metres  from  the  test-object,  which  is  usually  a  candle-flame,  and  one  eye  is 
covered  with  a  piece  of  red  glass.     This  distinguishes  the  flames. 

The  lighted  candle  is  then  moved  from  the  median  line  horizontally  to  the 
right  and  to  the  left,  and  the  relative  positions  of  the  images  noted.  In  like 
manner  it  is  moved  upward  and  downward  and  the  same  observation  re- 
corded. According  to  the  rules  already  given  under  diplopia  (see  page  778) 
the  false  image,  and  consequently  the  affected  eye,  can  usually  be  deter- 
mined, and,  by  a  process  of  exclusion,  the  paretic  muscle.  Many  tables  have 
been  constructed  to  aid  the  memory  in  this  respect.  The  following  is  very 
useful  and  has  been  prepared  by  Dr.  F.  C.  Hotz  :^ 

I.  Lateral  diplopia  indicates  paralysis  of  an  internal  or  an  external  rectus. 

1.  Homonymous  diplopia  indicates  paralysis  of  an  external  rectus. 

a.  Images  separating  to  the  right  indicate  paralysis  of  the  externus  of 
the  right  eye. 

b.  Images  separating  to  the  left  indicate  paralysis  of  the  externus  of  the 
left  eye. 

2.  Crossed  images  indicate  paralysis  of  an  internus. 

a.  Images  separating  to  the  right  indicate  paralysis  of  the  internus  of 
the  left  eye. 

b.  Images  separating  to  the  left  indicate  paralysis  of  the  internus  of  the 
right  eye. 

1  The  Diagnosis  of  Paralysis  of  the  Ocular  Muscles  by  the  Double-image  Test.  International 
Clinics,  vol.  iii.  fourth  series. 


DISEASES  OF  THE  CRANIAL  NERVES.  781 

II.  Vertical  diplopia  in  the  upper  field  indicates  paralysis  of  the  superior 
rectus  or  inferior  oblique. 

1.  Homonymovis  images  indicate  paralysis  of  the  inferior  oblique. 

a.  Image  of  right  eye  higher  means  paralysis  of  the  inferior  oblique  of  the 
right  eye. 

b.  Image  of  right  eye  lower  means  paralysis  of  the  inferior  oblique  of  the 
left  eye. 

2.  Crossed  images  indicate  paralysis  of  the  superior  rectus. 

a.  Image  of  right  eye  higher  means  paralysis  of  the  superior  rectus  of 
the  right  eye. 

b.  Image  of  right  eye  lower  means  paralysis  of  the  superior  rectus  of 
the  left  eye. 

III.  Vertical  diplopia  in  the  lower  field  indicates  paralysis  of  the  inferior 
rectus  or  superior  oblique. 

1.  Homonymous  images  indicate  paralysis  of  the  superior  oblique. 

a.  Image  of  the  right  eye  lower  means  paralysis  of  the  superior  oblique 
of  the  right  eye. 

b.  Image  of  the  right  eye  higher  means  paralysis  of  the  superior  oblique 
of  the  left  eye. 

2.  Crossed  images  indicate  paralysis  of  the  inferior  rectus. 

a.  Image  of  the  right  eye  lower  means  paralysis  of  the  inferior  rectus  of 
the  right  eye. 

b.  Image  of  the  right  eye  higher  means  paralysis  of  the  inferior  rectus 
of  the  left  eye. 

It  is  exceedingly  difficult,  however,  always  to  exactly  localize  the  affected 
muscle,  a  difficulty  which  is  much  increased  when  more  than  one  is  paretic, 
the  paresis  being  of  different  degrees. 

Varieties  of  Paralyses  of  the  Ocular  Muscles.  Some  authors  re- 
serve the  name  paralysis  for  those  cases  in  which  the  affection  is  unilateral, 
or  for  the  palsy  of  muscles  supplied  by  single  nerves,  and  ophthalmoplegia  for 
all  other  cases  ;  but  as  Knies  points  out,  this  distinction  is  not  always  main- 
tained with  accuracy,  and  hence  the  term  ophthalmoplegia  may  be  applied 
to  the  entire  group  of  eye-muscle  palsies.  According  to  Mauthner*  the  oph- 
thalmoplegias, as  well  as  the  single-muscle  palsies,  may  be  arranged  in  the 
following  manner : 

Ophthalmoplegia  (Myo-paralysis.) 

I.  Intra-cranial. 

a.  Cerebral. 

1.  Cortical. 

2.  Nuclear. 

3.  Fascicular. 

b.  Basal. 

II.  Orbital. 

III.  Peripheral.'' 

1  Die  Lehre  von  den  Augenmuskellahmungen,  1889,  p.  310. 

2  Collins  and  Wilde  (Amer.  Journ.   Med.  Sci.,  N.  S,  vol.  cii.  p.  512)  have  prepared  a  scheme  of 
division  which  is  more  elaborate  and  has  many  points  to  commend  it,  viz.: 

I.  Cerebral :  (a)  Cortical. 

(6)  Cortico-peduncular. 

(c)  Nuclear. 

lii.  I:  I  lifdSlfi^  I    "Ophthalmoplegiainterna." 

3.   )    Palsy  of  extra-ocular  muscles.    Ptosis. 
iv.  4.  Palsy  of  superior  oblique, 
vi.  5.  Palsy  of  external  rectus. 

(d)  Radicular  (and  commissural.) 

II.  Basal :      (a)  Region  of  pons. 

(6)  Region  of  peduncles. 

(c)  Region  of  cavernous  sinus. 

id)  Region  of  sphenoidal  Assure. 

III.  Orbital  (including  peripheral). 


782  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Orbital  and  Pekipheral  Palsies  of  the  Extra-ocular  Muscles. 
The  causes  residing  within  the  orbit  which  produce  paralysis  of  the  muscles 
(orbital  palsies),  are  chiefly  of  ophthalmological  interest,  namely,  cellulitis, 
tenonitis,  tumors,  hemorrhages,  fracture,  and  affections  of  the  frontal  sinus 
and  adjacent  cavities. 

It  is  very  diiBcult  to  make  an  accurate  separate  classification  of  peripheral 
palsies.  In  fact  many  writers  are  content  with  the  separation  of  the  ocular 
palsies  into  the  central  and  the  peripheral,  meaning  by  the  latter  those  caused 
by  an  interruption  in  the  course  of  the  nerve-trunks  themselves,  and,  there- 
fore, including  orbital  and  basal  palsies. 

It  is  more  accurate,  however,  as  Mauthner  and  other  writers  have  pointed 
out,  to  call  those  cases  peripheral  which,  so  far  as  diagnosis  is  possible,  are 
caused  by  influences  not  acting  in  the  orbit  or  at  the  base,  but  on  the  nerve 
within  the  muscle. 

Thus  rheumatism  probably  always  causes  a  peripheral  palsy,  and  the  ex- 
ternal rectus  is  the  muscle  most  usually  affected.  It  occurs  in  rheumatic 
subjects  after  exposure,  but  rarely  during  attacks  of  acute  articular  rheuma- 
rheutism.^  Mauthner  calls  attention  to  the  fact  that  many  cases  of  so-caUed 
matic  palsy  have  been  followed  years  afterward  by  tabes,  disseminated 
cerebral  sclerosis,  progressive  paralysis,  etc.,  and  may  be  looked  upon  as 
forerunners  of  such  affections  under  certain  circumstances. 

Certain  palsies  of  the  external  rectus  are  probably  occasioned  by  simple 
neurasthenia,  and  high  grades  of  insufficiency  of  the  same  muscle,  if  not  an 
actual  palsy,  result  from  uric-acid  diathesis,  gout,  and  similar  general  con- 
ditions. 

Diphtheria  may  also  occasion  a  peripheral  (as  well  as  nuclear)  palsy, 
andother  causes  are  to  be  found  in  diabetes,  influenza,  and  particularly 
certain  toxic  agents,  lead,  alcohol  (these  two  causing  a  neuritis),  gelse- 
mium,  conium,  chloral,  carbonic  acid,  and  spoiled  fish,  meats,  etc.  (ptomaine 
poisoning). 

Basal  Palsies  of  the  Extra-ocular  Muscles.  The  lesions  causing 
paralysis  of  the  ocular  nerves  by  afiecting  them  in  their  course  at  the  base  of 
the  brain  may  be  briefly  summarized  thus :  Hemorrhage,  pachymeningitis, 
meningitis,  both  simple  and  tubercular,  but  particularly  the  latter,  which 
sometimes  in  children  first  manifests  itself  by  sudden  convergent  strabismus 
and  diplopia  ;2  purulent  meningitis  and  localized  abscess,  for  example,  in 
connection  with  middle  ear  disease ;  aneurism,  thrombosis,  and  other  cliseases 
of  the  cavernous  sinus ;  arteritis  obliterans,  especially  syphilitic  disease  of  the 
basilar  arteries ;  tumors,  and,  finally,  those  conditions  which  Mauthner  (whose 
grouping  has  been  quoted)  has  called  essential  diseases  of  the  basal  branches 
of  the  motor  ocular  nerves :  neuritis,  gummatous  disease,  tuberculosis,  and 
gray  degeneration. 

Reverting  to  syphilis,  we  may  say  that  it  is  the  most  frequent  of  all  causes 
of  ocular  palsies,  constituting,  according  to  Alexander,  59.4  per  cent,  of  the 
cases.  It  may  cause  a  neuritis,  perineuritis,  inflammation  or  gummatous 
change  of  the  nerve-trunks  themselves,  or  originate  deposits  of  gumma,  or 
excite  a  periostitis  at  the  sphenoidal  fissure. 

According  to  the  region  affected,  the  sixth,  third,  or  fourth  nerves  may  be 
included,  the  oculo-motor  being  most  frequently  selected  by  syphilitic  disease. 
Generally  a  late  symptom,  and  occurring  usually  at  the  gummatous  stage  of 
the  disease,  syphilitic  oculo-motor  palsy  has  been  noted  as  early  as  the  sixth 
month  after  primary  infection,  particularly  in  the  form  of  ptosis.     It  should 

1  The  author  has  seen  one  such  case  iu  the  Philadelphia  Hospital. 

2  Mauthner  states  that  he  has  seen  under  these  circumstances  a  pure  type  of  trochlear  paralysis. 


DISEASES  OF  THE  CRANIAL  NERVES.  783 

be  remembered  that  it  may  also  be  a  symptom  of  inherited  sypliilis,  in- 
stances of  this  character  having  been  recorded  by  Graefe,  Nettleship,  and 
Lawford. 

Recurrent  Oculo-motor  Paralysis.  (Intermitting  paralysis  of  the  oculo- 
motor nerve,  sometimes  called  ophthalmoplegic  migraine — Charcot.)  This  is 
comparatively  a  rare  affection,  which  may  be  classed  among  basal  palsies, 
about  forty  cases  having  been  recorded  in  medical  literature.^  According 
to  Darquier's  collection,  the  disease  attacks  the  female  sex  more  frequently 
than  the  male,  nineteen  times  in  twenty-seven  observations  ;  but  Knapp  finds 
the  two  sexes  aifected  about  equally,  the  left  nerve  being  more  commonly 
involved  than  the  right.  It  generally  begins  at  an  early  period  of  life,  from 
the  second  month  to  the  fifth  year,  although  it  may  begin  later,  and  in  rare 
instances,  even  in  old  age. 

The  symptoms  are  violent  unilateral  headache,  lassitude,  nausea,  vomiting 
slight  fever,  and  usually  complete  paralysis  of  the  third  nerve  on  the  same 
side  as  the  pain.     Unusual  symptoms  are  purulent  discharge  from  the  eye. 

Fig.  270. 


Recurrent  ptosis  of  right  eye,  permanent  palsy  of  all  other  branches.    A  case  studied  by  Dr.  Dercum 
and  the  author  in  the  Jefferson  Medical  College  Hospital,  Philadelphia. 

swelling  of  the  lids,  and  anaesthesia  in  the  distribution  of  the  trigeminus. 
A  concomitant  symptom  may  be  facial  paralysis,  and  in  some  cases  there  were 
recurring  attacks  affecting  several  cranial  nerves.  A  similar  condition  of  the 
abducens  has  been  described  (Nieden,  Charcot),  and  the  fifth  has  been  in- 
volved in  a  few  instances. 

The  attacks  may  come  in  periodic  crises,  and  the  disease  may  last  from 
several  days  to  long  periods  of  time.  It  is  difficult  to  make  a  strict  classifi- 
cation, but  in  general  terms  it  may  be  stated  that  in  one  variety  there  is 
complete  recovery  of  the  paralyzed  muscles  during  the  interval,  while  in 
the  other  some  trace  of  the  afl^ection  remains,  for  examjale,  a  paretic  muscle. 
In  several  cases  there  was  complete  recovery  in  the  interval  between  the 

1  See  article  by  Darquier  entitled  "  De  Certaines  Paralysies  Recidivantes  de  la  troisieme  Paire." 
Annales  d'OcuIistique,  Tome  cs.  Octobre,  1893,  p.  257,  and  a  thorough  analysis  of  the  cases  by  Philip 
Coombs  Knapp,  in  the  Boston  Medical  and  Surgical  Journal,  September  27,  1894,  whose  article  has 
been  freely  quoted  in  the  following  paragraph. 


784  NERVOUS  BISJEASES  AND  THEIR  TREATMENT. 

earlier  attacks,  but  increasing  paralysis,  amounting  in  two  instances  to  com- 
plete paralysis,  in  the  interval  between  the  later  attacks.^ 

The  pathology  is  uncertain,  but  the  evidence  goes  to  show  that  it  is  a  basal 
disease,  for  example,  a  meningitis,  although  it  has  been  ascribed  to  hysteria, 
and  also  to  nuclear  lesion,  but  to  the  latter  apparently  without  good  cause. 
Knapp  says  "  the  most  tenable  hypothesis  is  that  recurrent  oculo-motor 
paralysis  is  due  to  some  vascular  change,  inflammatory  or  oedematous,  in  a 
focal  lesion  involving  the  root  of  the  third  nerve."  In  three  autopsies  thus 
far  reported  they  Avere  lesions  of  the  nerve  at  its  exit  in  front  of  the  pons. 

Cerebral  Extra-ocular  Palsies.  Paralyses  of  the  extra-ocular  muscles 
having  a  cerebral  origin  result  from  lesions  degenerative,  inflammatory  or 
hemorrhagic,  affecting  the  cortex  of  the  brain,  the  cortico-peduncular  region, 
the  nuclei  of  the  nerves,  or  the  nuclear  fibres. 

Certain  experiments  indicate  that  there  exist  centres  in  the  cortex  (cortical 
centres)  controlling  the  movements  of  the  ocular  muscles,  and  theoretically  a 
lesion  in  such  situation  would  be  followed  by  paralysis  of  the  ocular  move- 
ments under  its  control.  Risien  RusselP  believes,  as  the  result  of  elaborate 
experimentation,  that  all  the  movements  of  the  eyeball  are  represented  in  the 
cerebral  cortex  and  not  only  the  lateral  movements.  From  pathological  in- 
vestigations it  has  been  assumed  that  certain  isolated  paralyses  of  the  levator 
producing  the  symptom  of  ptosis  are  of  cortical  origin.^ 

A  lesion  not  affecting  the  cortex,  the  nuclei  projDcr,  the  nerve-trunk  at  the 
base  of  the  brain,  or  its  distribution  in  the  orbit  and  the  muscles  themselves, 
followed  by  paralysis  of  ocular  movements,  could  be  situated  only  in  the  region 
which  connects  the  cortical  centre  with  the  nuclear  origin.  These  palsies, 
which  might  be  inferred  from  concomitant  symptoms,  may  be  called,  accord- 
ing to  Mauthner,  fascicular  paralyses,  just  as  those  which  have  been  described 
in  the  previous  paragraph  may  be  denominated  cortical  palsies. 

Ophthalmoplegia.  Systematic  writers  have  particularly  reserved  for 
that  class  of  paralysis  of  the  orbital  muscles  due  to  disease  of  the  nuclei  of 
the  third,  fourth,  and  sixth  nerves  the  name  op>lithalinoplegia  or  nuclear 
paralysis. 

As  has  already  been  stated,  the  term  ophthalmoplegia  may  with  perfect 
propriety  be  used  to  describe  all  of  the  ocular- muscle  palsies,  altlaough  it  is  fre- 
quently restricted  by  writers  to  the  class  just  referred  to.  It  was  first  em- 
ployed by  Brunner,  and  later  by  Von  Graefe,  who  recorded  a  characteristic 
example  of  the  disease  under  the  term  progressive  ophthalmoplegia.  Jona- 
than Hutchinson  introduced  the  names  ophthalmoplegia  externa  and  ophthal- 
moplegia interna,  meaning  by  the  former  a  symmetrical,  progressive  paralysis 
of  the  external  ocular  muscles,  in  contrast  to  non-symmetrical,  single  muscle 
palsies,  and  by  the  latter  paralysis  of  the  intra-ocular  muscles  (iris  and  ciliary 
body),  which  he  believed  to  be  due  to  disease  of  the  lenticular  ganglion. 
This  distinction,  however,  is  not  now  maintained,  because  the  two  sets  of 
muscles  may  be  affected  in  the  same  case,  the  symmetrical  character  of  the 
palsy  does  not  always  exist,  and  Mr.  Hutchinson's  idea  of  the  pathology  of 
the  internal  palsies  is  not  correct.  Collins  and  Wilde  (loc.  cit.)  have  found 
when  palsy  of  either  the  iris  or  ciliary  muscle  coexisted  with  extra-ocular 
paralysis  it  was  more  frequently  the  former — 31  cases  among  34. 

1  The  author  has  studied  one  remarkable  case,  also  seen  by  Dr.  Dercum,  which  began  at  one  and 
one-half  years,  with  complete  right  oculo-motor  palsy.  The  branch  supplying  the  levator  recov- 
ered; the  rest  of  the  branches  remained  paralyzed.  From  the  time  of  the  original  attack  until 
the  twenty-ninth  year  there  were  numerous  crises,  with  the  typical  symptoms  which  have  been 
described,  always  resulting  in  recurrence  of  the  ptosis.  Finally,  a  violent  attack  occurred,  the  ptosis 
recurred,  but  has  never  disappeared ;  in  other  words,  there  is  now  permanent  oculo-motor  palsy. 
(See  Fig.  270.)  f  <    . 

-  Journal  of  Physiology,  1894,  vol.  1,  xvii. 

3  This  subject  is'  referred  to  again  on  p.  789. 


DISEASES  OF  THE  CRANIAL  NERVES.  785 

Ophthalmoplegia,  as  ordinarily  defined,  may  be  divided  into  acute  ophthal- 
moplegia, or  acute  nuclear  palsy,  and  into  chronic  ophthalmoplegia,  or  chronic 
nuclear  palsy.  When  it  so  happens  that  the  intra-ocular  muscles  alone 
are  affected,  there  is  no  objection  to  the  term  ophthalmoplegia  interna 
(interior  ophthalmoplegia,  either  complete  or  incomplete,  unilateral  or  bilat- 
eral), if  it  is  understood  that  it  does  not  necessarily  refer  to  a  special  disease. 
AVhen  the  external  muscles  are  alone  afiected,  in  like  manner,  external  oph- 
thalmoplegia (ophthalmoplegia  exterior,  complete  or  incomplete,  unilateral  or 
bilateral)  is  utilized.  When  both  sets  are  affected  ophthalmoplegia  universa, 
or  total  ophthalmoplegia,  is  the  term  employed,  synonymous  with  complete 
bilateral  inward  ophthalmoplegia  of  Dufour.^ 

Acute  ophthalmoplegia,  or  acute  nuclear  palsy,  is  characterized  by  rapid 
paralysis  of  all  the  ocular  muscles,  often  associated  with  fever,  vomiting,  and 
convulsions.  Dufour  classifies  27  of  these  cases  among  220  examples  of  oph- 
thalmoplegia.    In  the  severest  type  they  usually  have  been  quickly  fatal, 

Fig.  271. 


Bilateral  paralysis  of  the  external  recti  after  diphtheria.    From  a  case  studied  by  the  author 
in  the  service  of  Dr.  Weir  Mitchell  at  the  Infirmary  for  Nervous  Diseases. 

and  have  occured  with  hemorrhage  into  the  region  of  the  nuclei  (apoplexy), 
or  as  an  acute  hemorrhagic  polioencephalitis  on  the  floor  of  the  fourth  ven- 
tricle and  aqueduct,  the  primary  cause  being  tuberculosis,  syphilis  (?)  ptomaine 
toxaemia,  or  poisoning  from  alcohol  or  sulphuric  acid.  A  less  fatal,  or  even 
benign,  type  (67  among  220 — Dufour)  may  occur  under  the  influence  of  in- 
juries, and  certain  poisons — for  example,  nicotine,  lead,  and  carbonic  acid 
(Knapp),  or  result  from  constitutional  diseases  (diabetes,  syphilis,  epidemic 
influenza). 

It  is  probable  that  some  of  the  cases  of  diphtheritic  paralysis  of  the  exter- 
nal ocular  muscles  are  nuclear  in  type.  Independently  of  the  common 
cycloplegia  of  this  disease  (see  p.  801),  there  may  be  paralysis  of  a  single 
external  ocular  muscle,  most  frequently  the  external  rectus,  but  also  the 
superior  oblique  and  the  internal  recti,  or  paralysis  of  both  external  recti, 
or,  finally,  paralysis  of  all  the  ocular  muscles.  In  Mendel's  case  of  com- 
plete ophthalmoplegia  externa  he  believed  the  condition  to  be  due  to  capil- 
lary hemorrhages  (central),  associated  with  a  primary  peripheral  neuritis. 

Acute  ophthalmoplegia  may  be  associated  with  acute  poliomyelitis,  with 

Annal.  d'Ocul,  ciii.  p.  99. 
50 


786 


NERVOUS  DISEASES  AND  THEIB  TREATMENT. 


bulbar  palsy,  or  with  facial  paralysis.  It  may  be  confounded  with  an  acute 
peripheral  neuritis  of  the  orbital  nerves,  but,  as  Swanz}^  points  out,  there 
would  then  be  an  absence  of  the  concomitant  symptoms  referable  to  intra- 
cranial origin. 

Chronic  ophthalmoplegia,  or  chronic  nuclear  palsy,  is  characterized  by  loss 
of  power  in  one  or  more  eye  muscles,  which,  at  first  slight,  gradually  increases 
and  spreads  until  every  muscle  is  paralyzed,  although  the  levator  may  escape 
partially,  and,  indeed,  ptosis  may  be  absent.  Two  chief  forms  are  distinguish- 
able, a  stationary  and  a  progressive,  the  difference  in  their  clinical  characters 
depending  on  the  fact  that  in  the  former,  after  a  certain  development  of 
palsy,  usually  symmetrical,  the  process  comes  to  a  standstill,  while  in  the 
latter  it  is  truly  progressive,  as  before  stated,  until  all  muscles  are  involved. 
The  disease  is  not  always  symmetrical  (it  may  be  unilateral),  and  the  diplopia, 
early  present,  usually  disappears  in  the  later  stages.     The  disease  depends 


Fig.  272. 


Fig.  273. 


Chronic  ophthalmoplegia.    (Infirmary 
for  Nervous  Diseases.) 


Chronic  ophthalmoplegia  in  a  boy  under  the  author's 
care  in  the  Jefferson  Medical  College  Hospital,  showing 
eflfort  of  occipitalis  to  supplant  the  action  of  the  levators. 


upon  atrophy  or  degeneration  of  the  nuclei  of  the  third  and  fourth  nerves, 
and  also  the  correlated  nucleus  of  the  sixth,  and  occurs  (1)  as  a  sequel  of  an 
acute  ophthalmoplegia,  the  lesions  of  which  have  failed  to  clear  up,  or  have 
produced  chronic  degenerative  changes ;  (2)  as  a  congenital  (occasionally 
hereditary)  affection,  usually  in  the  form  of  bilateral  ptosis,  with  deficient 
power  in  the  superior  recti ;  (3)  as  an  acquired  affection  in  children  (with 
whom  it  is  more  serious),  or  in  adults,  preference  being  given  to  the  male 
sex ;  (4)  in  association  with  locomotor  ataxia,  paretic  dementia,  progressive 
muscular  atrophy,  chronic  bulbar  paralysis,  disseminated  sclerosis,  and 
atrophy  of  the  optic  nerve,  and  in  connection  with  palsy  of  the  oculo-facial 
group.^     (See  page  776.) 

It  is  often  difficult  to  ascribe  the  condition  to  an  exact  cause,  though  in 
many  instances  constitutional  syjohilis  can  be  demonstrated,  and  in  other  cases 
a  tubercular  process.    It  is  essentially  clironic,  and  may  last  for  many  years. 


1  See  cases  by  Hughlings  Jackson,  Lancet,  July  15, 1893. 


DISEASES  OF  THE  CRANIAL  NERVES.  787 

If  the  anterior  cell  group  (anterior-lateral  nucleus  of  Darkschewitsch)  of 
the  third-nerve  nucleus  escape  (which  is  not  necessarily  the  case),  the  intra- 
ocular muscles  (iris  and  ciliary  muscle)  are  unaffected,  and  there  is  strong 
presumptive  evidence  that  a  chronic  paralysis  of  the  external  ocular  mus- 
cles is  nuclear  in  origin,  but  it  is  not  a  characteristic  sign.  Dammron  (quoted 
by  Siemerhng)  has  recorded  a  case  due  to  peripheral  neuritis,  the  nuclei 
being  unaffected,  with  preservation  of  accommodative  power  and  the  pupil- 
lary reflexes,  and  Goldzieher^  has  described  a  child  with  complete  ophthal- 
moplegia externa,  without  changes  in  the  power  of  accommodation  or  iris- 
movements,  due  to  tumor  of  the  corpora  quadrigemina.  There  were  no 
obvious  changes  in  the  nuclear  area  (the  microscope  was  not  utilized). 
Siemerling  concludes  that  nuclear  disease  may  be  inferred  from  ophthal- 
moplegia externa,  if  it  is  not  maintained  that  nuclear  palsy  mtist  manifest 
itself  as  an  external  ophthalmoplegia. 

Nuclear  ophthalmoplegia  may  be  closely  simulated  by  the  ocular-muscle- 
symptoms  of  pontine  tumors,  by  patches  of  softening  or  sclerosis,  with  over- 
distention  of  the  Sylvian  aqueduct,  but,  as  Swanzy  remarks,  these  are  not  true 
nuclear  palsies,  and  must  be  differentiated  by  concomitant  symptoms. 

According  to  Siemerling,-  the  pathological  states  undeilying  progressive 
paralysis  of  the  ocular  muscles  may  reside  in  : 

1.  Nuclear  disease  (disappearance  of  the  ganglion  cells),  with  participa- 
tion of  the  nerves  to  their  termination  in  the  muscle. 

2.  Degeneration  of  the  muscles  and  of  the  nerve-trunks,  with  intact  nuclei. 

3.  Interruption  of  the  conducting  power  of  the  intra-medullary  roots  on 
account  of  sclerotic  foci,  with  intact  muscles,  nerve-trunks,  and  nuclei. 

Conjugate  Lateral  Paralysis.  If  the  eyes  are  turned  from  a  mid-posi- 
tion, with  practically  parallel  visual  axes,  to  fix  an  object  on  either  side,  the 
lateral  movement  is  accomplished  in  obedience  to  an  impulse  coming  from  the 
cortex,  and  causing  synchronous  action  of  the  external  rectus  of  one  eye  and 
of  the  internal  rectus  of  the  other.  (See  page  775.)  The  pathway  of  this 
impulse  is  from  the  cerebral  cortex  to  the  sixth-nerve  nucleus,  thence,  via 
the  posterior  longitudinal  fasciculus,  it  crosses  to  the  opposite  side  and  passes 
to  the  nucleus  of  the  third  nerve.  Lesions  interfering  with  this  movement 
beget  a  symptom  to  which  the  name  conjugate  lateral  paralysis  is  given,  and 
may  be  situated  in  the  cortex,  corona  radiata,  or  internal  capsule,  i.  e., 
above  the  nuclei ;  or  in  the  pons,  i.  e.,  in,  and  in  the  neighborhood  of,  the 
nuclei. 

Although  we  know  that  stimulation  of  the  middle  portion  of  the  frontal 
lobe  causes  turning  of  the  eyes  to  the  opposite  side  and  that  stimulation  in 
the  visual  area  in  the  occipital  lobe  causes  the  same  movement,  but  in  an 
opposite  direction,'^  we  also  know  that  conjugate  iiiovement  is  possible  from 
stimulation  almost  anywhere  in  the  cortex,  or,  in  other  Avords,  that  the  cor- 
tical centre  for  conjugate  deviation  is  unknown.  Moreover,  wherever  it 
exists,  it  is  readily  affected,  and  consequently  conjugate  deviation  may  often 
be  a  distant  symptom,  and  is  likely  to  occur  with  cortical  lesions,  diversely 
placed. 

Conjugate  deviation  is  a  common  symptom  in  gross  lesions  of  the  cere- 
brum (apoplexy),  and  often  is  transitory  (occasionally  permanent),  the  eyes 
being  turned  to  the  side  opposite  to  the  palsy  (Prevost's  symptom).  For 
example,  in  a  left  hemiplegia  there  is  left  conjugate  lateral  palsy  (i.  e.,  paral- 
ysis of  the  lateral  moving  j)ower  of  the  left  external  rectus  and  right  internal 

1  Centralbl.  f.  prakt.  Augenheilk.,  February,  1893. 

-  Archiv  f.  Psychiatrie  und  Nervenkrankheiten,  1891,  Bd.  xxii.  Siippl.  Heft. 

3  Consult  Eye  Paralysis  by  John  A.  JeftYies,  Best.  Med.  and  Surg.  Journ.,  Oct.  20  and  27, 1892.    This 
article  has  been  utilized  in  the  preparation  of  this  section. 


788  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

rectus),  the  eyes,  by  the  action  of  the  unaffected  right  external  rectus  and  left 
internal  rectus  being  turned  to  the  right.  If  the  lesion,  similarly  placed,  is 
an  irritative  one,  the  deviation  is  in  exactly  the  opposite  direction.  Al- 
though the  eyes  have  lost  the  power  to  make  a  movement  to  one  or  the  other 
side,  the  directing  power  of  the  muscles  may  be  unimpaired  when  they  exer- 
cise their  function  in  a  different  association,  e.  g.,  in  the  act  of  convergence ; 
hence,  there  is  palsy  of  movement  and  not  of  the  muscles  supplied  by  a 
given  nerve. 

If  the  sixth-nerve  nucleus  in  the  pons  is  destroyed  by  a  lesion  there  is 
conjugate  lateral  paralysis  of  the  same  side  and  conjugate  deviation  to  the 
opposite  side,  because  the  abducens  supplies  the  external  rectus  of  its  own 
side  and  partly  the  internal  rectus  of  the  opposite  side.  Should  the  lesion 
be  an  irritative  one,  the  deviation  is  in  an  exactly  contrary  direction.  Thus 
it  is  evident  that  the  conjugate  lateral  paralysis  caused  by  cerebral  lesions 
and  by  pontine  lesions  produces  reverse  forms  of  conjugate  deviation.  Swanzy^ 
records  this  in  the  following  tabular  manner : 

^      1     ,  ,    .         j  Destructive.     Eyes  turned  away  from  palsied  side. 

Uerebral  lesions:  1 1^,^.^^^^^^^^      j^^gg  t^^^rned  toward  convulsed  side. 

-p      .      ,    .  J  Destructive.     Eyes  turned  toward  palsied  side. 

Jr-ontme  lesions :  |  irritative.     Eyes  turned  from  convulsed  side. 

Certain  other  varieties  of  conjugate  palsy  have  been  observed :  Complete 
conjugate  paralysis  (i.  e.,  one  external  rectus  and  the  opposite  internal  rec- 
tus), so  that  neither  muscle  is  capable  of  motion  ;  the  eyes  turn  to  the  oppo- 
site side,  move  up  or  down,  but  cannot  pass  the  middle  Hne  toward  the  lesion. 
Lesions  occupying  an  area  in  the  pons  above  the  sixth  nucleus  or  immedi- 
ately below  and  in  front  of  it  have  been  followed  by  such  phenomena.  The 
same  condition,  except  that  the  internal  rectus  of  the  one  eye  was  normal 
in  convergence,  has  been  recorded  with  a  lesion  just  below  the  eminentia  teres 
and  in  the  upj)er  quarter  of  the  pons  (Mills;.  The  facial  nerve  may  be  af- 
fected at  the  same  time.  Jefiiies^  describes  two  other  conditions,  viz. :  (a) 
When  both  eyes  are  open,  the  eye  with  the  paralyzed  internal  rectus  will  not 
turn  in  for  objects  on  the  other  side  of  the  nose,  but  will  if  the  other  eye  is 
covered;  and  (6)  the  internal  rectus  will  not  act  in  conjugate,  but  will  act 
in  near  vision,  the  external  rectus  being  normal.  Autopsies  do  not  explain 
these  differences  satisfactorily. 

In  conjugate  palsy  of  upward  or  downward,  but  not  of  lateral  movement, 
autopsies  have  revealed  a  lesion  at  the  posterior  part  of  the  third  nerve  nuclei. 
The  same  condition  has  been  recorded  by  Wernicke  in  disease  of  the  corpus 
striatum  and  of  the  optic  thalamus.  Palsy  of  the  upward  movement  of  both 
eyes,  without  involvement  of  the  levators,  may  be  caused,  as  in  Gowers's 
case,  by  a  lesion  (tumor)  on  the  middle  line  behind  the  corpora  quadrigem- 
ina,  damaging  these  slightly,  the  velum,  and  the  inferior  vermiform  process 
of  the  cerebellum. 

Finally,  we  may  have  loss  of  the  power  of  association  of  the  internal 
recti  in  near  vision  (i.  e.,  convergence),  although  the  ability  to  make  lateral 
movements  is  unimpaired.  Sometimes  the  power  of  accommodation  is  pre- 
served, but  convergence  is  lost ;  usually  the  two,  normally  associated  to- 
together,  are  equally  affected.  Autopsies  do  not  explain  these  conditions, 
and  we  may  assume,  in  the  absence  of  hysterical(?)  states,  a  gross  lesion  affect- 
ing the  centres  for  convergence,  which  are  probably  separate  from  but  close 
to  those  for  accommodation. 

The  Ocular  Palsies  ;  Significance  of  Palsies  of  the  External 
Ocular  Muscles.     The  significance  of  the  palsies  depending  upon  orbital 

1  Diseases  of  the  Eye,  4lh  ed.  -  Loc  cit. 


DISEASES  OF  THE  CRANIAL  NERVES.  789 

and  peripheral  disease,  often  of  pure  ophthalmological  interest,  has  been 
sufficiently  detailed  in  the  classifications  which  have  preceded  (page  782). 
It  is  well  to  insist  with  John  Amory  JeflEries,  however,  "  that  an  eye  paral- 
ysis, however  simple  it  may  seem,  demands  prompt  and  thorough  examination 
of  the  patient." 

(a)  Sixth  Nerve,  or  Abducens  Palsy.  Abducens  paralysis  is  not  uncom- 
monly a  distant  symptom  ;  in  fact,  as  has  been  pointed  out  by  several  authors, 
perhaps  owing  to  the  long  course  of  this  sixth  nerve  at  the  base  of  the  brain, 
this  phenomenon  is  more  common  with  it  than  with  other  cranial  nerves, 
abducens  palsy,  according  to  Wernicke,  being  a  frequent  symptom  of  tumor 
of  the  cerebellum.     One  or  both  nerves  may  be  alFected. 

Paralysis  of  the  sixth  nerve  occurring  at  the  same  time  with  a  hemi- 
plegia of  the  opposite  side  indicates  a  lesion  in  the  pons  on  the  same  side  as 
the  ocular  paralysis.  This  condition,  as  Mauthner  points  out,  is  rather  rare, 
at  least  pure  cases  of  it  are  uncommon  ;  but  when  it  occurs  it  points  distinctly 
to  a  lesion  in  that  portion  of  the  pons  through  which  the  abducens  fibres 
pass,  therefore  a  fascicular  paralysis.  The  sixth  and  facial  nerves  may  be 
associated  in  a  palsy,  their  nuclei  being  in  close  proximity,  or,  indeed,  accord- 
ing to  some  authorities,  identical.  Abducens  palsy  occurring  as  a  distant 
symptom  with  cortical  hemiplegia  may  be  differentiated  from  one  which  is  a 
direct  symptom  of  pontine  lesion,  because  under  the  latter  condition  the 
paralysis  of  the  extremities  is  contra-lateral.  Complete  unilateral  paralysis 
of  the  sixth  nerve  is  nuclear  in  origin  when  the  associated  action  of  the  in- 
ternus  is  also  destroyed,  but  may  be  basilar  from  the  pressure  of  the  products 
of  syphilitic  or  tubercular  disease  when  there  is  no  loss  of  the  conjugate  move- 
ments of  the  eyes  toward  the  side  of  the  lesion.  Complete  non-rheumatic 
palsy,  focal  lesions  being  excluded,  indicates  syphilis  in  adults,  but  tuber- 
cular disease  in  children  (Wood.) 

(6)  Fourth  Nerve,  or  Trochlearis  Palsy.  Isolated  paralysis  of  the  fourth 
nerve  is  not  frequent.  It  is  recorded  twice  by  Collins  and  Wilde  among  116 
cases  of  ocular  palsy,  and  yet,  as  Mauthner  has  pointed  out,  the  purest  types 
of  trochlearis  paresis  may  occur  in  basilar  meningitis,  especially  in  children, 
and  not  only  from  basal  lesions,  but  in  the  form  of  a  fascicular  paralysis 
caused  by  the  pressure  of  an  intra-cerebral  lesion. 

As  a  focal  symptom  the  paralysis  is  still  more  uncommon.  Nieden  (quoted 
by  Swanzy)  found  this  paralysis  with  tumor  of  the  pineal  gland.  In  a  case 
presenting  symptoms  of  cerebellar  disease,  and  at  the  same  time  fourth-nerve 
palsy,  it  is  fair  to  assume,  according  to  Starr,  that  the  anterior  portion  of  the 
cerebellar  hemisphere  on  the  side  of  the  paralysis  is  the  part  of  the  cere- 
bellum aflfected. 

It  is  more  common  to  find  the  third  and  fourth  nerves  affected  together ; 
for  example,  in  the  Collins  and  Wilde  analysis  this  occurred  eight  times.  It 
might  be  basal  in  origin,  or  might  occur  with  lesion  of  the  cerebral  peduncle. 

(c)  Third  Nerve,  or  Oculo-motor  Palsy.  Third  nerve  palsy  may  be  a 
distant  symptom  of  lesion  in  the  cerebral  hemisphere.  Indeed,  Swanzy  be- 
lieves that  ptosis  as  the  result  of  cortical  lesion  is  of  this  character  in  many 
of  the  cases.  We  have  seen  (page  784)  that  ptosis  may  be  caused  by  a 
lesion  of  the  cortex' — the  co-called  cerebral  ptosis — on  the  opposite  side  of 
the  lesion,  for  example,  in  the  angular  gyrus  just  below  the  inter-parietal 
fissure,  as  in  a  case  of  Herter.^ 

Disease  of  the  corpora  quadrigemina,  as  in  a  case  of  tubercular  degenera- 
tion in  this  region  observed  by  Steffen,  may  cause  double  ptosis,  and,  indeed, 

1  For  an  analysis  of  the  cortical  centres  of  the  ocular  muscles,  see  Mauthner's  Die  Lehre  von  den 
Augenmuskellii  hmungen,  Wiesbaden,  1889,  p.  385-389.    Also  Russell's  recent  researches  (loc.  cit.). 

2  Journal  of  Nervous  and  Mental  Disease,  January,  1895. 


790  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

to  quote  Mauthner,  that  ptosis  wliich  accompanies  cerebral  and  cerebro-spinal 
disease,  as  Avell  as  that  ptosis  which  is  associated  with  abducens  paralysis  of 
the  same  side,  is  usually  nuclear  in  origin. 

Contraction  of  the  palpebral  fissure  producing  apparent  ptosis — called  by 
Swanzy  sympathetic  or  pseudo-ptosis — myosis,  slight  enophthalmos  and 
lachrymation  on  the  paralyzed  side,  has  been  described  by  Xothnagel  with 
lesions  of  the  corpus  striatum. 

Ptosis  with  crossed  hemiplegia  may  be  explained  by  an  intra-peduncular 
lesion.  If  there  is  partial  oculo-motor  paralysis,  (the  functions  of  the  iris 
and  ciliary  muscles  being  preserved),  associated  with  contra-lateral  hemi- 
plegia, with  or  without  facial  or  hypoglossus  j^aralysis,  according  to  Mauth- 
ner the  lesion  should  be  looked  upon  as  afiecting  the  fascicular  fibres.  If, 
on  the  other  hand,  Avith  the  same  symj^toms,  the  paralysis  is  a  total  one,  it  is 
almost  certainly  basilar,  and  when  unassociated  with  other  paralysis  and 
total  this  diagnosis  becomes  practically  certain.  The  common  symptom  of 
crossed  paralysis,  that  is  to  say,  oculo-motor  palsy  on  the  side  of  the  lesion 
and  hemiplegia  upon  the  opposite  side,  is  not  certainly  significant  of  crus 
disease  unless  the  two  paralyses  come  on  simultaneously  CHughlings  Jackson). 

Double  oculo-motor  paralysis  may  be  significant  of  nuclear  disease,  or  com- 
pression at  the  base  of  the  brain,  for  example,  by  a  deposit  from  meningitis. 
Occasionally  it  develops  someAvhat  rapidly  and  disappears  Avithout  giA'ing  any 
signs  of  intra-cranial  disease.'  SA^hilLs  may  be  suspected  in  many  third- 
nerve  palsies,  the  most  noted  exceptions  being  those  due  to  diphtheria  and 
those  occurring  in  non-syphilitic  tabetic  patients. 

The  regions  thus  far  discussed  refer  particularly,  so  far  as  the  base  is  con- 
cerned, to  the  pons  and  the  jDeduncles.     If,  now,  a  lesion  afifects : 

{d)  The  Region  of  the  Cavernous  Sinus,  the  sixth,  third,  and  fourth  nerves 
are  all  likely  to  be  iuA^oh'ed.  Thus,  thrombosis  of  this  A^enous  channel  pro- 
duces ophthalmoplegia  on  the  same  side  as  the  disease,  oedema  of  the  eyelids, 
proptosis,  at  first  contracted  and  afterward  dilated  pupil,  anaesthesia  in  the 
region  of  the  distribution  of  the  first  division  of  the  trigeminus,  and  some- 
times neuro-paralytic  keratitLs.  There  may  or  may  not  be  optic  neuritis  and 
distention  of  the  retinal  A^eins.  These  phenomena  are  markedly  A'isible  in 
the  so-called  pulsating  exojDhthalmos,  which  is  caused  by  an  arterio-A'enous 
aneurism  of  the  cavernous  sinus.  Meningitis,  injury,  or  any  form  of  pres- 
sui-e  or  lesion  in  the  same  region  is  Hkely  to  be  followed  by  similar  symptoms. 

Lesions  in  the  region  of  the  sphenoidal  fissure,  frequently  periostitis  and 
syphilitic  deposits,  are  fruitful  causes  of  ocular  palsies,  and  their  significance 
has  already  been  referred  to  on  page  782  et  seq.^ 

The  -significance  of  nuclear  disease,  in  the  form  of  acute  and  chronic  oph- 
thalmoplegia, and  all  those  A'arieties  of  palsy  originating  in  the  cortical  or 
cortico-peduncular  areas  which  are  conjugate,  need  not  again  be  rcAaewed. 

The  significance  of  certain  cau-sal  varieties  of  jxxralyses  of  the  external  ocu- 
lar muscles,  chief  among  which  are  those  seen  in  connection  Avith  tabes  dor- 
salis,  paretic  dementia  and  disseminated  sclerosis  remains  to  be  considered. 

The  frequency  of  ocular  paralysis  among  tabetic  patients  Agarics  Avith  dif- 
ferent authorities.  Berger  (loc.  cit.)  notes  it  in  38  per  cent.,  and  quotes 
Erb,  Avho  found  it  in  27  per  cent.,  and  Moeli  in  39.6  per  cent.     The  paral- 

1  For  a  description  of  these  palsies,  see  Grsefe's  Arcliiv.,  Bd.  xii.  2, 1866,  and  Mauthner,  loc.  cit.  p. 
415. 

2  The  preceding  paragraphs  on  the  significance  of  the  ocular  palsies  are  to  be  understood  as  a 
brief  and  necessarily  incomplete  resume  of  the  subject,  which  is  more  fully  treated  in  the  chapters 
devoted  to  cerebral  localization,  in  connection  with  which  the  study  of  cases  of  ocular  palsies  De- 
comes  of  paramount  importance.  The  aifthor  desires  to  note  special"  indebtedness  to,  and  frequent 
quotation  from,  Mr.  Swanzy's  admirable  Bowman  lecture  on  "  The  A'alue  of  Eye  Symptoms  in  the 
Localization  of  Cerebral  Disease."  Transactions  of  the  Ophthalmological  Society  of  the  United 
Kingdom,  vol.  ix.  1889,  and  Mauthner's  Monograph,  loc.  cit. 


DISEASES  OF  THE  CRANIAL  NERVES.  791 

ysis  is  most  apt  to  occur  in  the  earlier  aud  pre-ataxic  stage,  by  some  authori- 
ties, for  example,  Gowers,  being  considered  to  be  more  frequent  in  syphilitic 
subjects  than  in  others,  a  conclusion  not  reached  by  Berger,  who,  however, 
believes  that  the  paralyses  are  more  apt  to  be  permanent  in  the  syphilitic 
tabetics. 

There  is  some  difference  of  opinion  as  to  which  nerve  is  most  frequently 
affected,  Erb  and  Charcot  stating  that  the  oculo-motor  is  more  apt  to  be  in- 
volved than  others,  while  Woinow  believes  it  is  the  abducens,  especially  the 
left.  A  very  common  partial  oculo-motor  palsy  affects  the  branch  supplying 
the  levator.  The  internal  recti  may  also  be  involved  in  a  paralysis,  or  there 
may  be  merely — and  this  is  an  important  point  especially  dwelt  upon  by 
Landolt — insufficiency  of  their  converging  power,  an  observation  which  the 
author  has  also  made  in  a  number  of  cases. 

The  cases  of  complete  ophthalmoplegia  in  connection  with  tabes  have 
already  been  referred  to  on  page  786. 

We  are  uncertain  as  to  the  exact  cause  of  these  palsies,  some  being  explained 
as  nuclear,  others  as  the  result  of  a  descending  neuritis,  and  still  others  as  due 
to  a  chronic  ependymitis.  One  of  the  characteristics  of  tabetic  paralysis  is 
its  transitory  nature  in  many  instances,  and  by  this  peculiarity  it  may  often 
be  differentiated  from  the  lesions  of  the  nerve-trunks  themselv&s.  Fournier 
has  developed  the  following  table  : 

Symptoms  of  Tabes.  Symptoms  of  Lesions  of  the  Nerve-trunks. 

1.  Paralysis,  often  partial,  sometimes  attacking       1.  Paralysis,  total. 

only  the  Iris. 

2.  Paralysis,  associated  either  with  preservation       2.  No  such  association. 

of  the  accommodative  reflexes  or  with  my- 
osis. 

3.  Paralysis,  quiciily  passing  away,  lasting  per-       .3.  Paralysis,  lasting. 

haps  a  day,  or  even  a  few  minutes. 

4.  Paralyses  prone  to  relapses.  4.  Paralyses  not  prone  to  relapses. 

5.  Spontaneous  cure  common  5.  Cure  only  after  proper  medication. 

The  important  point  is  that  a  transient  external  ocular  palsy  may  be  a 
significant  and  early  symptom  of  locomotor  ataxia,  aud  should  never  be  dis- 
regarded. 

In  Friedreich's  ataxia  symptoms  referable  to  the  ocular  muscles  are 
not  usual  with  the  exception  of  nystagmus,  although  strabismus,  diplopia, 
blepharospasm,  and  ptosis  have  been  observed.^  Nystagmus  is  exceedingly 
common,  although  late  in  appearing,  occurring  in  fully  50  per  cent,  of  the 
cases.     Kystagmus,  although  less  frequent,  may  occur  in  advanced  tabes. 

According  to  Uhthoff  (Voe.  cit.),  paralysis  of  the  ocular  movements  was 
present  m  17  of  his  100  cases  of  disseminated  sclercsis,  namely,  of  the  sixth 
nerve,  6  times ;  the  third  nei've,  3  times ;  the  associated  movements,  3 
times ;  convergence,  3  times  ;  and  complete  ophthalmoplegia  in  2  cases.  The 
lesion  was  probably  nuclear,  and  in  no  case  was  there  complete  paralysis  of 
an  individual  nerve.  Coexistent  ny.stagmus  was  frequent,  and  ny.stagmus  or 
nystagmic  jerkings  were  met  with  in  50  per  cent,  of  the  cases. 

In  paretic  dementia,  as  in  tabes,  single  or  combined  oculo-motor  jDalsies 
may  be  early  symptoms,  probably,  as  in  the  other  disease,  of  nuclear  origin. 
The  abducens  seems  to  be  most  often  affected.  The  palsy  may  be  either  tem- 
porary, as  in  tabes,  or  become  complete,  all  muscles  being  affected  and  form 
one  of  the  four  types  of  ophthalmoplegia. 

The  significance  of  certain  ocular  palsies  as  the  result  of  diphtheria,  rheu- 
matism, diabetes,  influenza,  poisons,  and  injuries,  must  not  be  forgotten  in 
the  investigation  of  each  case. 

Prognosis.     The  prognosis  of  ocular  palsies  depends  upon  the  cause,  many 

1  Griffith,  loc.  cit. 


792  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

examples  of  peripheral  and  even  of  basal  palsies  due  to  rheumatism  or 
syphilis  being  readily  amenable  to  treatment.  Mauthner's  warning,  that  an 
apparent  rheumatic  palsy  may  be  the  forerunner  of  spinal-cord  disease, 
should  not  be  forgotten.  In  general  terms  it  may  be  stated  that  if  the 
primary  cause  can  be  influenced  by  treatment,  the  prognosis  is  good ;  but 
there  are  exceptions  to  this  rule.  For  example,  the  original  cause  may  beget 
a  structural  lesion,  which  exists  so  long  that  by  pressure  it  destroys  a 
definite  region,  for  instance,  the  nuclei.  Under  these  circumstances  power 
does  not  return  to  the  paralyzed  nerves,  even  though  the  cause  of  pressure  is 
removed. 

The  prognosis  of  nuclear  ophthalmoplegia  is  unfavorable  in  many  in- 
stances, fatal  in  a  few,  while  in  a  small  j)ercentage  there  is  amelioration  and 
even  recovery. 

Much  dispute  has  arisen  in  regard  to  the  relative  frequency  of  the  paralysis 
of  the  muscles,  most  authors  agreeing,  however,  that  paralysis  of  the  abducens 
is  met  with  mogt  frequently,  next  in  order  being  u.nilateral  paralysis  of  the 
oculo-motor.  After  these  come  paralysis  of  the  superior  oblique,  inferior 
rectus,  superior  rectus,  internal  rectvis,  and  inferior  oblique.  According  to 
Duane,^  isolated  paresis  of  the  superior  rectus  stands  next  in  order  to  that  of 
the  external  rectus,  surpassing  even  paralysis  of  the  superior  oblique  in 
frequency. 

Treatment.  In  syphilis  the  usual  remedies  are  applicable,  and  in  many 
instances  the  best  results  follow  large  doses  of  iodide  of  potassium.  These, 
however,  should  not  be  given  to  the  neglect  of  mercury,  a  good  plan  being 
to  follow  the  inunctions  with  massive  doses  of  the  drug  named.  In  recent 
times  there  has  been  a  revival  of  the  treatment  of  syphilis  by  intra-mus- 
cular  injections  of  mercury,  various  preparations  finding  favor  with  difierent 
surgeons.  Thus  far  the  author's  experience  with  these  injections  has  been 
an  unsatisfactory  one,  but  is  not  yet  sufiiciently  large  to  form  a  definite 
opinion. 

The  annoyance  of  double  images  may  be  prevented  by  covering  the  affected 
eye  with  a  patch  or  a  piece  of  ground-glass  mounted  in  a  frame.  Sometimes 
prisms  may  be  utilized  to  ftise  the  images.  In  order  to  stimulate  the  weak- 
ened muscles,  mechanical  treatment  has  been  suggested,  especially  by  Michel, 
the  conjunctiva  being  seized  near  the  insertion  of  the  affected  muscle  with 
forceps,  and  the  eyeball  drawn  forcibly  beyond  the  ordinary  limit  of  contrac- 
tion, and  then  back  again.  Electricity  may  be  of  occasional  service.  Or- 
dinarily, one  pole,  the  cathode,  is  placed  upon  the  closed  lid,  while  the 
other  is  put  upon  the  temple.  Usually  a  current  of  more  than  three  milli- 
amperes  is  unbearable,  especially  if  the  pole  is  placed  directly  over  the 
insertion  of  the  muscle  in  the  sclera.  Of  the  drugs  used  for  the  purpose 
of  stimulating  the  nerves,  strychnine  deserves  the  first  rank.  It  should  be 
given  in  full  doses,  if  necessary,  by  the  hypodermic  method.  The  suspension 
treatment  of  ataxia  is  said  to  have  been  followed  by  relief  of  the  ocular  dis- 
abilities of  this  disease,  not  only  in  the  optic  nerve,  but  also  in  the  muscles. 
The  surgical  measures  for  the  relief  of  the  diplopia  of  jjaralyzed  muscles  be- 
long to  ophthalmic  treatises,  to  which  the  reader  is  referred.  Necessarily  all 
medication  must  be  determined  by  the  cause ;  for  example,  salicylic  acid  in 
rheumatic  palsy. 

Spasmodic  Strabismus  and  Spasm  of  the  Ocular  Muscles.  The 
different  types  of  conjugate  deviation  which  arise  under  the  influence  of  a 
paralytic  and  convulsive  lesion  have  been  referred  to  on  page  788.  True 
spasmodic  convergent  strabismus  occurs  in  certain  types  of  cerebral  disease, 

1  Archives  of  Ophthalmology,  1894.  vol.  xxiii.  p.  61. 


DISEASES  OF  THE  CRANIAL  NERVES.  793 

particularly  iuflammatiou  at  the  base  of  the  brain  or  in  the  meninges,  and 
should  not  be  confiised  with  the  periodic  concomitant  squint  of  hyper- 
metropia. 

Si^asms  of  individual  ocular  muscles  (with  or  without  painful  sensations) 
are  rare,  but  they  have  been  described  with  several  conditions,  for  example, 
by  Gowers  in  chorea,  by  Samelsohn  (of  the  superior  recti)  in  tubercular  dis- 
ease at  the  base  of  the  brain,  and  by  a  number  of  writers  in  hystero-epilepsy, 
in  one  instance,  at  least,  associated  Avith  periostitis  of  the  jaw.' 

Hysteria  is  responsible  for  several  well-marked  anomalies  in  the  move- 
ments of  the  ocular  muscles,  and  those  which  belong  to  the  oculo-facial 
group,  the  most  usual  being  blepharospasm,  convergent  strabismus,  ptosis, 
and  the  so-called  abducens  palsy,  although  it  is  doubtful,  as  Mauthner  sug- 
gests, whether  the  term  "  palsy  "  is  at  all  applicable  to  these  cases  which,  in 
the  hiain,  partake  of  a  spasmodic  nature.  The  convergence  in  hysterical 
strabismus  is  extreme,  the  cornea  being  almost  buried  beneath  the  inner  com- 
missural angle.  Divergence  is  said  not  to  occur,  and  in  three  marked  cases 
studied  by  the  author,  although  the  spasmodic  movements  were  both  up  and 
in  and  usually  associated  with  intermitting  blepharospasm,  there  was  never 
outward  deviation  ;  in  one  there  was  marked  diplopia. 

Partial  convulsions  of  the  ocular  muscles  have  been  described  by  Gowers,'' 
one  case,  in  which  the  left  eye  moved  outward  near  to  the  external  can- 
thus,  the  right  remaining  still,  the  attack  being  associated  Ayith  blinking  of 
both  eyes,  and  when  it  had  ceased,  slight  drooping  of  the  left  eyelid,  being 
attributed  to  disease  in  the  centres  for  the  movements  of  the  eyes  in  the  pons, 
or  beneath  the  corpora  quadrigemina. 

Spasm  of  the  levator,  from  irritation  of  the  fifth  nerve,  is  a  phenomenon 
occasionally  observ^ed.  S}Tichronous  movements  of  the  upper  lid  and  the 
maxilla  have  been  reported  in  a  number  of  instances  since  Helfreich  and 
O.  Bull  described  examples  of  unilateral  paresis  of  the  levator  in  which 
opening  of  the  mouth  produced  an  involuntary  raising  of  the  lid.  This  con- 
dition has  been  explained  by  Gowers  by  assuming  that  the  levator  fibres  of 
the  third  nerve  in  these  cases  arise  from  the  motor  nucleus  of  the  fifth  nei've. 
Bull,'^  however,  dissents  from  this  explanation,  and  prefers  to  regard  the  con- 
traction of  the  levator  as  an  associated  or  reflex  movement. 

NvsTAGMUS.  This  phenomenon  is  characterized  by  a  rapid  involuntary 
movement  of  the  eyeballs,  usually  from  side  to  side,  but  sometimes  in  a  ver- 
tical or  rotary  direction;  it  may  be  congenital  or  acquired,  and  is  bilateral 
in  the  vast  majority  of  cases.  In  the  few  instances  of  unilateral  nystagmus 
which  have  been  reported  the  movements  Avere  usually  in  the  A^ertical  direc- 
tion. The  extent  of  the  moA^ement  A^aries  from  one  to  ten  millimetres,  and 
its  frequency  from  sixty  to  two  hundred  oscillations  per  minute  (GoAvers). 
Sometimes  the  mo\^ements  are  so  slight  that  they  are  detectable  only  by 
watching  the  fundus  of  the  eye  Avith  the  ophthalmoscope. 

Congenital  nystagmus  and  that  type  which  occurs  from  diseases  of  the  eye 
or  the  pursuance  of  certain  occupations,  for  example,  mining,  is  not  perti- 
nent to  the  present  subject. 

From  the  standpoint  of  neurology,  hoAveA^er,  inasmuch  as  nystagmus  is 
exceedingly  common  in  diseases  of  the  nervous  system,  the  symptom  may  be 
of  importance.  It  occurs  in  fully  50  per  cent,  of  the  cases  of  disseminated 
sclerosis  and  Friedreich's  ataxia,  and  sometimes  in  adA^auced  tabes  (see  also 
p.  791).  As  a  difierential  diagnostic  point  betAveen  disseminated  sclerosis  and 
hysteria,  it  is  a  very  important  phenomenon,  as  it  does  not  occur  in  functional 

1  Consult  also  Mauthoer :  Diagnostik  und  Therapie  der  Augenmuskellahmungen,  1889,  p.  628 
*  Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  iv.  p.  307. 
3  Archives  of  Ophthalmology,  vol.  xxi.  p.  354. 


794  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

diseases ;  indeed,  as  Dr.  Gowers  states,  it  may  be  the  only  marked  symptom 
of  the  early  stage  of  degenerative  disease  when  other  signs  are  still  in 
abeyance. 

As  a  localizing  sign,  however,  in  the  present  state  of  our  knowledge,  it  is 
not  of  much  value,  because  it  may  be  seen  with  almost  any  of  the  many 
cerebral  diseases.  It  has  been  noted  in  focal  disease  and  in  diffuse  degenera- 
tions, with  hemorrhages,  tumors,  inflammations  of  the  meninges  and  in 
lesions  in  many  regions  of  the  cerebro-spinal  axis.  There  is  no  doubt  that 
it  is  especially  common  in  tumors  of  the  cerebellum,  and  Gowere  states 
it  is  more  frequent  in  organic  brain  disease  when  there  is  impairment  of 
sight  from  optic  neuritis  than  when  this  is  not  present.  It  has  been  reported 
in  conjugate  deviation  with  disease  of  the  pons,  and  may  assume  a  convul- 
sive tj^Q. 

Sometimes  nystagmus  is  associated  Avith  other  movements,  although,  curi- 
ously enough,  it  is  rare  in  diseases  attended  with  tremor  other  than  those 
which  have  been  mentioned.  Vertical  nystagmus,  for  example,  may  be 
associated  with  a  movement  of  the  levator,  or  with  a  hippie  oscillation  of 
the  pupil  (Jessop).  Occasionally  it  is  developed  only  when  the  eyes  are 
moved  in  the  line  of  direction  of  a  weakened  muscle,  the  movements  then 
being  rather  jerky — the  so-called  nystagmic  jerks. 

jS'ystagmus  has  been  ascribed  to  chronic  fatigue  of  the  muscles,  oscillation 
of  the  globe  consequent  upon  the  muscular  atony,  and  also  to  a  central 
origin.  In  some  cases  it  is  probable  that  both  explanations  are  correct. 
Eisieu  Russell's  experiments  ^  with  nystagmus  caused  by  removal  of  portion 
of  the  cerebellum  indicate  that  there  are  two  varieties,  one  an  irritation 
phenomenon  and  the  other  a  paralytic  condition  due  to  weakness  of  the 
muscles  producing  rotation  in  any  direction,  or  of  their  opponents.  Its  anal- 
ogy to  vertigo,  especially  in  those  cases  in  which  external  objects  appear  to 
move  in  accord  with  the  ocular  movements,  has  been  pointed  out  by  Gowers. 


AFFECTIONS  OF  THE  INTRA-OOULAR  MUSCLES 
(Iris  and  Ciliary  Muscle). 

AsTATOMico-PHYSiOLOGiCAL  CONSIDERATIONS.  Slightly  toward  the  nasal 
side  of  the  iris,  the  stroma  of  which  is  composed  essentially  of  bloodvessels 
and  a  cellular  mesh-work,  is  the  pupil.  Close  to  its  margin  is  a  ring,  about 
one  millimetre  broad,  of  smooth,  muscular  fibres — the  sphincter  iridls,  which 
lies  near  to  the  posterior  surface  of  the  iris.  Beyond  the  sphincter,  lying 
between  posterior  pigmented  epithelium  and  the  vascular  layer,  resting  upon 
the  former,  is  a  thin  layer  composed  of  fibres  having  a  radial  dii*ection  from 
the  ciliary  to  the  pupillary  margin.  This  is  regarded  by  some  authors  as 
muscular  in  structure,  and  having  the  properties  of  a  dilating  mechanism, 
hence  the  dilator  iridis ;  but  by  others  it  is  considered  as  a  specially  developed 
limiting  membrane  without  such  physiological  properties. 

The  vascular  supply  of  the  iris  is  rich,  the  arteries  being  derived  from  the 
long  and  anterior  ciliary  arteries  and  the  vessels  of  the  ciliary  processes. 

The  nerve  supply  of  the  iris  is  derived  from  the  ophthalmic  division  of  the 
fifth,  the  third  nerve,  and  the  sympathetic,  as  follows :  The  ciliary  ganglion 
is  connected  by  its  shoi't,  or  motor  root,  with  the  third  nerve,  by  its  sympa- 
thetic root  with  the  cavernous  sympathetic  plexus  and  cervical  sympathetic 
nerve,  and  by  its  long,  or  sensory  root,  with  the  nasal  branch  of  the  ophthal- 
mic division  of  the  fifth.     Th6  short  ciliary  nerves  supply  the  iris  and  the 

1  Loc.  cit. 


DISEASES  OF  THE  CRANIAL  NERVES.  795 

ciliary  muscle,  and  the  long  ciliary  nerves  are  also  distributed  to  the  iris. 
The  filaments  from  the  motor  (short)  root  go  to  the  circular  fibres  (sphinc- 
ter), and  those  from  the  sympathetic  to  the  radiating  (so-called  dilator) 
fibres.  The  motor  sympathetic  fibres  come  from  the  superior  cervical  gang- 
lion and  run  in  the  carotid  plexus,  and  are  influenced  by  a  spinal  centre 
corresponding  to  the  lowest  part  of  the  cervical  cord  (about  the  seventh  cer- 
vical and  first  dorsal  vertebra) — the  so-called  cilio-spinal  centre  of  Budge. 

The  ciliary  muscle,  composed  of  unstriped  muscular  fibres,  is  the  chief 
agent  of  accommodation.  Its  nervous  mechanism  is  thus  summarized  by 
Foster :  "  The  ciliary  muscle  is  governed  by  fibres  which  may  be  traced 
through  the  short  ciliary  nerves  and  in  the  ciliary  ganglion,  along  the  third 
nerve  to  a  centre  which  lies  in  the  extreme  front  of  the  floor  of  the  aque- 
duct, or,  rather,  in  the  extreme  hind  part  of  the  floor  of  the  third  ventricle, 
and  which  is  especially  connected  with  the  extreme  front  of  the  nucleus  of, 
and  so  with  the  anterior  bundles  of,  the  third  nerve." 

The  relation  of  the  various  segments  of  the  nucleus  of  the  oculo-motor  to 
the  muscles  has  been  referred  to  on  page  774,  and  we  know  that  the  centres 
for  the  sphincter  of  the  iris,  accommodation,  and  convergence  he  close  to 
each  other  in  the  floor  of  the  aqueduct. 

The  Normal  Piqn/.  The  size  of  the  pupil  in  health  varies  with  ex- 
posure to  light  and  with  accommodation  and  convergence.  There  is  no 
physiological  standard  on  which  to  base  a  measurement,  the  average  diameter 
being  a  little  over  four  millimetres.  The  position  of  the  pupil,  as  already 
stated,  is  a  little  to  the  nasal  side,  and  under  equal  illumination  the  pupils 
should  be  round  and  of  equal  size.  The  diameter  of  the  pupil  varies  some- 
what mth  the  age  of  the  patient,  being  usually  larger  in  the  young  and 
smaller  in  the  old,  and  also  with  the  refractive  condition  of  the  eye. 

Measurement  of  the  Pupil.  The  pupil  may  be  measured  approximately  by 
holding  before  it  a  rule  marked  in  millimetres  and  noting  the  number  of 
spaces  its  width  occupies,  or  one  of  the  variety  of  instruments  known  as 
pupillometres  may  be  employed,  a  serviceable  device  being  one  which  con- 
sists of  a  scale  of  circles  held  close  to  the  observed  eye,  the  scale  being  slowly 
rotated  until  that  circle  which  matches  the  pupil  in  size  is  reached. 

It  is  much  to  be  desired  that  in  making  examination  of  the  pupils  a  uni- 
form light  should  be  employed  and  the  character  of  the  light  stated,  and  it  is 
much  to  be  regretted  that  in  the  recorded  examinations  such  loose  statements 
as  "pupils  dilated,"  "pupils  contracted,"  "pupils  medium-sized,"  have  been 
frequently  employed. 

Method  of  Testing  the  Pupillary  Reactions.  Before  attempting  to  record 
pupillary  phenomena  all  errors  of  accommodation  and  convergence  should 
be  eliminated,  and  the  absence  or  presence  of  attachment  between  the  iris 
and  the  capsule  of  the  lens  (synechise),  or  immobility  from  atrophy  of  the  iris, 
should  be  ascertained.  Numbers  of  errors  utterly  vitiating  the  value  of 
many  recorded  cases  have  occurred  from  negligence  in  regard  to  these  points. 

The  light  employed  for  testing  the  sensitiveness  of  the  retina  or  visual 
centre  should  not  be  more  intense,  as  Turner  well  observes,  than  that  to  which 
the  eye  is  usually  accustomed.  Therefore,  examinations  made  by  a  light 
reflected  from  a  mirror,  or  by  passing  a  flame  in  front  of  the  eye,  are  not 
accurate,  except  under  special  conditions  presently  to  be  described.  The  fol- 
lowing is  the  method  : 

The  patient  is  placed  before  a  window  in  difiuse  daylight  and  one  eye 
carefully  excluded.  He  is  directed  to  look  into  the  distance  with  the  ex- 
posed eye,  which  is  then  shaded,  and  if  it  is  normal  a  considerable  dilata- 
tion of  the  pupil  will  occur.  On  removal  of  the  covering  hand  or  card, 
when  the  liffht  strikes  the  retina  a  contraction  to  the  same  size  as  that  which 


796 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


existed  before  the  test  was  applied  takes  place.  This  is  the  direct  reflex  adioiv 
of  the  pupil,  and  is  brought  about  by  a  muscular  contraction  of  the  sphincter 
of  the  iris  following  the  stimulation  of  the  optic  nerve.  If  during  this 
examination  the  other  pupil,  which  has  been  shaded  by  a  card  or  a  covering 
hand,  is  observed,  it  will  be  found  it  has  acted  in  unison  with  its  fellow. 
This  is  the  consensual  or  indirect  reflex  action  of  the  pupjil.  Therefore,  in  nor- 
mal eyes  the  pupils  should  be  equal,  not  only  with  both  eyes  open,  but  with 
one  eye  shaded.^ 

Contraction  of  the  pupil,  or  the  response  of  the  iris  which  occurs  when  the 
eye  is  exposed  to  light,  is  a  reflex  phenomenon,  in  general  terms  brought 
about  by  an  impulse  passing  along  the  optic  or  aflerent  nerve  to  the  third  or 
efferent  nerve,  the  centre  being  in  the  aqueduct  at  a  level  with  the  anterior 
corpora  quadi'igemina.     The  exact  pathway  of  the  reflex,  however,  is  not 

Fig.  274. 


3  N,  centre  of  third  nerve  ;  1,  connection  between  nuclei  of  third  nerves ;  2,  Meynert's  fibres ;  Q, 
corpora  quadrigemina ;  C,  chiasma  ;  0,  optic  nerve ;  P,  myotic  fibres  of  third  nerve  ;  L,  seat  of  lesion  ; 
arrows  show  path  of  impulse  in  lesion  of  right  tract  at  L.    (Swanzy.) 

definitely  determined.  Thus,  light  falling  on  one  eye  starts  an  impulse  along  the 
optic  nen^e,  which,  owing  to  semi-decussation  of  the  fibres  in  the  chiasm,  passes 
with  equal  facility  along  each  tract  to  the  corpora  quadrigemina,  and  thence 
by  the  communicating  fibres  between  these  bodies  and  the  third  nerve  centre 
(Meynert's  fibres)  to  the  special  centre  of  the  sphincter  pujoillre  (pupil-con- 
tracting centre),  and  from  there  by  the  ciliary  branches  to  each  ciliary  gan- 
glion, the  ciliary  nerves  and  circular  iridic  fibres.  This  would  explain  the 
contraction  (direct  reflex)  in  the  illuminated  as  well  as  that  (consensual)  in 
the  non-illuminated  eye.  Fibres  directly  connecting  the  thu'd  nerve-centres 
are  probably  also  present  (Fig.  274). 

Many  other  connections  have  been  described,  one  of  which,  that  given  by 
Mendel  (quoted  by  Swanzy),  may  be  cited :  Optic  nerve,  optic  tract,  to 
ganglion  habenulae  of  the  same  side,  thence  by  the  posterior  commissure  to 
the  nucleus  of  the  third  nervp,  and  thence  to  the  ciliary  nerves.     This  may 


1  The  iris  response  to  the  stimulus  of  light  should  also  be  tested  with  both  eyes  open  and  exposed 
to  the  source  of  illumination  ;  they  are  then  alternately  covered  and  exposed  and  the  reactions  noted. 


DISEASES  OF  THE  CRANIAL  NERVES.  797 

be  spoken  of  as  the  optic  oculo-motor  reflex,  and  represents  the  sensory  motor 
arc  of  the  pupil. 

If  the  eyes  are  directed  to  a  near  object — for  example,  the  point  of  a  pencil 
— contraction  takes  place  under  the  influence  of  accommodation  and  con- 
vergence ;  that  is  to  say,  the  sphincter  of  the  iris  contracts  in  association 
with  the  ciKary  muscle  and  the  internal  recti.  This  is  the  associated  action  of 
the  pupils.  Accommodation  increases  pupillary  contraction,  but  this  does 
not  take  place  under  the  influence  of  accommodation  unassociated  with  con- 
vergence. It  does  occur  with  convergence  Avithout  the  act  of  accommodation. 
The  nervous  mechanism  has  been  described  on  page  795. 

Contraction  of  the  pupil  can  also  take  place  after  division  of  the  cervical 
sympathetic,  section  of  the  spinal  cord  (cilio-spinal  centre),  or  depression  of 
the  pupil-dilating  centre  in  the  medulla  (front  part  of  the  aqueduct). 

Dilatation  of  the  Pupil.  The  mechanism  of  dilatation  is  still  in  dispute, 
the  tliree  most  prominent  theories  being  that  it  is  caused  by  the  action  of  the 
sympathetic  vaso-constrictor  nerves,  or  by  contraction  of  the  radially  placed 
muscular  fibres  Tdilator  pupillse),  or  by  inhibition  of  the  sphincter  through 
the  action  of  the  sympathetic,  which  presupposes  the  presence  of  elastic  tis- 
sue in  the  iris  (Gaskell).  Recently  Langley  and  Anderson'  have  reviewed 
the  evidence,  and  the  indications  are  that  a  dilator  muscle  is  demonstrable. 

The  long  ciliary  nerves  are  known  as  the  mydriatic  nerves.  They  arise  from 
the  front  of  the  aqueduct  and  are  in  connection  with  the  cilio-spinal  centre ; 
they  pass  out  with  the  first  two  dorsal  nerves,  reach  the  cervical  and  cavern- 
ous sympathetic  and  Gasserian  ganglion,  and  finally  the  eye  via  the  gangli- 
onic branch  of  the  fifth,  the  ciliar}^  ganglion  and  its  branches  of  distribution. 
The  pupil-dilating  centre  is  in  the  medulla  and  is  very  sensitive  to  stimuli  of 
all  kinds,  e.  g.,  irritation  of  the  skin  of  neck  {skin  reflex),  the  emotions,  and 
deep  respiration.  Independently  of  the  action  of  dilating  fibres  in  the  iris, 
as  Foster  puts  it,  the  dilating  mechanism  is  apparently  tonic  in  nature,  but 
subject  to  augmentation  from  various  causes,  and  the  cervical  sympathetic  is 
the  eflPerent  channel. 

The  Pupil  ix  Disease.  While  investigating  the  pupil-changes  (see  page 
795),  as  William  McEwen'^  insists,  five  possibilities  should  suggest  themselves, 
namely:  Are  they  caused  by  (a)  the  action  of  a  drug;  (6)  ocular  disease 
or  optical  defects ;  (c)  spinal  or  sympathetic  lesion ;  (d)  localized  cerebral 
lesion  in  special  centres  or  tracts;  (e)  abeyance  of  brain  function ;  (/)  cere- 
bral irritation. 

In  order  to  localize  that  portion  of  the  reflex  ring  which  is  afiected,  this 
may  be  divided,  according  to  Magnus''  and  other  authors  into  the  following 
three  portions : 

1.  The  centripetal  part,  including  the  optic  nerve,  chiasm,  tracts  and  connect- 
ing jih  res  to  the  coHex.  If  the  disease  has  rendered  one  optic  nerve,  for  ex- 
ample, the  right,  impermeable  to  the  transmission  of  impulses,  the  pupil  on 
that  side  fails  to  react  to  light,  but  reacts  normally  when  light  falls  upon  the 
left  or  opposite  e^'e ;  the  left  pupil  has  a  normal  light  reaction,  but  fails  to 
contract  when  light  falls  upon  the  right  eye.  The  reactions  to  convergence 
and  accommodation  are  normal. 

Lesions  affecting  the  chiasm  and  the  tract  are  accompanied  by  hemian- 
opia  and  the  special  pupillary  phenomena  which  belong  to  this  condition, 
while  lesions,  in  the  optical  pathway  between  the  corpora  quadrigemina  and 

1  Journal  of  Physiology,  vol.  xiii.  No.  6.  See  also  Juler's  demonstration,  Trans.  Eighth  Interna 
tional  Ophthalmological  Congress,  1894,  p.  67. 

-  The  Pupil  in  its  Semeiological  Aspect,  American  Journal  of  the  Medical  Sciences,  new  series, 
vol.  xciv.,  July  to  October,  p.  123. 

3  Klin.  Monatsbl.  f.  Augenheilk. ,  xxvi.  p.  255. 


798  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  cortex,  while  accompanied  by  probable  changes  in  the  visual  fields,  are 
unassociated  with  pupillary  disturbances. 

2.  The  part  of  the  reflex  ring  tchich  carries  the  light  impulse  from  the  cor- 
pora quadrigemina  to  the  oculo-motor  nuclei  (Metjnerfs  fibres).  If  both  sides 
are  affected,  neither  pupil  reacts  to  the  impulse  of  light  falling  on  either 
eye,  but  there  is  normal  reaction  to  accommodation  and  convergence.  (See 
Argyll-Robertson  Symptom,  page  800.) 

3.  Lesion  of  the  centrifugal  portion  of  the  reflex  ring,  namely,  the  nucleus  of 
the  sphincter  of  the  iris,  \he  third  nerve  and  the  termination  of  the  third  nerve 
in  the  iris  prevents,  if  the  right  nucleus  is  affected,  the  direct  light  reflex  of 
the  right  pupil,  and  also  the  indirect  reflex,  i.  e.,  the  one  which  should  occur 
when  light  is  directed  into  the  left  eye.  A  beam  of  light  directed  into  the  left 
eye  is  followed  by  reaction  both  in  that  eye  and  the  eye  upon  the  opposite 
side,  although  somewhat  lessened  in  degree.  There  is  normal  reaction^  to 
accommodation  and  convergence.  The  pupils  are  unequal,  the  right  being 
the  wider. 

If  the  trunk  of  the  right  oculo-motor  is  affected  there  is  pupillary  immo- 
bility under  the  influence  of  light  directed  into  the  right  eye,  and  also  when 
it  is  directed  into  the  left  eye,  as  well  as  loss  of  accommodation  upon  the 
right  side.  Light  falling  into  the  left  eye  produces  normal  reaction — a  reac- 
tion which  is  also  manifested  on  this  side  if  the  light  is  directed  into  the 
opposite  eye.  The  pupils  are  unequal,  the  right  being  the  larger.  Similar 
conditions'  arise  if  the  peripheral  fibres  of  the  oculo-motor  at  their  termina- 
tion in  the  iris  are  affected  upon  one  side. 

We  have  now  to  consider  a  little  more  in  detail : 

1.  Dilatation  of  the  Pupil  (mydriasis).  This  occurs  in  ocular  disease,  for 
example,  glaucoma,  in  cases  of  non-conductivity  of  light  (optic  nerve  atrophy), 
in  orbital  disease,  and  under  the  influence  of  mydriatic  drugs.  It  is  further 
seen  in  fright,  emotion,  ansemia,  in  depressed  nervous  tone,  neurasthenia, 
aortic  insufliciency  and  irritation  of  the  cervical  sympathetic.  It  is  noted  in 
vomiting,  forced  respiration,  and  aneemia  of  the  brain,  for  example,  syncope, 
and  is  said  to  be  present  in  those  of  low  mental  development,  for  example, 
idiots. 

In  disease  of  the  nervous  system  dilatation  of  the  pupil,  when  of  cerebral 
origin,  indicates  extensive  lesion ;  when  of  spinal  origin,  irritation  of  the 
part  (McEwen).  Systematic  writers  have  divided  dilatation  into  irritation 
mydriasis,  caused  by  irritation  of  the  pupil-dilating  centre  or  fibres,  and 
paralytic  mydriasis,  caused  by  paralysis  of  the  pupil-contracting  centre  or  fibres, 
or  because  stimulus  is  not  conducted  from  the  retina  to  the  centre. 

The  former  is  apt  to  be  seen  in  hypersemia  and  irritation  of  the  cervical 
portion  of  the  spinal  cord,  in  spinal  meningitis,  in  cases  of  tumor  of  the 
spinal  cord,  and  also,  under  certain  circumstances,  in  tumor  of  the  cerebral 
contents,  in  psychical  excitement,  for  example,  acute  mania,  and  in  tabes 
dorsalis  and  progressive  paralysis  of  the  insane.     (See  pages  799  and  800.) 

The  latter,  which  is  also  known  as  iridop/egia,  is  found  in  disease  at  the 
base  of  the  l)rain  affecting  the  centre  of  the  third  nerve,  in  pressure  of  the 
cerebrum  when  in  great  amount,  as  from  hemorrhage,  tumors,  the  late  stages 
of  thrombosis  of  the  sinuses,  or  large  abscesses ;  also  in  the  late  stages  of 
meningo-encephalitis.  It  is  said  to  be  present  in  acute  dementia  when  there 
is  oedema  of  the  cortex,  and  is  found  in  cerebral  softening.  Hemorrhage  into 
the  centrum  ovale  and  cerebral  peduncles  also  produces  mydriasis  (McEwen). 

2.  Contraction  of  the  pupil  (myosis)  appears  in  congestion  of  the  iris, 
paralysis  of  the  sympathetic  arrd  also  of  the  fifth  nerve,  in  certain  fevers,  in 
plethora,  venous  obsti'uction,  mitral  disease  and  under  the  influence  of  myotics. 

If  the  myosis  is  of  cerebral  origin,  it  indicates  an  irritative  stage  of  the 


DISEASES  OF  THE  CRANIAL  NEBVES.  799 

affection  ;  if  of  spinal  origin  a  depression,  paralysis,  or  even  destruction  of 
the  part  (McEwen).  Systematic  writers  divide  contraction  of  the  pupil  into 
irritation  myosis,  caused  by  irritation  of  the  pupil-contracting  centre  or  fibres, 
and  paralytic  myosis,  caused  by  a  paralysis  of  the  pupil-dilating  centre  or 
fibres,  or  by  a  combination  of  both. 

The  irritation  myosis,  as  just  noted,  is  found  in  the  inflammatory  affections 
of  the  brain  and  its  meninges,  e.  g.,  meningitis,  abscess  ( at  the  first  myosis  on 
same  side  as  lesion)  and  beginning  sinus-disease.  According  to  the  rule  pre- 
viously given,  myosis  may  change  to  dilatation  if  the  products  of  disease 
become  excessive ;  hence  the  serious  prognostic  import  of  mvdriasis  under 
these  circumstances.  Myosis  is  seen  in  the  early  stages  of  cerebral  tumor,  in 
small  hemorrhages  into  the  cerebellum,  and  at  the  onset  of  cerebral  apoplexy. 
Berthold,  quoted  by  Swanzy,  uses  myosis  as  a  diagnostic  symptom  between 
apoplexy  and  embolism.  McEwen  points  out  that  the  convulsions  arising 
from  meningo-encephalitis  are  accompanied  by  myosis,  while  those  due  to 
epilepsy  are  usually  associated  with  mydriasis.  Apoplexy  of,  or  pressure  upon, 
the  pons  is  associated  with  myosis. 

Paralytic  myosis,  often  known  as  spinal  myosis,  occurs  in  lesions  above  the 
dorsal  vertebrae.  It  is  especially  noteworthy  in  tabes  dorsalis.  At  first  the 
pupil  reacts  to  light  and  convergence,  but  later  exhibits  the  Argyll-Eobert- 
son  phenomena  (see  page  800).  Paralytic  myosis  is  also  met  with  in 
paralysis  of  the  insane,  pseudo-dementia  paralytica  of  syiDhilitic  origin, 
bulbar  palsy  when  complicated  with  progressive  muscular  atrophy  or  sclerosis 
of  the  brain  and  spinal  cord,  and,  according  to  ^Nlills,  in  some  forms  of  mul- 
tiple neuritis. 

Unequal  pupils  are  rarely  seen  in  health,  although  it  is  stated  by  one 
observer  (Iwanow)  that  among  one  hundred  and  thirty-four  healthy  military 
recruits,  the  right  pupil  Avas  larger  in  forty-nine  and  the  left  in  fifty-three, 
equal  width  being  found  in  only  twelve.  If  there  is  recent  wide  dilatation 
of  one  pupil  and  no  disease  of  the  eye,  the  instillation  of  a  mydriatic  may 
be  suspected.  Unequal  pupils  occur  in  eyes  with  widely  dissimilar  refrac- 
tion, if  one  eye  is  blind,  in  aneurism,  dental  disease,  traumatism,  and  in  dis- 
eases of  the  nervous  system.  If  the  disease  is  cerebral,  unequal  pupils  denote 
unilateral  or  focal  brain  disease.  They  are  not  uncommon  in  tabes,  dissemin- 
ated sclerosis,  and  paralytic  dementia. 

Varying  inequality  of  the  pupil,  or  a  mydriasis,  now  occurring  on  the  one 
side  and  now  on  the  other,  is,  according  to  Von  Graefe,  a  serious  premonitory 
symptom  of  insanity.' 

The  pupillary  phenomena  of  certain  well-known  diseases,  already  several 
times  referred  to,  are  so  important  that  the  following  special  paragraphs  are 
introduced. 

The  Pupils  in  Locomotor  Ataxia.  Unequal  pupils,  either  with  mydriasis 
or  myosis,  or  of  medium  size,  occur  in  fully  27  per  cent,  of  the  cases,  accord- 
ing to  Berger,  a  percentage  which  agrees  entirely  with  the  author's  observa- 
tions.    They  are  slightly  more  frequent  in  the  initial  stage  of  the  disease. 

The  pupil  is  often  elliptical  or  pear-shaped,  commonly  associated  with 
myosis,  and,  perhaps,  as  Berger  suggests,  this  is  due  to  palsy  of  the  iris  vessels, 
varying  in  different  meridians.  The  iris  reacts  peculiarly  to  mydriatics,  which 
dilate  such  a  pupil  Tspinal  myosis)  only  partially,  and  their  effect  is  for  a 
long  time  manifest.  Myotics,  however,  contract  it  ad  maximum.  Heddaeus^ 
states  that  the  ordinary  form  of  small  pupil  in  reflex  iridoplegia  is  dilated 

1  The  author  is  especially  indebted  to  Swanzy's  article,  "  The  Motions  of  the  Pupil  in  Health  and 
Disease,  '  Diseases  of  the  Eye,  4th  edition,  chapter  xi.,  in  the  prapartion  of  the  sections  devoted  to 
the  anomalies  of  the  pupil. 

2  Archives  of  Ophthalmology,  vol.  xxiii.  p.  8. 


800  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

readily  with  cocaine.  This  indicates  that  its  narrowness  is  due  to  stimula- 
tion of  the  third  nerve  and  not  to  palsy  of  the  sympathetic.  It  is  possible 
that  a  spastic  myosis  may  also  occur  in  tabes.  Irritation  or  spastic  mydriasis 
may  appear  on  account  of  irritation  of  the  posterior  columns,  especially  in 
the  initial  stages  of  tabes,  while  paralytic  mydriasis  is  often  one  of  its  earliest 
symptoms. 

In  tabes  clorsalis  the  light  reaction  is  first  lost ;  later,  there  may  be  loss 
of  reaction  to  accommodation,  a  peculiarity  which  is  also  present  in  the  pro- 
gressive paralysis  of  the  insane,  sometimes  in  cerebral  syphilis,  and  is  said  to 
be  produced  by  certain  poisons,  for  example,  bisulphide  of  carbon  (Uhthoff ). 

Normal  pupillary  reactions  are  not  common  in  ataxia,  Berger  having 
found  them  in  only  3.7  per  cent,  of  his  cases,  and  he  gives  the  following  table 
to  show  the  various  phenomena  which  are  present : 


Good  reaction  of  the  pupil 

Gowers'i  symptom 

Slow  light,  good  accommodation  reaction    . 
Argyll-Robertson  symptom,  unilateral         .... 

"  "  "  bilateral 

Pupil  irresponsive  to  light  and  accommodation  unilateral 
"  "  "      "        '■  "  bilateral 


In  the  stadium. 

Preataxia. 

Ataxia. 

Paralytic. 

3 

1 

0 

6 

2 

0 

2 

1 

2 

0 

') 

0 

10 

-24 

18 

0 

1 

2 

0 

11 

10 

With  the  spinal  myosis,  the  light  reflex,  and  the  contraction  associated 
with  accommodation  and  convergence  may  be  preserved,  when  the  lesion  is 
still  confined  to  the  cilio-spinal  region,  or  perhaps  somewhat  higher  up. 

Reflex  Iridoplegia  is  the  name  given  to  a  pupil  responding  only  slightly  or 
not  at  all  to  the  light  impulse,  and  when  this  exists  without  loss  of  the  asso- 
ciated action  of  the  iris  (contraction  in  accommodation  and  convergence), 
the  term  "Argyll-Robertson  symptom  "  is  applied  to  the  phenomenon.  It  may 
occur  in  any  stage,  being  present  in  fully  one-half  of  the  patients.  It  is  asso- 
ciated with  mydriasis,  myosis,  medium-sized  and  unequal  pupils,  and  may  be 
unilateral  or  bilateral.  The  pathological  lesion  which  determines  the  pres- 
ence of  this  phenomenon  is  situated  in  the  fibres  which  pass  from  the  proxi- 
mal end  of  the  optic  tracts  to  the  oculo-motor  nuclei  of  the  same  side.  Tur- 
ner,'^ however,  prefers  to  assume  that  a  single  lesion  situated  in  the  Sylvian 
gray  matter  forming  forepart  of  the  oculo-motor  nucleus^  is  the  cause  of  both 
the  myosis  and  the  reflex  iridoplegia. 

Unilateral  Reflex  Iridoplegia,  that  is,  a  condition  when  one  pupil  is  unaf- 
fected by  varying  degrees  of  illumination  of  both  eyes,  but  acts  to  accommo- 
dation, the  unaffected  pupil  responding  to  separate  light  stimulus  of  either 
eye,  may  exist  with  or  without  mydriasis,  but  usually  (always  according  to 
Heddaeus)  is  wider  than  its  fellow.  It  is  not  a  common  phenomenon,  and  is 
seen  in  tabes,  and  probably  may  be  due  to  syphilis.  It  was  formerly  regarded 
as  indicating  a  lesion  affecting  the  iris-branch  of  the  third  between  the 
sphincter  and  nucleus,  but  by  Moebius  and  Seggel  is  regarded  as  an  inter- 
ruption in  ]Meynert's  fibres.  Heddaeus  (foe.  €11^)  suggests  it  may  be  explained 
by  assuming  that  the  iris-branch  of  the  third  nerve  is  formed  of  two  roots, 

1  By  Gowers'  symptom  Berger  means  after  a  marked  contraction  of  the  pupil  a  dilatation,  fol- 
lowed by  vacillation. 

2  Royal  London  Ophthalmic  Hospital  Reports,  vol.  xiii.  part  3,  page.  344. 

•5  His  studies  have  led  him  to  suggest  the  following  subdivision  of  the  forepart  of  the  oculo-motor 
nucleus:  1.  A  sphincter-inhibitory  centre,  closely  associated  with  a  sphincter-contracting  centre ; 
wnich  two  subserve  the  pupillary  light  reflex.  2.  A  centre  for  accommodation.  3.  A  centre  for 
contraction  of  the  pupil  with  convergence,  in  close  association  with  the  centre  for  the  associated 
action  of  the  internal  recti  muscles. 


DISEASES  OF  THE  CRANIAL  NERVES.  801 

one  from  the  sphincter-nucleus  and  one  from  the  accommodation-nucleus ; 
if  the  former  is  destroyed  there  is  reflex  iridoplegia  and  mydriasis,  but  pre- 
served accommodative  action  unless  the  latter  is  also  affected.  This  phe- 
nomenon should  be  distinguished  from  unilateral  reflex  blindness,  e.  g.,  in 
embolism  of  central  artery  of  retina  (Heddaeus),  in  which  there  is  pupil- 
lary resj^onse  to  light  directed  into  both  eyes,  or  into  the  unaffected  eye, 
but  failure  of  response  in  either  pupil  when  light  falls  on  the  blind  eye  (see 
also  page  797). 

Schwarz^  has  recorded  a  case  of  right  incomplete  reflex  iridoplegia  and  left 
incomplete  accommodation  palsy,  a  most  unusual  and  perhaps  unique  obser- 
vation, and  accepts  Heddaeus's  explanation  of  the  two  roots  of  the  iris-branch 
of  the  third  nerve. 

Occasionally  the  converse  of  the  Argyll-Robertson  symptom  is  observed, 
both  with  and  without  signs  of  tabes,  i.  e.,  the  pupils  react  to  light,  but  con- 
traction fails  during  attempts  at  convergence.  This  indicates  disease  in  a 
special  part  of  the  oculo-motor  nucleus,  as,  for  example,  in  a  case  of  Turner's 
{loc.  cit.)  with  lesion  in  the  second  and  third  subdivisions  of  the  nucleus  (see 
foot-note,  also  Heddaeus's  explanation,  p.  800).  According  to  Gowers,  when 
the  Argyll-Robertson  pupils  are  not  small,  the  skin-reflex  persists,  and  when 
they  are  small,  it  is  lost,  a  fact  which  Turner  regards  as  confirming  his  view. 
This  explains  contracted  Argyll-Robertson  pupils,  which  have  been  observed 
without  evidence  of  sclerosis  of  the  cervical  region  of  the  cord. 

Abolition  of  accommodative  reaction,  with  preservation  of  normal  power 
of  accommodation  and  normal  reaction  to  light,  according  to  Heddaeus,  has 
never  been  observed  (see  page  797). 

The  Pupils  in  Paralytic  Dementia.  Abnormal  pupillary  phenomena  are 
common  in  this  disease,  and  consist  of  inequality,  sometimes  of  varying  in- 
equality, and  of  reflex  iridoplegia. 

Inequality  of  the  jDupils  is  seen  not  only  in  progressive  paralysis  of  the 
insane,  but  in  various  types  of  mental  disorder,  and  has  been  estimated  to 
occur  in  half  of  the  cases.  Certainly  this  percentage  is  correct  for  paraly- 
tic dements.  UhthoiF,  who  examined  4000  cases  of  mental  disease,  found 
492  examples  of  reflex  iridoplegia ;  of  these  421,  or  85.5  per  cent.,  were 
paralytic  dements. 

Irregularly  shaped  pupils  and  irregular  pupillary  reactions  are  frequent ; 
indeed,  it  is  said  that  they  exceed  in  frequency  inequality  of  the  pupil.  Fi- 
nally, accommodation  may  also  fail  and  the  pupil  become  motionless  both 
to  the  stimulus  of  light  and  convergence  (absolute  iridoplegia).  The  dilata- 
tion upon  irritation  of  the  skin  may  be  preserved  for  a  long  time.  Accord- 
ing to  W.  Bevan  Lewis,''  however  the  sequence  of  the  morbid  phenomena  in 
the  iris  in  this  disease  is  (a)  paralysis  of  reflex  dilatation  to  cutaneous  stimu- 
lation, (b)  reflex  iridoplegia,  (c)  partial  and  occasionally  complete  interior 
ophthalmoplegia . 

Pupils  in  Epilepsy.  The  pupils  of  epileptics  are  not  infrequently  unequal, 
Browning'^  concluding  that,  on  an  average,  one  in  every  five  or  six  epileptics 
will  have  some,  perhaps  only  slight,  inequality  of  the  pupils.  He  divides  the 
pupillary  phenomena  in  this  respect  into  three  grades :  decided  inequality, 
probably  dej)ending  upon  localized  intra-cranial  trouble ;  slight  but  fairly 
constant  inequality  ;  and  the  so-called  latent  anisocoria,  in  which  the  in- 
equality is  evident  only  on  faint  illumination,  a  condition  not  uncommon  in 
diseases  other  than  those  analogous  to  epilepsy. 

Paralysis  of  the  Ciliary  Muscle.  This  may  be  present,  and  is 
known  as  cycloplegia,  without  co-existing  affection  of  the  pnpil,  and  is  most 

1  Centralblatt  f.  Prakt.  Augenbeilk,  Dec,  1894. 

-  Trans.  Ophth.  Soc.  United  Kingdom,  vol.  iii.  p.  219. 

a  Journal  of  Nervous  and  Mental  Disease,  January,  1892. 

51 


802  NERVOUS  DISEASES  AXD  THEIR  TREATMENT. 

common  after  diphtheria.  Sometimes  there  is  slight  mydriasis.  As  already- 
noted,  CTcloplegia,  with  preservation  of  the  light  reflex  of  the  pupils  is  seen 
in  locomotor  ataxia  and  in  other  allied  pathological  conditions.  These  cases 
probably  depend  upon  aflection  of  the  centres  for  accommodation. 

When  both  iris  and  ciliary  muscle  are  paralyzed — as,  for  example,  in  third 
nerve  palsy^ — -we  have  the  condition  known  as  cydoplegia  with  mydriasis. 

Ophthalmoplegia  interna,  or,  in  other  words,  cydoplegia  and  total  irido- 
plegia,  as  intimated  in  preceding  paragraphs,  may  be  the  ultimate  result  of 
a  condition  which  begins  as  an  ordinary  failure  of  the  reflex  mobility  of  the 
pupil.  It  has  always,  as  is  well  known,  been  described  as  a  primary  condi- 
tion, and  was  attributed  by  Mr.  Hutchinson  to  disease  of  the  ciliary  gan- 
glion, and  by  Hulke  to  lesion  of  the  intra-ocular  ganglionic  cells.  We  know 
from  anatomical  examinations  that  it  is  of  nuclear  origin,  and  may  or  may 
not  be  associated  with  an  external  ophthalmoplegia,  and  may  result  from 
allied  lesions  and  causes  (see  page  784). 

Ceetaix  Special  Pupillary  Phexomexa.  Hemiopic  VupiUary  Inac- 
tion. This  phenomenon,  first  described  by  Heddaeus  in  1880,  and  designated 
by  Wernicke  (sometimes  called  Wernicke's  symptom)  hemiopic  pupillary 
reaction  sign,  is  the  means  for  determining  whether  or  not  a  lesion  lies 
between  the  optic  chiasm  and  the  corpora  quadrigemiua  or  further  on  in 
the  visual  pathway. 

Given  a  case  of  lateral  hemianopsia,  the  examination  is  made  as  follows : 
One  eye  being  careftilly  excluded,  the  patient  being  seated  in  a  dark  room, 
with  the  source  of  Hght  somewhat  behind  him,  the  eye  under  examination  is 
illuminated  by  a  weak  Kght  reflected  from  a  plane  mirror.  The  observer  then 
reflects  a  more  intense  beam  of  hght  by  means  of  the  concave  mirror  of  the 
ophthalmoscope  into  the  pupillary  space,  care  being  taken  that  the  light  falls 
obliquely,  and  is  not  diffused  over  the  entire  retina.  If  the  beam  of  light 
falling  upon  the  blind  side  of  the  retina  causes  no  contraction  of  the  pupil, 
it  is  assumed  that  the  lesion  is  in  that  portion  of  the  sensory  motor  arc  of  the 
pupillary  reflex  included  between  the  chiasm  and  the  corpora  quadrigemiua. 
If  there  is  reaction  of  the  pupil  when  the  light  strikes  both  the  seeing  and 
the  blind  side  of  the  retina,  the  lesion  is  further  on  in  the  visual  j)athway. 
The  examination  must  be  made  with  great  care. 

It  may  be  a  transient,  permanent,  or  recurrent  j^henomenon.  Rothmann,^ 
who  has  observed  a  transient  case,  concludes  that  this  sign,  when  persistent, 
indicates  basal  disease  in  the  region  of  the  tracts,  but,  if  transient,  a  distant 
lesion  beyond  the  origin  of  the  reflex  fibres.  Hemianopsia  without  the  sign  is 
presumptive  evidence  of  disease  outside  the  reflex  arc,  while  late  apjDcarance 
of  this  pupil  symptom  in  hemianopsia  may  mean  secondary  degeneration. 
Hemianopic  inaction  of  the  pupil  may  be  present  without  hemianojisia  if  there 
is  lesion  between  the  third-nerve  nucleus  and  its  related  tract  on  one  side. 
Henschen's^  conclusions,  based  upon  a  most  careful  study  of  the  literature, 
as  well  as  observations  of  his  own,  are  as  follows : 

1.  Hemiopic  reaction  (H.  R.)  does  not  appear  with  softening  of  the  occip- 
ital, parietal,  or  temporal  lobes,  even  when  it  is  extensive,  or  has  reached 
the  neighborhood  of  the  corpora  geniculata,  and  is  absent  with  tumors  of 
these  regions,  even  when  they  have  destroyed  the  optic  radiations,  and 
pressed  on  the  pulvinar  or  the  corpora  quadrigemiua. 

2.  Mere  pressure  on  the  tract  may  cause  the  reaction. 

3.  Lesions  of  the  tract  produce  the  reaction,  as  a  rule,  even  when  very 
minute. 

1  Deutsch.  med.  Wochenschrift.  1894,  No.  15. 

2  Beitrage  zur  Pathologie  desGehirn's.  Teil,  iii.  s.  100-115.  See  also  abstract  in  Ophthalmic  Keview, 
December,  1894. 


DISEASES  OF  THE  CRANIAL  NERVES.  803 

4.  Lesion  of  the  outer  corpus  geniculatum  seems  not  to  produce  the 
reaction. 

5.  The  effect  of  lesions  of  the  inner  corpus  geniculatum  is  uncertain. 

6.  Destruction  of  the  pulvinar  does  not  cause  the  reaction. 

7.  Destruction  of  the  posterior  corpus  quadrigemina  does  not  produce  it. 

8.  Lesions  of  posterior  segment  of  thalamus  and  pulvinar  do  cause  the 
reaction — perhaps  from  pressure  on  the  tract,  or  by  destroying  the  brachium 
anterius. 

9.  Lesions  of  the  chiasma  produce  it,  though  occasionally,  for  some  un- 
known reason,  it  is  not  present. 

10.  It  may  occur  in  injury  to  the  nerve,  with  monocular  hemianopsia. 
The  Gerehral  Cortex  Reflex  of  the  Pupil.     If  one  sits  in  a  darkened  room  a 

marked  bilateral  pupillary  contraction  will  occur,  without  change  of  accom- 
modation or  convergence,  if  only  the  attention  is  directed  to  a  bright  object 
already  present  within  the  compass  of  the  field  of  vision.  The  brighter  the 
object  the  more  pronounced  the  contraction. 

Haab  believes  that  this  reflex  must  be  cortical  in  nature.  It  is  lessened 
in  patients  who  are  likely  to  have  reflex  iridoplegia,  namely,  tabetics  and 
dements. 

Hippus,  or  a  rhythmical  contraction  and  dilatation  of  the  pupil,  occurring 
without  alteration  of  illumination  or  fixation — a  normal  phenomenon  for  a 
few  seconds  after  light  stimulus  to  the  retina  and  optic  nerve — is  present  in 
various  nervous  diseases.  Damsch  has  reported  the  condition  in  multiple 
cerebro-spinal  sclerosis,  disseminated  sclerosis,  and  in  neurasthenia.  In 
psychical  disturbances,  epilepsy,  and  in  the  early  stages  of  acute  meningitis 
and  palsy  of  the  oculo-motor  it  has  also  been  observed.  The  most  marked 
examples  the  author  has  seen  were  in  a  patient  with  recurrent  mania  and  in 
one  of  grave  hysteria. 

The  Skin  Reflex.  This  is  the  second  reflex  action  of  the  iris,  the  other 
being  its  contraction  under  the  stimulus  of  a  beam  of  light,  and  consists  of  a 
dilatation  of  the  pupil  when  some  cutaneous  nerve  is  stimulated,  especially 
in  the  region  of  the  skin  of  the  neck.  The  motor  path  for  this  action  is  in 
the  cervical  sympathetic,  and  in  the  connecting  fibres  with  the  spinal  cord 
in  the  cervical  region,  and  the  centre  probably  beneath  the  corpora  quadri- 
gemina. The  reflex  is  lost  in  disease  of  the  cervical  sympathetic  and  in  cer- 
tain lesions,  especially  those  impairing  sensibility  in  the  upper  portion  (cer- 
vical) of  the  spinal  cord. 

Section  of  the  fifth  nerve  is  followed  by  pupillary  phenomena  similar  to 
those  seen  in  paralysis  of  the  sympathetic,  due  probably  to  the  fact  that 
the  trigeminus  contains  sympathetic  fibres  which  are  thus  paralyzed,  and  a 
direct  influence  of  this  nerve  upon  a  contraction  of  the  pupil  has  been  de- 
scribed, but,  as  Swanzy  points  out,  this  should  be  regarded  purely  as  a  reflex 
action. 

In  certain  cases  of  reflex  pupillary  immobility,  anaesthesia  over  portions  of 
the  distribution  of  the  fifth  cranial  nerve  will  be  found.  This,  as  Turner 
insists,  is  suggestive  of  the  presence  of  a  sclerotic  lesion,  either  in  the  trunk 
of  the  nerve  or  in  the  distribution  of  its  roots,  and  he  believes  that  the  cause 
of  this  anaesthesia  is  connected  with  the  distribution  of  the  so-called  ascend- 
ing root  of  the  fifth  nerve.  Such  anaesthesia,  then,  in  connection  with  pupil- 
lary phenomena,  is  strongly  suggestive  of  early  progressive  degenerative 
lesion  in  the  upper  portion  of  the  central  nervous  apparatus.^ 

1  Consult  Turner,  loc.  cit.,  p.  342. 


CHAPTER    XXYII. 
DISEASES  OF  THE  CRANIAL  NERVES 

(Continued). 
By  C.  a.  HERTER,  M.D. 


Many  of  the  disorders  of  the  functions  of  the  cranial  nerves  are  brought 
about  by  brain  disease  and  not  by  disease  located  in  the  nerves  themselves. 
Strictly  speaking,  disturbances  arising  in  this  way  should  not  be  treated  in 
a  chapter  dealing  with  the  diseases  of  the  nerves,  but,  owing  to  the  fact  that 
the  disturbances  of  function  arising  from  centi*al  disease  are  of  the  same 
kind  symptomatically  as  those  due  to  peripheral  disease,  it  is  convenient  in 
practice  to  touch  upon  the  former  in  speaking  of  the  latter. 


AFFECTIONS  OF   SMELL. 

Anosmia.  Anosmia,  or  loss  of  the  sense  of  smell,  is  much  more  often  the 
result  of  disease  of  the  olfactory  mucous  membrane  (chronic  rhinitis,  nasal 
polypi)  than  of  disease  of  the  nerve  or  brain,  and  such  local  processes  must 
be  carefully  excluded  before  a  nervous  lesion  can  be  seriously  considered. 
Any  out  of  the  following  conditions  may  lead  to  anosmia :  mere  excess  of 
nasal  secretion  ;  defective  secretion,  or  changes  in  the  mucous  membrane,  such 
as  may  occur  in  paralysis  of  the  fifth  nerve ;  blows  on  the  head  which  me- 
chanically tear  the  olfactory  filaments  from  the  bulb  (very  rare  cause)  ; 
pressure  on  the  nei'vous  bulb  by  tumor  in  the  anterior  fossa  of  the  skull,  or 
by  caries  of  adjacent  bone,  or  by  syphilitic  meningitis  or  by  hydrocephalus  ; 
primary  degenerative  changes  associated  with  locomotor  ataxia ;  primary 
senile  atrophy  of  the  bulbs ;  congenital  absence  of  the  nerves ;  excessive 
olfactory  stimulation. 

Disease  of  the  sensory  part  of  the  internal  capsule  (posterior  limb)  has 
been  known  to  cause  anosmia  on  the  side  opposite  the  lesion,  and  an  exten- 
sive cortical  or  subcortical  lesion  in  the  area  of  the  middle  cerebral  artery 
may  produce  the  same  result.  Disease  of  the  tip  of  the  temporo-sphenoidal 
lobe,  involving  the  olfactory  centre,  is  probably  a  cause  of  anosmia.  A 
functional  loss  of  smell  occasionally  occurs  in  hysteria  and  in  neurasthenic 
states. 

Diagnosis.  The  diagnosis  of  anosmia  of  nervous  origin  depends  on  de- 
tection of  loss  of  smell  and  on  exclusion  of  disease  of  the  mucous  mem- 
brane. In  testing  the  condition  of  the  sense  of  smell  it  is  important  to  make 
use  of  substances  that  stimulate  the  sense  of  smell  only.  It  is  convenient  to 
use  oil  of  cloves  in  various  degrees  of  dilution.  If  there  is  loss  of  smell, 
with  ability  to  distinguish  flavors,  the  trouble  is  certainly  due  to  disorder  of 


DISEASES  OF  THE  CRANIAL  NERVES.  805 

the  mucous  membrane.  In  the  very  rare  cases  where  the  ordinary  tests  of 
smell  do  not  suffice,  an  electrical  current  may  be  used  to  stimulate  the 
nerves,  a  phosphorus-like  odor  being  perceived  if  the  nerves  are  normal. 

Prognosis.  The  prognosis  of  anosmia  of  nervous  origin  is  bad  as  regards 
recovery  except  in  ftinctional  cases  and  some  syphilitic  and  some  traumatic 
cases. 

Treatment.  The  treatment  of  nervous  anosmia  is  practically  the  treat- 
ment of  the  cause  of  the  anosmia,  and  is  consequently  unsatisfactory.  But 
treatment  should  be  attempted  in  the  hoj)e  that  the  nerve-elements  are  func- 
tionally inactive  rather  than  destroyed.  One-thirtieth  of  a  grain  of  strych- 
nine in  olive  oil  may  be  used  as  a  snuff.  A  weak  galvanic  current  should 
be  applied  with  the  negative  pole  to  the  nasal  bones.  Occasionally  electri- 
cal treatment  is  of  actual  service. 

Hyperosmia  is  an  occasional  occurrence  in  hysteria  and  insanity.  It 
consists  of  a  very  remarkable  acuteness  of  the  sense  of  smell,  comparable  to 
that  normally  possessed  by  some  animals.  The  condition  is  apt  to  be  asso- 
ciated with  a  changed  appreciation  of  the  character  of  odors.  A  physiolo- 
gical hyperosmia  is  sometimes  the  result  of  cultivation,  as  in  the  case  of  the 
blind  and  those  who  follow  certain  occupations,  such  as  tea-tasting. 

Olfactory  hallucinations  occur  in  the  insane  and  as  the  aurge  of  epilepsy. 
In  rare  instances  olfactory  hallucinations  have  resulted  from  tumor  or  soft- 
ening in  the  anterior  part  of  the  temporo-sphenoidal  lobe.  Olfactory  halluci- 
nations are  usually  of  an  unpleasant  character  and  are  generally  unassoci- 
ated  with  anosmia. 

Parosmia,  or  perversion  of  the  sense  of  smell,  is  a  condition  in  which  all 
or  most  things  smell  alike.  It  may  result  from  irritative  disease  of  the  nerve 
or  brain,  but  is  very  rarely  so  caused.  It  is  not  a  very  uncommon  condition 
in  neurasthenics  and  in  persons  suffering  from  digestive  derangement.  In 
some  persons  a  dose  of  purgative  salts  gives  rise  regularly  to  a  perversion  of 
the  sense  of  smell,  lasting  many  hours  or  even  days.  The  odor  perceived  is 
usually  disagreeable  and  may  have  a  fecal  character.  The  sense  of  taste 
may  be  coincidently  j)erverted. 


AFFECTIONS    OF    TASTE. 

The  path  by  which  sensations  of  taste  pass  to  the  brain  is  still  the  subject 
of  discussion,  but  the  facts  of  pathology  warrant  the  following  conclusions  : 
1,  that  the  sense  of  taste  from  the  anterior  two-thirds  of  the  tongue,  and  in 
sonie  cases  from  the  back  of  the  tongue  as  well,  is  conveyed  in  a  circuitous 
course  by  the  Ungual  branch  of  the  fifth,  then  by  the  chorda  tympani,  then 
by  the  facial  (between  the  stylo-mastoid  foramen  and  the  geniculate  gan- 
glion), and  lastly  by  the  great  superficial  petrosal  to  the  second  division  of 
the  fifth,  and  by  it  to  the  root  of  the  fifth  ;  2,  that  the  sense  of  taste  from 
the  back  of  the  tongue  and  from  the  palate  is  conveyed  by  the  glosso-pharyn- 
geal  nerve  in  most  cases,  but  is  switched  off  before  reaching  the  glosso-pharyn- 
geal  root,  to  the  second  division  of  the  fifth,  by  means  of  certain  fibres  of 
connection  between  the  ninth  and  the  fifth  ;  3,  that  the  stimuli  of  taste,  both 
from  the  anterior  two-thirds  of  the  tongue  and  from  the  posterior  third  of 
the  tongue  and  the  palate,  having  reached  the  second  division  of  the  fifth, 
pass  by  it  to  the  root  of  the  fifth,  and  thence  by  the  fifth  to  the  cortex  of  the 
brain  (probably  the  general  sensory  region). 

Ageusia,  or  loss  of  the  sense  of  taste,  may  arise  from  disease  in  any  portion 
of  the  taste-path  just  described.  The  most  common  cause  of  ageusia  is 
facial  neuritis  between  the  geniculate  ganglion  and  the  point  of  departure 


806  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  the  chorda  tymjoani  from  the  facial.  The  loss  of  taste  is  then  on  the  an- 
terior two-thirds  of  the  corresponding  half  of  the  tongue,  and  is  associated 
with  facial  paralysis.  Ageusia  from  peripheral  lesions  located  elsewhere  is 
not  common,  but  disease  of  the  chorda  from  tympanic  disease,  or  from  dis- 
ease of  the  second  division  of  the  fifth,  does  not  belong  to  the  great  rarities. 
Loss  of  taste  from  disease  of  the  giosso-pharyngeal  uerye  alone  probably  does 
belong  to  the  greatest  rarities.  Complete  loss  of  taste  probably  never  results 
from  disease  of  the  mucous  membrane  of  the  tongue,  but  a  partial  loss  occa- 
sionally arises  in  this  way.  Loss  of  taste  due  to  disease  of  the  path  within 
the  brain  is  of  rare  occurrence.  Such  loss  may,  however,  occur  as  part  of  a 
general  hemian^esthesia  from  disease  of  the  cerebrum  involving  the  sensory 
crossway.  Much  more  frequently  ageusia  forms  part  of  the  hemiansesthesia 
of  hysteria.  Disease  of  the  pons  has  been  known  to  cause  complete  one- 
sided ageusia  under  conditions  that  suggest  the  proximity  of  the  taste-path 
in  the  pons  to  the  motor  root  and  nuclei  of  the  fifth. 

The  recognition  of  ageusia  is  not  difficult,  but  it  should  be  remembered 
that  the  patient  may  be  quite  unconscious  of  a  unilateral  ageusia.  The  sense 
of  taste  includes  only  the  perception  of  the  following  kinds  of  sensations : 
bitterness,  sweetness,  sourness,  saltiness,  and  metallic  sensations.  Solutions 
of  sugar,  quinine,  salt,  and  citric  acid  may  be  employed  as  tests,  and  a  weak 
galvanic  current  applied  to  the  tip  of  the  tongue  may  be  used  as  an  actual 
test  of  the  mtegrity  of  the  nerve-elements.  Caution  should  be  used  to  con- 
fine the  action  of  the  test  solution  to  the  part  of  the  tongue  examined,  and 
flavors  (which  are  perceived  through  the  olfactory  nerve)  should  not  be  con- 
founded with  tastes. 

The  treatment  of  the  symptom  ageusia  is  the  treatment  of  the  condition 
on  which  it  depends,  this  being  most  often  a  facial  neuritis.  The  nerves 
of  taste  may  readily  be  stimulated  by  galvanism,  one  electrode  being  placed 
on  the  tongue,  the  other  on  the  mastoid.  Such  applications  seldom  do  harm, 
but  on  the  other  hand  are  rarely  of  much  service.  In  hysterical  ageusia 
faradization  of  the  tongue  may  be  used. 

Parageusia,  or  perversion  of  the  sense  of  taste,  is  sometimes  met  with  in 
insanity,  hysteria,  tabes,  neurasthenia,  and  local  catarrhal  conditions.  It 
consists  in  the  perception  of  gustatory  sensations  different  from  those  nor- 
mally produced,  sweet  things  tasting  bitter,  etc. 

Hyperageusia,  or  increased  sensitiveness  of  taste  and  subjective  sensations 
of  taste,  occurs  under  conditions  like  those  in  which  parageusia  occurs.  Sub- 
jective sensations  of  taste  are  sometimes  part  of  the  aura  of  epileptic  seizures, 
and  are  not  rare  among-  the  hallucinations  of  the  insane. 


AFFECTIONS  OF  THE  AUDITORY  NERVE. 

Acoustic  Paralysis — nervous  deaftiess. 

Etiology.  Deafness  due  to  disturbance  or  imperfection  of  some  part  of  the 
nervous  mechanism  of  hearing,  as  distinguished  fi'om  deafness  due  to  middle 
or  external  ear  disease,  may  be  congenital  or  acquired.  Congenital  nervous 
deafness  is  the  cause  of  four-fifths  of  all  cases  of  deafmutism,  the  remaining 
one-fifth  occurring  from  disease  in  early  life.  Inheritance  is  a  very  important 
factor  in  the  causation  of  deafmutism,  but  of  the  pathology  of  the  condition 
practically  nothing  is  known.  jSTervous  deaftiess  other  than  deafmutism  may 
arise  from  disease  in  any  part  of  the  auditory  path,  from  the  labyrinth  to  the 
cortex  of  the  brain. 

1.  Disease  of  the  labyrinth  is  the  cause  of  the  great  majority  of  all  cases 


DISEASES  OF  THE  CRANIAL  NERVES.  807 

of  nervous  deafness,  the  morbid  process  being  either  primary  in  the  labyrinth 
or  extending  to  it  from  the  middle  ear.  The  morbid  process  may  be  an 
acute  or  a  chronic  inflammation,  a  syphilitic  exudate,  a  degeneration,  or  a 
hemorrhage,  or,  as  secondary  changes,  fibrous  or  calcareous  degeneration. 
Exposure  to  cold,  gout,  or  a  toxic  blood  state  may  appear  to  determine  the 
occurrence  of  the  labyrinthine  disease.  Drugs  which,  like  quinine,  are 
capable  of  causing  deafness  probably  do  so  by  their  action  on  the  labyrinth, 
by  acting  either  on  the  nerve-endings  of  the  acoustic  nerve  or  on  the  struc- 
ture in  which  these  terminate.  A  very  loud  noise,  i.  e.,  one  with  much 
concussion,  may  give  rise  to  complete  deafness,  temporary  or  permanent, 
probably  by  causing  hemorrhage  into  the  labyrinth.  Persons  subject  to 
jarring  or  continuous  noise,  as  locomotive  engineers  and  boilermakers,  not 
rarely  suffer  from  deafness  of  labyrinthine  origin. 

2.  Lesions  of  the  auditory  nerve,  either  in  the  course  through  the  temporal 
bone  or  at  the  base  of  the  brain,  are  much  less  frequently  the  cause  of  nervous 
deafness  than  disease  in  the  internal  ear.  The  following  are  the  chief  forms 
of  disease  of  the  nerve  :  pressure  on  the  nerve  from  new  growths  outside  the 
nei've,  or  from  syphilitic  or  other  forms  of  meningitis,  or  from  narrowing  of 
the  meatus,  inflammation  through  extension  from  adjacent  structures,  hemor- 
rhage or  tumor,  or  calcareous  degeneration  within  the  nerve  (very  rare), 
primary  degeneration  of  the  nerve  (as  in  locomotor  ataxia  or  senility),  and, 
possibly,  primary  neuritis  and  the  so-called  rheumatic  neuritis. 

3.  The  auditory  nuclei  in  the  pons  are  rarely  the  seat  of  disease.  Occa- 
sionally nervous  deafness  is  the  result  of  hemorrhage,  acute  softening  or  a  new 
growth  involving  these  nuclei. 

4.  Disease  in  any  part  of  the  auditory  path  above  the  nuclei  in  the  pons 
is  an  occasional  cause  of  nervous  deafness.  Thus  disease  of  the  superficial 
layer  of  the  tegmentum  of  the  crus,  or  of  the  sensory  portion  of  the  internal 
capsule,  or  of  the  cortex  of  the  temporo-sphenoidal  lobe,  or  of  the  white  sub- 
stance just  beneath  the  cortex,  has  been  known  to  give  rise  to  deafness. 
Functional  loss  of  hearing  is  met  with  in  hysteria  as  part  of  hemiansesthesia, 
in  anaemia  (the  defect  being  then  partial),  and  in  cases  of  profuse  hemorrhage. 
In  these  conditions  the  cortex  is  probably  the  seat  of  nutritional  or  vasomotor 
disturbance. 

Symptoms.  The  most  important  characteristic  of  nervous  deafness  relates 
to  the  conduction  of  sound  through  the  bones  of  the  head.  Normally,  the 
vibrations  of  a  tuning-fork  can  be  heard  longer  through  the  air  than  through 
the  bone,  i.  e.,  when  the  subject  can  no  longer  hear  the  tuning-fork  held  to 
the  skull  he  can  still  hear  it  if  it  is  placed  just  opposite  the  external  auditory 
meatus  (this  is  "  Rinne's  test  ").  If  there  is  disease  of  the  middle  ear,  conduc- 
tion through  the  bone  is  better  than  conduction  through  the  air.  But  if 
there  is  some  deafness  to  sounds  conducted  through  the  air,  and,  notwith- 
standing this,  sounds  are  heard  better  through  the  air  than  through  the  bone, 
the  deafness  depends  on  labyrinthine  or  nerve  disease,  i.  e.,  it  is  nervous 
deafness.  The  deafness  in  these  cases  is  especially  marked  for  short  sounds 
of  high  pitch. 

Considerable  study  has  been  devoted  to  the  characters  of  the  electrical 
reactions  in  nervous  deafness,  but  the  changes  in  reaction  found  in  such  cases 
are  neither  distinctive  nor  do  they  occur  in  all  cases.  Moreover,  the  applica- 
tion of  the  test  is  extremely  disagreeable.  The  test  is  thus  impracticable. 
The  position  of  the  disease  which  causes  nervous  deafness  is  to  be  determined 
by  means  of  the  associated  symptoms.  If  there  is  facial  paralysis  with  nerve 
deafness,  and  there  is  no  evidence  of  middle-ear  or  bone  disease,  the  auditory 
nerve  is  involved  at  the  base  of  the  brain  or  in  the  internal  meatus.  Deaf- 
ness of  sudden  onset,  associated  with  paresis  of  the  arm  and  leg  of  the  oppo- 


808  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

site  side,  and  other  bulbar  or  pontine  symptoms,  is  probably  due  to  disease 
of  the  auditory  nuclei,  but  if  these  bulbar  symptoms  exist  with  deafness  of 
slow  onset  this  inference  cannot  be  made.  If  nervous  deafness  is  associated 
with  hemiplegia  or  hemiansesthesia  on  the  same  side  the  lesion  is  probably  in 
the  internal  capsule,  in  the  cortex,  or  just  beneath  the  cortex. 

Bilateral  nervous  deafness  is  less  common  than  unilateral  affection,  but  is 
nevertheless  common.  Its  chief  causes  are  bilateral  disease  of  the  labyrinth 
(common),  symmetrical  disease  of  the  auditory  nerves  (very  rare),  destruc- 
tive lesions  of  the  superficial  layer  of  the  crustse  of  the  crura  (very  rare),  and 
disease  of  the  auditory  centre  in  each  temporo-spheuoidal  lobe  (very  rare). 

Treatment.  The  treatment  of  deafness  due  to  labyrinthine  disease  is 
described  in  text-books  of  otology.  When  the  symptom  is  due  to  a  central 
or  nerve  lesion  the  principles  which  govern  treatment  are  those  which  relate 
to  the  treatment  of  the  same  process  elsewhere.  When  deafness  is  acute  in 
onset  counter-irritation  does  good.  Chronic  cases  are  not  usually  amenable 
to  treatment,  but  slight  improvement  is  sometimes  observed  during  the  use  of 
counter-irritation,  hypodermic  injections  of  strychnine,  and  galvanism  to  the 
nerve. 

Auditory  Hyperesthesia.  The  term  auditory  hypersesthesia  is  used 
in  a  general  way  to  designate  increased  action  of  the  auditory  nerve  or  centre 
and  various  perversions  of  their  function. 

True  Hyperesthesia  (hyperacusis,  oxyecoia),  or  increased  keenness  of 
hearing,  is,  when  well  pronounced,  a  condition  of  great  rareness.  In  this  state, 
of  which  there  are  authentic  examples,  all  sounds  or  particular  sounds  (as 
the  high  notes  of  a  Galton's  whistle)  are  heard  with  undue  loudness.  Usually 
the  state  is  a  transient  one  of  a  few  hours'  duration.  It  is  generally  asso- 
ciated with  other  disorders  of  hearing.  The  following  are  the  chief  morbid 
states  in  which  hyperacusis  has  been  observed :  in  hysteria  (associated  with 
increased  acuteness  of  other  senses)  ;  in  the  mental  excitement  induced  by 
alcohol  (Politzer);  at  the  onset  of  acute  cerebral  and  general  diseases ;  during 
recovery  from  tubal  catarrh ;  just  preceding  the  development  of  central  dis- 
ease of  the  auditory  path  (Moos). 

Auditory  Dysesthesia,  or  dysacusis,  is  a  more  common  condition  in 
which  sounds  cause  discomfort,  although  they  are  not  heard  with  undue  loud- 
ness. Such  discomfort  is  experienced  in  a  variety  of  morbid  conditions  of  the 
middle  ear,  in  labyrinthine  disease,  in  partly  deaf  persons,  and  in  some  who 
are  completely  deaf  (Jacobson),  in  trigeminal  neuralgia,  migraine,  neuras- 
thenia, and  various  organic  cerebral  diseases  (meningitis,  general  paralysis). 
The  discomfort  is  probably  not  produced  by  direct  irritation  of  the  acoustic 
nerve. 

The  treatment  of  these  hypersesthesise  varies  with  the  nature  of  the  primary 
affection.  The  symptom  itself  is  almost  always  relieved  by  full  doses  of  the 
bromides. 

Tinnitus  Aurium.  The  subjective  sounds  to  which  the  name  tinnitus 
aurium  is  given  constitute  a  rather  common  and  often  a  most  distressing  ail- 
ment. The  affection  is  much  more  frequent  in  the  second  than  in  the  first 
half  of  life,  and  is  almost  unknown  in  children.  It  is  probably  of  nearly  equal 
frequency  in  the  two  sexes. 

Although  tinnitus  aurium  varies  much  in  its  character  and  arises  under  a 
variety  of  conditions,  it  is  always  dependent  in  part  upon  irritation  of  some 
portion  of  the  auditory  tract  or  upon  some  one  of  the  various  sound-produc- 
ing processes  in  the  neighborhood  of  the  normal  ear.  Of  all  cases  of  tin- 
nitus, labyrinthine  disease  is  by'  far  the  most  common.  There  are  distinct 
evidences  of  nerve-deafness  in  four-fifths  of  all  the  cases  that  come  under  the 
physician's  notice  (Gowers),  and  this  large  proportion  of  cases  would  be  in- 


DISEASES  OF  THE  CRANIAL  NERVES.  809 

creased  by  including  the  cases  of  occasional  tinnitus  in  which  there  is  con- 
tinually very  slight  nerve-deafness. 

The  following  are  the  chief  direct  causes  of  tinnitus :  1.  Various  forms 
of  ear  disease :  (a)  disease  of  the  external  ear,  as  new  growths  in  the  mea.tus, 
accumulations  of  cerumen;  (6)  disease  of  the  middle  ear,  acute  and  chronic 
suppurative  otitis,  catarrhal  otitis,  spasm  of  the  stapedius  muscle  ;  (c)  disease 
of  the  internal  ear,  including  the  various  causes  of  nerve-deafness  (vide  ante). 
The  mechanism  by  which  these  causes  are  operative  in  producing  tinnitus  is 
a  matter  of  conjecture. 

2.  Irritation  of  the  auditory  nerve  or  of  its  central  path  by  organic 
changes,  hemorrhage,  softening,  degenerations,  concretions  in  the  nerve,  etc., 
usually  associated  with  nervous  deafness. 

3.  Irritation  of  the  auditory  nerve  or  centre  dependent  on  functional  or 
nutritional  disorder  in  these  parts.  This  is  probably  the  origin  of  the  sub- 
jective sensations  of  sound  which  are  perceived  in  some  cases  of  epilepsy  as 
an  aura,  in  rare  cases  of  migraine,  and  in  some  cases  of  functional  derange- 
ment of  a  neurasthenic  character.  In  the  former  cases  the  tinnitus  doubt- 
less depends  on  cortical  irritation  due  to  perverted  nutrition  of  the  nerve- 
elements. 

4.  Intense  stimulation  of  the  auditory  mechanism  through  loud  or  long 
continued  sounds.  The  report  of  a  cannon,  a  loud  railway  whistle,  have 
each  been  followed  by  long-continued  tinnitus.  Sounds  less  loud,  but  long 
continued,  are  capable  at  times  of  causing  tinnitus,  usually  of  moderate 
degree  and  short  duration.  Piano-tuners,  boiler-makers,  etc.,  are  sometimes 
aifected  in  this  way. 

5.  The  movement  of  the  blood  in  the  vicinity  of  the  ear.  Normally  the 
blood-currents  there  and  in  the  ear  give  rise  to  no  sound,  but  they  may  be 
so  changed  as  to  be  perceived.  The  most  common  form  of  such  disturbance 
is  the  murmur  in  the  ears  sometimes  heard  in  anaemia,  and  due  probably  to 
vibrations  of  the  blood-current  in  the  carotid.  The  pulsation  may  be  les- 
sened by  pressure  on  the  carotid  in  the  neck.  Pressure  on  the  cervical 
sympathetic  has  seemed,  in  some  instances,  to  cause  subjective  sounds,  doubt- 
less by  causing  dilatation  of  the  labyrinthine  vessels.  In  very  rare  cases  an 
intra-cranial  aneurism  causes  a  murmur  similar  to  that  of  anaemia. 

Any  disorder  of  the  general  health  which  leads  to  defective  nutrition  of 
the  brain,  especially  its  cortex,  constitutes  a  most  important  predisposition 
to  the  development  or  intensification  of  tinnitus.  It  is  further  most  im- 
portant to  recognize  the  fact  that  the  continuous  overaction  of  the  auditory 
centres  leads  to  nutritional  changes  there,  which,  after  a  time,  may  become 
as  potent  an  influence  in  the  maintenance  of  tinnitus  as  the  aural  changes 
themselves. 

Symptoms.  The  sounds  vary  much  in  character,  intensity,  duration,  and 
in  the  situation  to  which  they  are  referred.  Generally  they  are  simple  in 
nature,  that  is,  of  a  low  degree  of  elaboration,  and  are  spoken  of  as  "singing," 
"ringing,"  "hissing,"  "buzzing,"  "humming,"  "whistling,"  etc. 

Much  more  rarely  the  sounds  are  more  elaborate  in  character  and  are 
likened  to  the  ringing  of  bells,  the  rustling  of  wind  in  the  trees,  or  the 
mingling  of  voices.  Faint  sounds  are  often  low  pitched,  loud  sounds  are 
generally  high  pitched.  The  sound  may  be  intermittent  or  constant,  pulsa- 
tory or  continuous.  In  cases  of  slight  labyrinthine  disease,  the  sounds  may 
recur  at  long  intervals  and  last  only  a  few  minutes.  The  subjective  char- 
acter of  the  sounds  is  generally  realized,  but  sometimes  at  the  commencement 
of  the  affection  a  slight  but  elaborate  sound  is  thought  to  have  an  actual 
objective  existence.  The  sounds  are  more  often  unilateral  than  bilateral, 
and  generally  referred  to  the  ear,  but,  strangely  enough,  sometimes  to  the 


S 1 0  NE^  VO  us  DISEASES  AND  THE  IB  TREATMENT. 

head,  generally,  or  to  a  particular  part  of  the  head  at  a  distance  from  the 
ear.  In  the  same  patient  considerable  variations  may  occur  in  the  intensity 
and  character  of  the  subjective  sounds.  Tinnitus  is  usually  influenced  to 
some  extent  by  external  sounds,  sometimes  decreased,  sometimes  increased. 
Usually  a  loud  continuous  noise  (like  that  of  a  railway  car)  reduces  the  sub- 
jective sounds,  at  the  same  time,  in  some  cases  of  labyrinthine  disease,  dimin- 
ishing the  degree  of  deafaess.  The  condition  of  hearing  varies  much  in 
different  cases.  Owing  to  the  frequent  labyrinthine  origin  of  tinnitus,  nerve- 
deafness  on  one  or  both  sides  is  common.  Shght  continuous  deafness  may 
be  temporarily  increased  by  transient  tinnitus.  In  some  cases  there  is 
deafness  only  while  the  tinnitus  lasts.  In  some  hearing  is  quite  normal  at 
all  times,  and  in  a  few  there  is  hyperacusis. 

Clicking  sounds  in  the  ear  generally  depend  on  contraction  of  muscles 
connected  Avith  the  Eustachian  tube,  vibratory  sounds  on  contraction  of  the 
stapedius  or  tensor  tympani.  Tinnitus  is  frequently  associated  with  head- 
ache, neuralgia,  insomnia,  nutritive  disorders,  and  neurotic  states  generally. 
(See  chapter  on  Neurasthenia).  In  many  cases  these  conditions  are  gradu- 
ally developed  as  a  consequence  of  the  depression  in  health  induced  by  the 
distressing  and  persistent  nature  of  the  tinnitus.  The  depression  that  results 
in  some  obstinate  cases  leads  to  suicide.  Occasionally  an  intractable  tinnitus 
is  at  least  the  immediate  cause  of  the  development  of  insanity. 

Diagnosis.  The  diagnosis  of  the  origin  of  tinnitus  rests  mainly  on  the 
associated  symptoms.  Of  these  the  chief  is  deafness,  and  the  cause  of  deaf- 
ness is  usually  also  the  cause  of  the  tinnitus.  The  various  causes  of  nerve- 
deafness  have  been  discussed  elsewhere. 

In  trying  to  distinguish  between  tinnitus  from  labyrinthine  disease  and 
tinnitus  from  disease  of  the  nerve,  the  enormous  preponderance  of  the  former 
should  be  mentioned.  The  character  of  the  tinnitus  gives  little  help,  as  a 
rule.  Roughly,  speaking  elaborate  sounds  are  of  central  origin  ;  but  simple 
sounds  are  also  frequently  of  central  origin. 

Prognosis.  The  prognosis  depends  on  the  ability  to  recognize  and  remove 
the  cause  of  the  symptoms.  Where  a  case  depends  on  external  or  middle- 
ear  disease  or  constitutional  derangement  of  a  remediable  nature,  the  chances 
of  recovery  are  very  good  if  the  case  is  recent.  But  when  the  trouble  de- 
pends on  labyrinthine  or  central  disease,  the  outlook  is  uncertain.  There  is 
no  way  of  predicting  which  cases  will  prove  intractable  and  which  will  be 
benefited  by  treatment. 

Treatment.  While  there  are  many  cases  in  which  treatment  is  of  no  avail 
there  are  also  many  in  which  intelligently  planned  treatment  gives  con- 
siderable relief.  The  first  step  in  treatment  is  to  remove  any  conditions 
which  may  directly  or  indirectly  result  in  tinnitus :  the  treatment  of  local 
morbid  states  on  the  one  hand  and  constitutional  states  on  the  other.  The 
treatment  of  anaemia,  gout,  or  rheumatism,  where  these  exist,  may  in  itself 
be  sufiicient  to  effect  improvement.  Where  the  tinnitus  comes  on  only 
after  fatigue  or  excitement,  as  is  sometimes  the  case,  the  indication  is  plain. 
Where  digestive  disorder  exists  it  should  be  carefully  remedied ;  even  when 
there  is  no  evidence  of  indigestion  the  diet  should  be  simple  and  nourish- 
ing. Attention  should  be  given  to  the  state  of  nutrition  in  all  cases  where 
uric  acid  is  excreted  in  excess.  The  action  of  a  blue  pill  is  sometimes  fol- 
lowed by  considerable  relief,  lasting  perhaps  for  days.  Those  who  are  ex- 
posed to  continuous  noise  and  suffer  in  consequence  should  have  rest  in  a 
quiet  place.  But  all  efforts  to  combat  the  causes  of  tinnitus  may  fail,  in 
fact  do  fail  in  a  majority  of  cases.  Treatment  must  then  be  addressed  to 
the  symptom  itself. 

The  drugs  which  have  been  found  useful  in  the  treatment  of  tinnitus  act 


DISEASES  OF  THE  CRANIAL  NERVES.  811 

either  upon  the  fimctions  of  the  labyrinth  or  upon  the  cortical  centres. 
Quinine  and  salicylate  of  soda  both  act  upon  the  internal  ear,  and  in  physio- 
logical doses  cavise  tinnitus  deafness  and  vertiginous  sensations.  Both  drugs 
exert  a  considerabe  influence  in  some  cases  in  mitigating  the  intensity  of  the 
sounds,  and  at  times  the  effect  lasts  after  the  drugs  have  ceased  to  be  admin- 
istered. Quinine  should  be  given  in  doses  large  enough  to  produce  physio- 
logical effects — 10  to  15  grs.  t.  i.  d.  Salicylate  of  soda  is  serviceable  in  a  much 
larger  proportion  of  cases  and  rarely  fails  to  do  some  good.  The  dose  should 
be  from  10  to  20  grs.  t.  i.  d.  The  drug  should  be  given  a  thorough  trial  if  the 
patient  can  take  it  without  gastric  disturbance.  Neither  of  these  drugs 
should  be  employed  in  the  tinnitus  of  acute  ear  disease.  Of  the  drugs  which 
reduce  that  overaction  of  the  central  nerve-elements,  which  in  many  cases 
of  tinnitus  comes  to  be  a  most  important  factor,  the  bromides  are  the  most 
useful.  There  are  a  few  cases  of  tinnitus  that  are  not  in  some  degree  bene- 
fited by  the  administration  of  bromide  of  sodium  or  ammonium  in  doses  of 
10  to  20  grs.  twice  or  three  times  daily.  When  giddiness  accompanies  the 
sounds  this  also  is  relieved.  The  combination  of  the  bromide  with  bella- 
donna is  sometimes  advantageous.  The  bromide  treatment  may  often  be 
continued  indefinitely  without  any  reduction  in  its  effect.  In  very  severe 
cases  of  tinnitus  it  may  be  necessary  to  use  morphine  hypodermatically. 

Counter-irritation  is  also  of  service  in  many  cases.  A  fly-blister  over  the 
mastoid  often  reduces  the  noise  for  days  after  its  use.  The  painting  of  the 
cartilaginous  part  of  the  external  ear  with  a  Liniment  containing  the  tinc- 
ture of  valerian  is  frequently  of  service  (Politzer).  Daily  exposure  of  the 
patient  to  a  sound  of  an  opposite  character  to  that  heard — to  a  low  note, 
where  the  sound  heard  is  high,  and  vice  versa — sometimes  mitigate  the  trouble 
(Lucae). 

DISEASES   OP   THE    FIFTH   NERVE. 

Paralysis. 

Etiology.  The  fifth  nerve  may  be  damaged  by  disease  in  any  part  of  its 
course.     The  following  are  the  chief  causes  of  its  involvement  : 

1.  The  three  divisions  of  the  nerve,  ophthalmic,  superior,  and  inferior 
maxillary,  are  exposed  to  different  lesions,  owing  to  the  difference  in  their 
course.  The  ophthalmic  lies  in  the  cavernous  sinus,  where  it  may  be  dam- 
aged by  tumors  in  the  pituitary  region,  and  within  the  orbit  may  be  injured 
by  new  growths  or  inflammatory  processes.  The  superior  and  inferior  maxil- 
lary divisions  lie  in  the  spheno-maxillary  fossa  and  are  liable  to  suffer  from 
wounds,  and  the  new  growths,  which  frequently  invade  this  region  ( osteo-sar- 
comata,  parotid  tumors,  etc.). 

2.  At  the  base  of  the  brain  (in  the  posterior  or  middle  fossa)  the  fifth 
nerve  is  liable  to  suffer  from  tumors,  syphilitic  meningitis,  or  caries  of  the 
temporal  bone. 

3.  Disease  in  the  pons,  as  hemorrhage,  acute  softening,  and  new  growths, 
occasionally  also  a  patch  of  sclei'osis,  may  damage  the  fifth.  When  the  root- 
fibres  are  implicated  the  paralysis  may  be  complete  in  both  motor  and  sensory 
portions  of  the  nerve. 

When  the  sensory  nuclei  of  origin  are  affected  the  paralysis  is  partial,  as 
a  rule,  because  the  sensory  nucleus  is  so  extensive  that  it  is  rarely  affected 
throughout.  The  motor  nucleus  is  apt  to  escape  degenerative  changes,  even 
when  these  are  widespread  in  the  pons  and  medulla.  The  descending  root  is 
occasionally  involved  in  a  degenerative  process,  which  leads  to  facial  hemi- 
atrophy. 


812  NERVOUS  DISEASES  AND   THEIR  TREATMENT. 

4.  Certain  traumatisms  to  the  mouth  and  nose  (pistol  shots,  punctured 
wounds)  are  hable  to  damage  the  branches  of  the  nerve. 

5.  Primary  neuritis  of  the  nerve  is  rare,  probably  because  its  deep  course 
protects  it  from  the  influence  of  cold.  Such  a  neuritis  may  occur,  however, 
in  persons  in  depressed  health,  especially  in  the  gouty,  rheumatic  and  syph- 
ilitic. The  neuritis  which  causes  herpes  zoster  is  not  uncommon  in  the  fifth 
nerve. 

Symptoms.  The  chief  symptoms  of  paralysis  of  the  sensory  division  of  the 
fifth  nerve  are  as  follows : 

1.  Loss  of  sensibility  in  the  parts  supplied  by  the  fifth.  The  loss  may 
involvfe  the  entire  region  supplied  by  the  fifth  when  there  is  disease  of  the 
root  of  the  nerve,  or  when  all  three  branches  (ophthalmic,  superior  maxil- 
lary, and  inferior  maxillary)  are  implicated  in  a  lesion  at  the  base  of  the 
brain.  When  individual  branches  are  involved  the  anaesthesia  is  limited  to 
the  regions  supplied  by  them.  The  tactile  sense  is  commonly  lost  before  the 
pain  sense,  but  eventually  both  are  involved.  Besides  loss  of  sensibility  of 
the  skin,  sensation  is  abolished  in  the  mucous  membranes  supplied  by  the 
nerve  (nose,  tongue,  and  mouth  on  the  side  of  the  lesion).  In  some  cases 
the  back  of  the  tongue  and  the  hard  and  soft  palate  share  in  the  sensory  loss, 
but  in  others  (even  when  the  entire  nerve  is  probably  involved)  only  the 
anterior  two-thirds  of  the  tongue  loses  its  sensibility. 

2.  Pain,  neuralgic  in  character,  in  the  distribution  of  the  nerve,  may  pre- 
cede the  development  of  anaesthesia.  There  may  also  be  tender  points  in  the 
course  of  the  nerves,  and  hyperalgesia. 

3.  Loss  of  taste  on  one  side  of  the  tongue  and  palate  results  from  severe 
damage  to  the  sensory  portion  of  the  fifth.  When  taste  is  not  involved  in 
lesions  of  the  fifth  it  is  probably  because  the  disease  is  partial  or  the  lesion 
is  within  the  pons.  Loss  of  taste  confined  to  the  anterior  two-thirds  of  the 
tongue  occurs  where  the  lingual  branch  of  the  fifth  is  diseased  between  the 
peripheral  distribution  and  its  junction  with  the  chorda  tympani. 

4.  Various  trophic  and  vasomotor  disturbances  may  result  from  lesions  of 
the  fifth  nerve.  Diminution  in  lachrymal  and  salivary  secretion  is  observed 
in  destructive  lesions ;  increase  in  these  secretions  may  occur  where  there  is 
irritative  disease.  Occasionally  the  face  is  distinctly  paler  on  the  afiected 
side,  owing  to  decreased  vascularity.  The  most  important  trophic  change  is 
that  which  occurs  in  the  nutrition  of  the  eye  and  results  in  inflammation  of 
the  eyeball.  The  cornea  becomes  dry  and  opaque,  ulceration  occurs,  and 
this  may  go  on  to  perforation  and  eventual  destruction  of  the  globe  of  the 
eye.  These  ocular  changes  are  especially  frequent  in  irritative  disease  involv- 
ing the  Gasserian  ganglion  or  the  nerve  anterior  to  it,  and  are  rare  in  lesions 
between  the  ganglion  and  the  superficial  origin  of  the  nerve  from  the  pons. 
Another  trophic  change  that  results  especially  from  lesions  that  affect  the 
Gasserian  ganglion  or  the  nerve  anterior  to  it  is  herpes  zoster,  which  most 
often  aflfects  the  superior  maxillary  distribution  of  the  nerve.     It  is  thought 

.  by  some  that  common  catarrhal  herpes  of  the  lips  depends  on  neuritis  of  the 
peripheral  branches  of  the  fifth  ;  but  this  view  is  not  supported  by  satisfactory 
pathological  evidence. 

Hemiatrophy  of  the  face  is  certainly  due,  in  many  cases  at  least,  to  disease 
of  the  descending  or  trophic  root  of  the  fifth. 

The  principal  symptoms  of  disease  of  the  motor  portion  of  the  nerve  are 
weakness  of  the  masseter,  temporal,  and  external  pterygoid  muscles  on  the 
side  of  the  lesion.  The  weakness  of  the  masseter  and  temporal  muscles  is 
evident  when  the  finger  is  placed  over  these  muscles  and  the  patient  brings 
the  upper  and  lower  teeth  forcibly  together.  When  the  loss  of  power  is  con- 
siderable it  is  shown  by  the  weakness  or  complete  absence  of  contraction, 


DISEASES  OF  THE  CRANIAL  NERVES.  813 

when  the  loss  is  shght  the  weak  muscle  may  contract  a  little  later  than  the 
normal  one.  The  pterygoid  paralysis  is  shown  by  defective  lateral  move- 
ment of  the  jaw,  which  can  be  moved  toward  but  not  away  from  the  paralyzed 
size,  and  also  by  deviation  of  the  jaw,  Avhen  depressed,  to  the  paralyzed  side. 
The  tensors  of  the  palate  and  tympanum  have  been  supposed  to  be  paralyzed 
by  a  lesion  of  the  fifth,  but  there  is  no  satisfactory  clinical  evidence  that  this 
is  actually  so.  There  may  be  some  sinking  in  of  the  temporal  and  zygomatic 
fossae  in  consequence  of  the  muscular  atrophy,  and  some  limitation  of  the 
downward  motion  of  the  jaw  from  shortening  of  the  muscles. 

Diagnosis.  Complete  paralysis  of  the  fifth  nerve,  including  paralysis  of 
motor  portion  of  the  nerve,  can  hardly  be  confounded  with  any  other  condi- 
tion. When,  however,  the  sensory  jDortion  is  alone  affected  and  there  is 
anaesthesia  of  adjacent  areas,  difiiculties  in  diagnosis  may  arise.  In  hemi- 
ansesthesia  the  loss  of  sensibility  includes  the  very  parts  supplied  by  the 
sensory  portion  of  the  fifth.  But  in  hemiansesthesia  the  loss  involves  also 
the  back  of  the  head,  the  limbs  and  the  trunk  on  one  side,  and  often  there 
is  hemianopsia.  When  pain  is  the  only  symptom  of  disease  of  the  fifth,  as  it 
may  be  for  a  time,  it  is  important  to  avoid  confounding  the  condition  with 
neuralgia.  When  ansesthesia  appears,  corresponding  in  area  to  that  supplied 
by  the  fifth  or  one  of  its  branches,  the  nature  of  the  affection  is  plain.  The 
appearance  of  loss  of  taste  upon  one  side  is  also  an  important  aid  in  diagnosis. 

The  diagnosis  of  the  locality  of  the  disease  which  gives  rise  to  paralysis  of 
the  fifth  rests  entirely  on  the  extent  of  the  ansesthesia  and  the  condition  asso- 
ciated with  this  loss  of  function.  Paralysis  of  all  three  divisions  of  the 
sensory  portion,  with  paralysis  of  the  motor  portion  of  the  nerve,  points  to 
disease  at  the  base  of  the  brain,  or,  perhaps,  at  the  Gasserian  ganglion.  If 
there  is  also  paralysis  of  the  sixth  nerve  the  lesion  is  surely  near  the  point  of 
emergence  of  the  fifth  at  the  side  of  the  pons.  If  the  loss  of  function  is 
confined  to  the  distribution  of  the  superior  maxillary  division  of  the  nerve, 
the  lesion  is  probably  at  the  sphenoidal  fissure  or  in  the  orbit,  and  this  belief 
is  strengthened  if  there  is  also  paralysis  of  the  nerves  to  the  eyeball.  If  the 
inferior  maxillary  division  of  the  nerve  is  alone  affected  the  lesion  is  probably 
in  the  spheno-maxiUary  fissure  or  in  the  superior  maxillary  bone.  Paralysis 
of  the  second  and  third  division  of  the  nerve,  without  involvement  of  the 
first  division,  is  generally  due  to  disease  in  or  near  the  spheno-maxillary  fossa. 

Crossed  paralysis  of  the  fifth  nerve  (fifth  on  one  side,  ansesthesia  of  arm 
and  leg  on  the  other)  always  depends  on  a  lesion  in  the  lower  half  of  the  pons 
or  upper  part  of  the  medulla,  if  the  onset  is  sudden.  The  association  of 
conjugate  deviation  (to  the  side  of  the  lesion)  with  paralysis  of  the  fifth  is 
positive  evidence  of  a  pontine  lesion. 

Treatment.  Success  in  the  treatment  of  paralysis  of  the  fifth  nerve  de- 
pends largely  on  the  ability  to  recognize  and  remove  its  cause.  In  many 
cases  the  nature  of  the  lesion  is  such  (new  growth,  traumatism)  that  little 
can  be  done.  The  treatment  of  a  syphilitic  process  involving  the  fifth  is  that 
of  a  similar  process  elsewhere  in  the  nervous  system.  Where  there  is  simple 
neuritis  vigorous  counter-irritation  at  the  occiput  or  over  the  mastoid  may  do 
good,  at  least  by  relieving  pain.  If  the  neuritis  follows  exposure  to  cold  the 
application  of  a  large  linseed  poultice  over  the  head  and  face  of  the  affected 
side  may  be  of  service.  Care  must  be  taken  to  avoid  setting  up  trophic 
changes  in  the  skin. 

Pain  may  be  very  severe,  especially  at  the  onset.  If  it  is  not  relieved  by 
local  applications  of  heat  and  the  use  of  phenacetine  or  antifebrine,  mor- 
phine should  be  injected  hypodermatically.  The  galvanic  current  is  of  very 
little  service  in  the  relief  of  such  pain.  If  there  is  local  ansesthesia  this  may 
be  much  benefited  (where  the  ansesthesia  does  not  depend  on  destruction  of 


814  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

nerve-fibres  with  a  break  of  continuity)  by  frequent  stimulation  of  tlie  insen- 
sitive area  with  the  faradic  current  through  a  wire  brush.  The  current 
should  be  strong  enough  to  be  felt,  if  this  is  possible.  Frequent  gentle  rub- 
bing of  the  ansesthetic  area  helps  to  maintain  the  nutrition  of  the  skin.  If 
there  is  any  evidence  of  altered  nutrition  of  the  eyeball  the  greatest  care 
must  be  taken  to  exclude  all  causes  of  irritation  from  the  eye.  The  eye 
should  be  kept  constantly  covered.  The  conjunctiva  should  be  washed  from 
time  to  time  with  a  saturated  solution  of  boric  acid.  But  the  irritation  of 
the  diseased  nerve  may  be  so  great  from  the  beginning  that  no  measures  can 
prevent  the  destruction  of  the  eyeball,  and  perhaps  the  involvement  of  the 
other  eye. 

Neuralgia  of  the  Fifth  Nerve. 

Trigeminal  or  Trifacial  Neuralgia ;  Tic  Douloureux  ;  Prosopalgia. 

The  fifth  nerve  is  by  far  the  most  important  nerve  of  common  sensibility, 
and,  owing  probably  to  the  highly  difierentiated  structure  of  its  central  con- 
nections, is  particularly  prone  to  suffer  from  disturbances  of  nutrition.  Neu- 
ralgia of  the  fifth  nerve  is  considerably  more  frequent  than  all  other  forms 
of  neuralgia  taken  together.  It  is  not,  therefore,  surprising  that  the  etio- 
logical characteristics  of  this  form  of  neuralgia  and  most  of  the  facts  relat- 
ing to  prognosis  and  treatment  should  apply  to  neuralgia  in  general. 

Etiology.  Neuralgia  of  the  fifth  is  essentially  a  disease  of  adult  life.  It 
is  rare  in  childhood  and  old  age.  Some  of  the  most  distressing  and  intract- 
able cases,  however,  begin  after  sixty.  Women  are  certainly  somewhat  more 
liable  to  the  disease  than  men,  but  the  diflTerence  in  sexual  incidence  is  not 
so  striking  a  feature  as  some  authors  have  stated.  In  a  very  small  propor- 
tion of  cases  a  direct  neuralgic  heredity  can  be  traced.  Much  more  fre- 
quently there  is  general  neuropathic  heredity  as  shown  by  a  history  of  mi- 
graine, of  epilepsy  or  insanity. 

Persons  of  so-called  "nervous"  temperament,  who  are  excitable,  irritable, 
and  excessively  emotional  are  very  liable  to  be  sufferers  from  neuralgia  of  the 
fifth.  The  disease  is  very  much  more  common  in  persons  of  feeble  constitution 
than  in  those  who  are  robust.  It  is  true  that  the  condition  is  met  with  among 
persons  in  excellent  general  health,  but  it  is  also  true  that  in  most  severe 
cases  where  the  health  is  apparently  good  there  is  in  reality  some  disturbance 
of  nutrition.  Persons  who  have  what  are  known  as  rheumatic  tendencies 
are  very  prone  to  trigeminal  neuralgia.  It  may  probably  be  said  that  in 
almost  all  cases  of  an  intractable  nature  the  excretion  of  uric  acid  is  habitu- 
ally much  increased  both  absolutely  and  in  comparison  with  the  amount  of 
urea. 

All  influences  that  impair  the  general  health  may  operate  as  exciting 
causes  of  neuralgia  of  the  fifth.  Overfatigue,  bodily  and  mental,  prolonged 
emotional  excitement,  excessive  venery,  overlactation,  etc.,  are  all  factors  of 
the  highest  moment  in  determining  the  development  of  neuralgia  of  the  fifth. 
Excessive  use  of  the  eyes  without  errors  of  refraction  is  competent  to  bring 
on  a  seizure  in  some  persons.  Errors  of  refraction  and  pronounced  insuffi- 
ciency of  the  extrinsic  ocular  muscles  (especially  esophoria)  are  occasionally 
important  factors  in  bringing  about  a  trifacial  neuralgia,  but  it  must  not  be 
forgotten  that  these  conditions  very  often  depend  on  reduction  of  the  general 
health. 

Exposure  to  cold,  local  or  general,  may  excite  a  neuralgic  seizure.  In 
some  persons  a  rapid  lowering  of  the  temperature  of  the  air  is  apparently  suf- 
ficient to  determine  a  seizure,  although  there  has  been  no  exposure.     Periph- 


DISEASES  OF  THE  CRANIAL  NERVES.  815 

eral  irritation,  of  whatever  origin,  is  an  important  cause  of  neuralgia  of  the 
face. 

The  important  influence  of  carious  teeth  should  always  be  borne  in  mind. 
It  is  an  important  fact  that  the  pain  may  not  be  greatest  in  the  nerve-root 
irritated,  but  in  a  neighboring  nerve-distribution.  Traumatism  of  a  branch 
of  the  fifth,  with  or  without  resulting  neuritis,  occasionally  operates  as  a 
cause  of  neuralgia  of  the  fifth.  The  various  toxaemic  influences,  as  alcohol- 
ism, lead-poisoning,  diabetes,  malaria,  and  the  grippe,  are  potent  and  not 
infrequent  causes  of  the  disease.  Malarial  neuralgias  of  the  face  are  not  so 
common  as  some  writers  would  have  us  believe.  The  neuralgias  which  fol- 
low the  grippe  are  occasionally  very  severe.  There  is  little  evidence  to  favor 
the  view  that  active  syphilis  is  ever  a  cause  of  true  neuralgia.  Old  standing 
syphilis  may  of  course  operate  through  its  influence  in  depressing  the  general 
health.  Acute  gastro-intestinal  derangement  has  been  rapidly  succeeded  in 
some  instances  by  neuralgia  of  the  fifth.  The  nature  of  the  relation  is 
obscure.     A  toxsemic  state  probably  underlies  the  symptoms. 

Symptoms.  The  pain  of  trigeminal  neuralgia  has  no  distinctive  charac- 
ters ;  it  is  spontaneous,  paroxysmal,  and  felt  in  certain  regions,  usually 
limited  in  extent  of  nerve-distribution,  thus  resembling  the  pain  of  neuralgia 
generally.  Further,  it  is  usually  unilateral,  is  usually  constant  for  a  time  in 
its  position,  and  is  usually  referred,  not  to  the  skin,  but  to  more  deeply  lying 
structures,  the  pain  often  corresponding  to  the  position  of  the  nerve-trunk  or 
branch.  Trigeminal  neuralgia  is  about  equally  common  on  the  two  sides, 
and  much  more  commonly  affects  one  or  two  divisions  of  the  nerve  than  all 
three.  Neuralgia  of  any  one  of  the  three  divisions  of  the  nerve  is  apt  to 
lead  to  the  establishments  of  tender  spots.  During  the  paroxysms  the  pain 
is  commonly  most  intense  at  certain  points,  and  pressure  at  these  points  is 
especially  painful.  After  a  time  these  spots  remain  tender  in  the  interval 
between  the  paroxysms. 

Neuralgia  of  the  first  or  ophthalmic  division  of  the  fifth  involves  mainly 
the  supra-orbital  branch,  and  is  usually  referred  to  as  supra-orbital  neuralgia. 
It  is  also  known  as  "  brow  ague,"  owing  to  the  fact  that  it  is,  perhaps  more  fre- 
quently than  any  other  form  of  neuralgia,  due  to  malarial  infection.  The 
pain  is  felt  radiating  over  the  front  of  the  head  from  the  supra-orbital  notch. 
It  may  be  felt  also  in  the  eyelid,  in  the  eyeball  itself,  and  at  the  side  of  the 
nose,  high  up  on  the  same  side.  A  tender  point  often  exists  at  the  supra- 
orbital notch  or  a  little  above  it  in  the  course  of  the  nerve.  Occasionally 
the  following  painful  points  occur :  a  palpebral  in  the  upper  eyelid,  a  nasal 
at  the  exit  of  the  long  nasal  branch  at  the  junction  of  the  nasal  bone  with 
the  cartilage,  and,  according  to  some  authors,  an  indefinite  focus  within  the 
globe  of  the  eye.  Pain  above  the  eyebrows  is  not  very  uncommon  as  the 
result  of  morbid  processes  in  the  frontal  sinuses.  Such  pain  may  be  neural- 
gic in  character,  and  depends  in  some  cases  on  certain  influences  which  act  at 
a  distance,  as,  for  instance,  in  the  cases  where  neuralgic  sinus  pains  are  caused 
by  eating  ices.  Sometimes  there  is  neuralgic  pain  referred  to  the  soft  parts 
just  below  the  supra-orbital  nerve-trunk. 

Ocular  neuralgia,  neuralgic  pain  referred  to  the  eyeball  itself,  is  a  particu- 
larly distressing  and  not  very  infrequent  form  of  neuralgia.  The  pain  is 
often  severe,  may  be  spontaneous  or  excited  by  use  of  the  eyes,  and  may  be 
accompanied  with  slight  or  considerable  dimness  of  vision  and  lachrymation. 
The  pain  is  usually  one-sided,  but  is  sometimes  bilateral.  It  may  or  may  not 
be  associated  with  other  neuralgic  pain  in  the  region  of  the  fifth.  Sometimes 
it  seems  to  depend  upon  an  error  of  refraction,  but  often  none  can  be  dis- 
covered. The  pain  is  sometimes  described  as  a  tearing  pain  deep  in  the  orbit. 
The  general  health  is  probably  always  impaired  in  severe  ocular  neuralgia. 


816  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Not  rarely  the  subjects  are  ansemic  young  women.  Tile  past  subjects  of 
rheumatic  iritis  are  prone  to  this  form  of  neuralgia. 

In  neuralgia  of  the  second  (superior  maxillary)  division  of  the  fifth,  the 
pain  is  referred  to  the  area  lying  between  the  orbit  and  the  mouth  and  often 
to  the  side  of  the  nose.  In  infra-orbital  neuralgia  the  chief  painftil  spot  is 
at  the  emergence  of  the  nerve  from  the  infra-orbital  foramen.  Not  rarely 
there  are  the  following  painful  foci ;  a  molar  over  the  prominent  part  of  the 
bone,  a  gingival  line  along  the  gums  of  the  upper  jaw,  and  a  nasal  point  at 
the  side  of  the  nose.  It  is  said  that  a  palatine  point  is  occasionally  the  seat 
of  intolerable  pain  (Anstie).  When  the  inferior  maxillary  division  is  afiected 
the  following  are  the  chief  foci  of  pain :  a  temporal  at  a  point  on  the  auri- 
culo-temporal  branch  just  in  front  of  the  ear  (a  common  focus)  or  in  the 
posterior  part  of  the  temple,  an  inferior  dental  opposite  the  emergence  of 
the  nerve  from  the  foramen,  a  parietal  just  above  the  parietal  eminence  at 
the  point  of  conjugation  with  the  branches  of  the  great  occipital  nerve  (a 
very  small  point  and  the  most  frequent  of  all),  and  occasionally  a  hngual 
point  at  the  side  of  the  tongue.  In  many  cases  of  neuralgia  of  the  third 
division,  the  pain  is  not  confined  to  a  small  area,  but  extends  throughout  the 
various  branches  to  the  temple,  parietal  eminence,  ear,  lower  jaw,  and  tongue. 
Sometimes  the  pain  is  confined  to  the  tongue,  and  is  then  very  intense.  In 
the  temporal  region  the  pain  is  apt  to  be  boring  in  character.. 

While  it  is  comparatively  rare  for  neuralgia  of  the  fifth  to  occupy  all 
three  divisions  of  the  nerve,  it  is  by  no  means  rare  for  pain  to  extend,  from 
time  to  time,  from  the  division  chiefly  afiected  to  the  branches  of  a  neighbor- 
ing division  or  even  to  the  branches  of  other  nerves.  Thus  in  superior 
maxillary  neuralgias  the  pain  may  extend  to  the  branches  of  the  oph- 
thalmic, to  the  distribution  of  the  great  occipital  over  the  occiput,  to  the 
lingual  branch  of  the  inferior  maxillary,  or  even  to  the  cervical  nerves.  The 
pain  of  trigeminal  neuralgia  is  apt  to  be  excited  by  movement  and  by  con- 
tact. Mastication  is  often  difiicult  or  impossible  in  neuralgias  of  the  inferior 
maxillary  nerve.  Occasionally  there  is  reflex  muscular  facial  spasm  ("tic 
convulsif ")  when  the  neuralgic  pain  is  acute  and  intense.  Shght  paralysis 
of  the  third  nerve  has  sometimes  followed  paroxysms  of  the  supra-orbital 
neuralgia.  Supra-orbital  neuralgias  are  sometimes  associated  with  marked 
vasomotor  disturbances.  When  trophic  disturbances  are  pronounced  and 
of  long  duration,  it  is  probable  that  some  portion  of  the  nerve  has  under- 
gone structural  change.  Migratory  pains  are  often  felt  in  various  parts  of 
the  scalp,  and  may  be  associated  with  tenderness  of  the  skin  during  and  after 
the  paroxysms.  These  pains  may  bear  no  distinct  relation  to  the  nerve- 
trunks,  and  cannot,  perhaps,  be  strictly  designated  neuralgias.  In  some 
cases  such  pains  alternate  with  true  neuralgia. 

The  neuralgias  of  the  fifth  may  be  advantageously  classified  according  to 
their  characteristics  and  causes.  The  term  epileptiform  is  applied  to  an 
agonizing  form  of  neuralgia  in  which  attacks  are  characterized  by  the  great 
suddenness  and  severit}^  of  their  onset,  their  short  duration,  and  frequent 
occurrence.  This  form  of  the  disease  belongs  especially  to  the  second  half  of 
life,  and  may  develop  after  sixty.  The  maxillary  divisions  are  more  fi'equently 
affected  than  the  ophthalmic  division  of  the  nerve,  and  more  than  one  branch 
is  usually  affected.  Facial  spasm  may  accompany  the  pain.  A  neuralgia 
may,  perhaps,  be  termed  reflex  when  the  pain  is  felt  in  a  nerve  distribu- 
tion different  from  that  in  which  its  cause  lies.  Thus  a  carious  tooth  may 
cause  neuralgia  in  a  distant  part  of  the  fifth,  and  an  injury  of  the  ulnar  may 
be  the  cause  of  a  trigeminal  neuralgia.  Some  neuralgic  pains  in  the  oph- 
thalmic region  of  the  fifth  are  accompanied  with  a  herpetic  eruption  over 
the  forehead,  and  such  cases  have  been  designated  herpetic  neuralgia,  but  it 


DISEASES  OF  THE  CRANIAL  NERVES.  817 

is  probable  that  an  actual  ueuritis  exists  in  such  instances.  The  fifth  nerve 
is  often  the  seat  of  what  are  known  as  degenerative  neuralgias — intractable 
neuralgias — which  come  on  late  in  life  and  are  associated  with  evidences  of 
degeneration  of  the  central  nervous  system.  EpilejDtiform  neuralgia  some- 
times belongs  to  this  category.  The  causative  relations  of  rheumatism,  gout, 
diabetes,  anaemia,  malaria,  and  syphilis  to  neuralgia  have  led  writers  to 
speak  of  a  rheumatic  neuralgia,  a  gouty  neuralgia,  etc. 

Diagnosis.  The  recognition  of  the  nature  of  neuralgic  affections  of  the 
fifth  is  usually  easy ;  the  relation  of  the  pain  to  a  nerve  trunk  or  branch  or 
area,  its  unilateral  distribution,  distinctly  paroxysmal  and  migratory  char- 
acter, and  the  absence  of  all  evidence  of  organic  disease  of  the  nerve  in- 
volved (absence  of  tenderness  and  swelling  along  the  course  of  the  nerve 
affected),  are  unmistakable  features.  Sometimes  it  is  difficult  to  say  whether 
a  pain  referred  to  the  skull  should  be  called  headache  or  neuralgia.  A  head- 
pain  is  to  be  considered  neuralgic  only  when  there  is  a  distinct  correspond- 
ence on  the  part  of  the  pain  to  the  course  of  the  branch  or  branches  of  a 
nerve  or  to  an  entire  nerve-area.  Actual  neuralgia  may,  however,  cause  a 
difilise  head-pain  in  its  neighborhood,  which  is  sometimes  called  a  "  neuralgic 
headache." 

The  trigeminal  pains  that  occur  in  the  course  of  organic  brain  disease  are 
to  be  recognized  by  their  associated  symptoms. 

Prognosis.  The  outlook  for  cases  of  trigeminal  neuralgia  is  influenced  by 
the  same  indications  that  determine  the  prognosis  of  neuralgia  generally. 
The  prognosis  is  best  in  cases  where  there  is  a  conspicuous  and  remediable 
constitutional  cause,  as  ansemia.  Other  things  being  equal,  it  is  poor  where 
after  careful  examination  no  cause  whatever  can  be  found.  Cases  in  which 
there  is  a  pronounced  neurotic  heredity  yield  much  less  readily  than  where 
there  is  no  hereditary  taint.  Most  cases  are  intractable  in  proportion  to 
their  duration  and  severity.  The  fact  that  the  pain  has  during  manj^  years 
been  shifting  from  j^lace  to  place  is  an  unfavorable  feature.  The  chances  of 
relief  by  treatment  is  much  greater  in  youth  and  middle  life  than  after  sixty. 
Epileptiform  neuralgia  is  the  most  intractable  of  all  varieties.  It  is  probably 
incurable  by  means  of  drugs.  In  all  varieties  of  neuralgia  the  liability  to 
recurrence  is  very  great  if  the  affection  has  been  Avell  established  for  many 
months.  Even  the  most  agonizing  forms  of  neuralgia  appear  not  to  shorten 
life  apparently,  though  they  may  render  it  difficult  to  endure. 

Treatment.  In  any  case  of  trigeminal  neuralgia  it  is  necessary  to  direct 
treatment,  first,  to  the  pain  itself;  secondly,  to  the  removal  of  the  cause  of 
the  neuralgia.  The  measures  taken  to  remove  the  cause  of  the  affection  are 
of  the  first  importance,  but  the  relief  of  pain  is  naturally  apt  to  be  the  first 
stej)  in  treatment.  Where  the  condition  is  not  "  idiopathic,''  but  neuritic  in 
character,  the  treatment  is  that  recommended  in  connection  with  neuritis. 

Of  the  measures  which  ai'e  employed  for  the  relief  of  pain  it  is  convenient 
to  consider,  first,  the  use  of  drugs  which  operate  by  entering  the  general  cir- 
culation, and,  second,  the  use  of  purely  local  measures.  A  large  number  of 
drugs  have  been  employed  for  their  sedative  or  anodyne  action,  but  reliance 
can  be  placed  on  few.  The  bromides  (especially  the  bromide  of  potassium) 
have  been  extensively  used  for  their  sedative  action.  They  have  surpris- 
ingly little  influence  upon  the  pain  and  are  apt  to  increase  the  digestive  dis- 
turbance which  often  exists.  In  irritable,  nervous  patients  the  drug  may  be 
useful  in  moderate  doses  (5  to  10  grs.  t.  i.  d.),  in  rendering  more  endurable  the 
pain  of  paroxysmal  neuralgia.  When  the  pain  is  at  all  severe  the  bromides 
cannot  be  counted  upon.  Salicylate  of  soda  is  considered  of  use  in  "rheu- 
matic" neuralgias.  Its  control  over  trigeminal  pain  is  limited,  and  it  not 
merely  does  not  remove  the  "rheumatic"  basis  of  the  pain,  but  may  aggra- 

52 


818  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

vate  it.  The  antipyretics,  antipyrine,  antifebrine,  plienacetin,  and  exalgin, 
have  been  extensively  and  somewhat  recklessly  employed  in  neuralgias  of 
the  fifth.  In  moderate  doses  each  of  these  drugs  (especially  antifebrine) 
has  a  remarkable  influence  over  the  pain,  even  when  this  is  severe.  The 
promptness  with  which  relief  may  be  obtained  and  the  absence,  in  most  in- 
stances, of  distinctly  and  immediately  objectionable  after-afiects  has  popu- 
larized the  use  of  these  agents,  not  merely  with  practitioners,  but  with  the 
laity.  But  the  fact  should  not  be  lost  sight  of  that  these  drugs  employed  in 
even  moderate  doses,  continuously  for  weeks  or  months,  are  capable  of  modi- 
fying nutrition  profoundly,  probably  by  increasing  haemolysis  or  checking 
hsemogenesis.  The  writer  has  met  with  several  instances  in  which  a  consid- 
erable grade  of  anaemia  and  complex  disorders  of  nutrition  were  referable  to 
such  use  of  these  antipyretics.  The  fact  that  these  drugs  may  be  readily 
abused  for  the  relief  of  pain  does  not  of  course  condemn  them,  but  should 
render  the  practitioner  exceedingly  cautious  to  keep  the  dose  as  small  as 
possible  and  to  intermit  frequently  in  the  course  of  their  administration.  AJl 
of  these  drugs  are  liable,  after  prolonged  use,  to  grow  less  efficacious  in  the 
relief  of  pain. 

Nervine  stimulants  (alcohol,  valerian,  sulphuric  ether)  sometimes  abort  a 
neuralgic  attack,  but  are  of  little  use  after  the  pain  has  become  established. 
The  repeated  use  of  alcohol  is  of  course  to  be  deprecated.  The  use  of  small 
doses  of  nitroglycerin  (y^o'  S^-  ^-  '^-  ^•)i  ^loiie  or  combined  with  tonic  treat- 
ment, may  be  very  serviceable  for  the  relief  of  neuralgia.  It  probably  acts, 
in  a  measure  at  least,  by  improving  the  nutrition  of  the  nerve-elements  con- 
cerned in  initiating  painful  stimuli,  by  flushing  them  with  blood. 

Opium  and  morphine  are  the  drugs  which  give  the  quickest  and  most 
certain  relief  to  the  pain  of  neuralgia.  The  hypodermatic  injection  of  a 
moderate  dose  {\-\  gr.)  of  sulphate  of  morphine  gives  relief  to  the  severest 
forms  of  neuralgia,  especially  if  the  injection  be  made  into  or  near  the  seat 
of  the  pain.  But  the  danger  of  forming  the  morphine  habit  is  so  great  that 
the  drug  should  be  used  with  the  greatest  caution  and  only  in  cases  where 
pain  is  so  severe  as  to  be  unendurable,  as,  for  example,  in  cases  of  epilepti- 
form neuralgia.  Even  here  all  other  resources,  including  those  which 
surgery  affords,  should  be  employed  before  making  repeated  use  of  morphine. 
The  injection  of  cocaine  (yV^i  g^'O  i^^o  the  seat  of  pain  usually  brings  rapid 
relief  from  neuralgic  pains,  but  the  danger  of  establishing  a  habit  is  hardly 
less  great  than  in  the  case  of  morphine.  In  no  case  should  the  patient  be 
permitted  to  make  the  injection.  At  times  the  use  of  morphine  and  cocaine 
does  more  than  palliate;  the  formation  of  a  "pain  habit"  may  be  avoided, 
for  the  repeated  relief  of  pain  helps  to  prevent  its  recurrence. 

The  use  of  belladonna  or  of  atropia  beneath  the  skin  is  effective  in  some 
cases  of  trigeminal  neuralgia,  but  the  dryness  of  the  throat  and  constitu- 
tional symptoms  that  are  produced  render  these  drugs  objectionable  for  gen- 
eral use.  Chloral  has  little  influence  over  neuralgic  pains.  Croton-chloral, 
in  doses  of  five  grains  or  more,  is  said  to  be  serviceable  in  some  neuralgias  of 
the  fifth,  but  it  is  doubtful  if  much  reliance  can  be  placed  upon  it.  Indian 
hemp  likewise  has  been  recommended  highly,  especially  in  neuralgias  in 
which  the  pains  are  sudden,  sharp,  and  of  short  duration,  but  only  of  mode- 
rate severity.  The  dose  is  from  a  quarter  of  a  grain  to  a  grain  three  times 
daily.  The  readiness  with  which  the  drug  brings  on  hallucinations  in  some 
persons  and  the  frequency  with  which  it  deranges  digestion  are  very  objec- 
tionable features. 

All  things  considered,  aconitia  is  probably  the  most  satisfiictory  drug  at 
our  command  for  the  relief  of  trigeminal  neuralgias.  In  a  large  majority 
of  cases,  including  even  some  of  the  severest  type,  progressively  increasing 


DISEASES  OF  THE  CRANIAL  NERVES  8X9 

doses  of  aconitia  greatly  modify  or  stop  the  pain.  The  beginning  dose  is 
2^^  gr.  In  slight  cases  this  amount,  or  double  this  amount,  often  gives  distinct 
relief.  When  the  pain  is  severe  the  administration  of  the  drug  must  be 
pushed  to  the  point  of  producing  distinct  physiological  effects  :  numbness  of 
the  tongue,  slow  heart-action,  and  pei'haps  nausea.  The  dose  should  be  in- 
creased from  day  to  day  by  -g-^-Q  gr.  until  these  effects  are  produced.  The 
relief  afforded  is,  in  many  cases,  more  than  temporary.  There  is  no  evi- 
dence to  show  that  the  long-continued  use  of  aconitia  impairs  the  general 
health.     In  a  small  proportion  of  cases  it  is  without  effect. 

In  cases  of  neuralgia  of  the  fifth  that  are  of  malarial  origin  and  in  many 
that  are  not,  AVarburg's  tincture  is  exceedingly  efficacious.  Its  administra- 
tion should  be  preceded  by  a  mercurial  purgative.  The  fluid  extract  of 
ergot  in  doses  of  one  drachm  (twice  repeated,  if  necessary)  has  been  highly 
recommended  in  cases  of  severe  periodic  (usually  daily  recurrent)  neuralgias 
of  the  fifth.  The  drug  may  also  be  given  by  the  rectum  (gij,  water  gij),  if 
its  use  by  mouth  causes  nausea  or  vomiting.  Ergot  is  said  to  succeed  fre- 
frequeutly  where  aconitia,  quinine,  and  the  antipyretics  have  failed. 

The  irritant  or  sedative  effects  of  local  treatment  are  often  of  service  in 
trigeminal  neuralgias  of  moderate  severity.  Blisters  and  sinapisms  cannot 
usually  be  conveniently  employed  about  the  head,  but  the  actual  cautery 
may  be  of  great  service,  especially  in  supra-orbital  neuralgia.  The  applica- 
tion should  be  superficial  and  should  be  made  with  the  instrument  heated  to 
a  dull  red.  Acupuncture  and  aquapuncture  are  not  suitable  for  use  about 
the  head.  The  hypodermatic  injection  of  osmic  acid  cannot  be  recommended, 
although  it  is  sometimes  very  efficacious.  Camphor  chloral  and  chloro- 
form liniment  sometimes  do  good.  Menthol  is  useful  only  when  the  pain  is 
slight.  The  ointments  of  belladonna,  veratrine,  and  aconitia  may  give  tem- 
porary relief.  The  oleate  of  morphine  has  little  efficacy.  Local  heat  and 
moisture  frequently  give  a  great  deal  of  relief  from  pain  and  a  sense  of 
comfort.  A  wai'm  saline  nasal  douche  may  relieve  frontal  pain  that  is  asso- 
ciated with  neuralgia.  The  ether  spray  is  not,  as  a  rule,  satisfactory.  A 
strong  ointment  of  cocaine  made  up  with  lanoline  may  be  very  useful,  but 
should  not  be  used  near  mucous  membranes.  Occasionally  electricity  (farad- 
ism  or  galvanism)  gives  a  temporary  relief  to  a  trigeminal  neuralgia,  but  it 
cannot  be  regarded  as  an  effective  and  reliable  therapeutic  measure.  If  it 
seems  desirable  to  try  electricity,  the  best  effect  will  usually  be  obtained  by 
placing  the  anode  over  the  seat  of  pain  and  the  cathode  at  some  indifferent 
point.  The  current  should  be  weak,  and  should  never  cause  pain,  but  merely 
a  slight  sensation  of  tingling  or  burning.  From  two  to  five  milliamperes 
will  usually  suffice. 

The  use  of  electricity  for  the  purpose  of  diffusing  a  medicinal  substance 
at  the  seat  of  pain  is  far  more  efficacious.  Special  electrodes  are  made  for 
the  purpose  of  effecting  this  difiiision,  but  any  metal  electrode  will  answer. 
The  cataphoric  action  is  effected  by  the  positive  pole  (anodal  difflision). 
Chloroform,  the  tincture  of  aconite,  or  a  strong  solution  of  cocaine  may  be 
employed.  Cocaine  is  most  satisfactory.  A  piece  of  tissue-paper  is  satu- 
rated with  a  20  per  cent,  solution  of  cocaine,  the  paper  is  placed  over  the 
metal  electrode  and  the  latter  is  applied  to  the  painful  spot  (Peterson).  This 
method  is  economical  and  secures  a  degree  of  accuracy  in  dosage.  A  weak 
current  is  used  for  five  or  ten  minutes.  Relief  is  usually  prompt  and  may 
last  for  many  hours.  Although  the  direct  relief  of  pain  first  demands  at- 
tention, nothing  is  more  important  for  the  successful  treatment  of  trigeminal 
neuralgia  than  those  measures  which  operate  through  their  effect  upon  the 
general  health  by  the  removal  of  a  local  cause  of  irritation.  The  removal 
of  anv   distinct  cause  of  irritation,  such  as  carious  teeth,   cicatrices,  etc., 


820  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

.  should  uot  be  delayed.  The  effect  upon  the  pain  is  often  most  striking, 
especially  if  the  local  condition  has  not  been  long  operative,  but  it  is  impor- 
tant to  realize  that  the  cases  are  not  rare  in  which  the  removal  of  a  local 
condition  which  seems  sufficient  to  explain  the  existence  of  a  neuralgia  does 
not  in  itself  materially  benefit  the  patient. 

In  every  case  of  trigeminal  neuralgia  the  character  of  the  patient's  environ- 
ment should  be  carefully  studied,  and  every  effort  should  be  made  to  render 
his  surroundings  as  hygienic  as  possible.  AH  influences  that  tend  to  depress 
the  general  health — sedentary  habits,  sexual  excess,  excessive  use  of  alcohol, 
tobacco,  tea,  and  coffee,  emotional  excitement,  worry,  and  over-fatigue — 
should  l3e  removed  so  far  as  possible.  An  out-of-door  life  should  be  advised 
where  this  is  practicable ;  in  any  case  the  patient  should  be  out  of  doors  at 
least  two  hours  daily.  In  some  severe  cases  of  neuralgia  a  removal  of  resi- 
dence to  a  warm,  equable  climate  (Southern  California,  Florida)  may  be 
necessary.  When  possible  the  patient  should  exercise ;  but,  if  the  exercise 
of  walking  or  horseback  riding  causes  exhaustion,  massage  is  to  be  preferred. 
It  is  very  imj)ortant  that  exercise  should  never  be  carried  beyond  the  degree 
that  causes  an  agreeable  sense  of  fatigue.  Unless  there  are  exceptional  rea- 
sons (diabetes,  excessive  intestinal  putrefaction)  for  restricting  the  diet,  this 
should  be  full  and  repi'esentative  of  the  various  types  of  food-stuffs.  IS^itro- 
genous  food  should  be  taken,  chiefly  as  meat,  and  where  the  pain  is  very  se- 
vere beef  is  to  be  distinctly  preferred.  Contrary  to  general  opinion,  gouty 
and  rheumatic  neuralgias  are  no  exception  to  this  rule.  Cod-liver  oil,  iron, 
arsenic,  and  strychnine  are  valuable  aids  in  treatment.  Quinine  is  much 
less  valuable  than  strychnine.^  Warburg's  tincture  is  an  excellent  tonic  in 
many  cases.  Zinc  j^hosphate  and  phosphorus  have  been  highly  recom- 
mended, but  have  little  effect.  Mixed  treatment  must  be  employed  where 
there  is  recent  syj)hilis. 

It  occasionally  happens,  especially  in  persons  in  the  second  half  of  Hfe, 
that  all  attempts  to  relieve  a  trigeminal  neuralgia  are  without  avail.  In  such 
cases  the  only  measure  Avhich  offers  a  prospect  of  success  is  the  interruption 
of  the  passage  of  all  impulses  along  the  nerve,  from  its  peripheral  distribu- 
tion to  the  cortical  centres.  This  may  be  accomplished  by  means  of  nerve 
section,  by  neurectomy,  by  evulsion,  or  by  the  removal  of  the  Gasserian  gan- 
glion, and  perhaps  by  nerve-stretching.  Xerve-stretching  has  been  of  tem- 
porary benefit  in  some  forms  of  neuralgia,  but  is  unsuitable  for  trigeminal 
neuralgias.  jS^erve-section  is  apt  not  to  give  permanent  results,  in  part  because 
union  is  likely  to  take  place  between  the  divided  ends,  which  remain  in  con- 
tiguity. The  most  satisfactory  operation  upon  nerves  is  that  of  neurectomy, 
in  Avhich  a  short  piece  of  the  trunk  of  the  nerve  is  removed,  although  in  some 
situations,  as  in  the  case  of  the  inferior  dental  nerve,  it  is  better  to  practice 
evulsion  and  remove  as  much  as  possible  of  the  peripheral  end  of  the  nerve. 
Cases  are  on  record  in  which  long  relief  has  followed  neurectomy,  but  in  a 
considerable  proportion  of  cases,  probably  a  majority,  the  pain  has  recurred 
in  from  six  to  eighteen  months.  In  many  cases  the  relief  from  operation  is 
slight  and  transitory,  the  pain  soon  returning  with  unabated  intensity  and 
rendering  the  life  of  the  patient  unendurable.  In  such  eases  the  question  of 
removing  the  Gasserian  ganglion  arises.     Several  cases  are  now  upon  record 

1  A  tablet  triturate  (Eraser's)  having  the  following  composition  is  often  serviceable  as  a  tonic  and 
as  a  means  of  relieving  pain  in  cases  of  moderate  severity  : 

Quin.  sulph '/2gr. 

Morph.  sulph '/so  &r- 

Strych.  sulph 1/120  &r- 

Acid,  arsen.  .        .        .        .    ' '/so  gr- 

Ext.  aconite Vg  gr. 

This  tablet  is  not  suitable  for  continued  use,  on  account  of  the  morphine  it  contains. 


DISEASES  OF  THE  CRANIAL  NERVES.  821 

in  which  this  has  been  successfully  done,  and  in  which  there  was  immediate 
and  entire  relief  from  pain.  As  regards  the  length  of  time  for  Avhich  relief 
from  pain  may  be  expected,  the  observations  are  at  present  far  too  few  to 
enable  us  to  arrive  at  a  conclusion.  The  operation  as  devised  by  Hartley, 
of  New  York,  is  not  likely  to  prove  one  from  which  the  mortality  is  great, 
and,  while  there  is  still  considerable  uncertainty  as  to  the  duration  of  the 
relief  afforded,  it  may  be  recommended  without  hesitation  in  cases  where  all 
other  means  have  failed  and  the  morphine  habit  is  the  only  alternative.  The 
anaesthesia  of  the  face  is  of  slighter  extent  than  might  be  expected  after  re- 
moval of  the  Gasserian  ganglion.  The  sense  of  taste  is  apt  to  be  lost  in  the 
anterior  two-thirds  of  the  tongue  upon  the  corresponding  side.  Trophic  dis- 
turbances of  the  skin  and  eyeball  were  absent  in  two  cases  reported  by 
Thomas,  and  probably  do  not  usually  occur.  The  masseters  are  apt  to  be 
paralyzed,  and  some  branches  of  the  facial  nerve  are  liable  to  be  cut  in  the 
course  of  the  operation.     (See  also  Chaj)ter  XXXIII.) 

It  seems  probable  that  the  chances  of  success  from  neurectomy  are  much 
increased  by  doing  the  operation  as  early  as  seems  justifiable. 

Cutting  operations  upon  the  extrinsic  muscles  of  the  eyeball  have  of  late 
come  into  vogue  in  certain  quarters  for  the  relief  of  trigeminal  neuralgias. 
The  practice  is  based  on  the  belief  that  many  neuralgias  of  the  fifth  are  oc- 
casioned by  insufficiency  of  the  ocular  muscles,  and  that  the  correction  of 
this  defect  is  essential  to  recovery.  There  is  some  evidence  that  the  correc- 
tion of  a  high  grade  of  insufficiency  has  benefited  a  small  number  of  cases 
where  the  neuralgia  has  been  distinctly  related  to  the  use  of  the  eyes.  These 
defects  can  usually  be  overcome  by  the  use  of  prisms.  The  operation  of 
cutting  has  been  extensively  performed  without  the  slightest  justification, 
and  often  with  distinct  injury  to  the  patient.  If  the  operation  has  any  legiti- 
mate use,  it  is  certainly  in  an  exceedingly  limited  class  of  cases.  Errors  of 
refraction  should,  of  course,  receive  careful  attention  in  all  cases  of  neuralgia 
of  the  first  division  of  the  fifth,  although  it  is  only  rarely  that  a  causative 
influence  can  be  ascribed  to  this  condition. 


FACIAL  PARALYSIS. 

The  muscles  of  the  face  are  paralyzed  by  a  lesion  anywhere  in  the  facial 
path  which  lies  between  the  motor  centre  for  the  face  in  the  lowest  third  of 
the  Rolandic  area  and  the  face  muscles  of  the  opjDOsite  side.  But  the  nature 
of  the  paralysis  differs  according  to  the  position  of  the  lesion — according  as 
the  lesion  affects  the  facial  path  between  the  nucleus  of  the  facial  in  the 
pons  and  the  cortex  (supra-nuclear  facial  paralysis),  or  involves  the  nucleus 
of  the  facial  or  the  fibres  of  the  nerve  itself  (nuclear  or  infra-nuclear  paral- 
ysis). In  the  supra-nuclear  form  the  upper  muscles  of  the  face  (orbicularis 
palpebrarum  and  frontalis)  retain  their  power,  voluntary  movements  may  be 
more  impaired  than  emotional  movements,  and  the  electrical  reactions  re- 
main little  or  not  at  all  changed.  In  the  nuclear  or  infra-nuclear  form  all 
the  muscles  of  one  side  of  the  face  (including  the  orbicularis  and  frontalis) 
are  paralyzed,  emotional  movements  are  lost  equally  with  voluntary  ones, 
and  the  electrical  reactions  are  altered  in  character. 

Supra-nuclear  paralysis  is  often  referred  to  as  "central,"  in  distinction 
from  paralysis  due  to  nerve  lesions,  which  is  termed  "  peripheral."  Paral- 
ysis from  disease  of  the  nucleus  or  the  nerve-roots  in  the  pons  is  sometimes 
called  "  central,"  sometimes  "  peripheral."  The  character  of  such  palsies  are 
peripheral,  although  the  lesions  which  cause  them  are  central.  Only  the 
peripheral  palsies  (using  the  term  in  the  broad  sense)  are  considered  here ; 


822  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

supra-nuclear  paralysis  is  treated  with  the  hemiplegia,  with  which  it  is  com- 
monly associated. 

Etiology  and  Pathology,  Peripheral  facial  paralysis,  though  not  so  fre- 
quent in  its  occurrence  as  some  other  form  of  peripheral  palsy  (e.  g.,  mus- 
culo-spinal  paralysis),  is  yet  one  of  the  most  common  of  peripheral  j)aral- 
yses.  Probably  two-thirds  of  the  cases,  including  cases  of  every  origin, 
occur  between  the  twentieth  and  fortieth  years,  and  the  condition  is  more 
often  seen  in  men  than  in  women,  and  has  been,  owing  to  their  greater  ex- 
posure, met  with  in  children.  The  following  ax"e  the  chief  causes  of  periph- 
eral facial  paralysis  : 

1.  Neuritis  of  the  facial  nerve  is  the  cause  of  a  very  lai'ge  proportion 
(probably  more  than  80  per  cent.)  of  all  cases  of  peripheral  palsy.  It  is 
the  cause  of  Bell's  palsy,  using  that  term  in  its  original  sense.  The  neuritis 
is  commonly  termed  "  rheumatic."  Whatever  that  may  mean,  it  is  true  that 
the^  palsy  generally  comes  on  after  exposure  to  cold.  The  exposure  may  be 
considerable  in  degree  and  special  in  kind,  as  sitting  by  an  open  window  in 
a  passenger  car,  standing  in  an  open  doorway,  or  driving  in  the  cold  (one 
side  of  the  face  being  usually  more  exposed  than  the  other),  or  it  may  be 
more  or  less  habitual,  and  consists  of  frequent  exposure  to  draughts.  Occa- 
sionally the  subjects  are  distinctly  rheumatic  or  gouty,  but  usually  there  is 
no  evidence  of  either  condition.  It  is  extremely  probable  that  the  general 
nutrition  of  the  patient  is  somewhat  impaired  as  a  rule,  at  least  temporarily. 
There  are,  however,  cases  in  which  there  is  no  reason  even  to  suspect  impair- 
ment of  general  nutrition ;  the  palsy  may  occur  in  the  midst  of  apparently 
the  best  of  health.     Probably  the  exposure  in  these  cases  is  unusually  severe. 

It  was  formally  thought  that  exposure  to  cold  causes  facial  paralysis  by 
paralyzing  the  terminations  of  the  facial  nerve  in  the  muscles.  There  is  now 
good  reason  to  believe  that  the  aifection  always  depends  on  an  inflammation 
of  the  trunk  of  the  nerve  (perhaps  involving  chiefly  the  sheath)  within  the 
Fallopian  canal.  In  some  cases  the  nerve-fibres  undergo  complete  degenera- 
tion. There  is  no  evidence  that  the  inflammation  ever  involves  the  nerve 
after  its  emergence  from  the  canal. 

2.  Injury  is  an  important  cause  of  facial  paralysis.  The  nerve  may  be 
torn  or  compressed  in  fracture  of  the  base.  The  disability  is  then  immediate. 
In  other  cases  of  fracture  of  the  base  the  paralysis  has  come  on  in  the  course 
of  several  days,  in  one  case  at  the  end  of  five  days.  Here  the  involvement 
of  the  nerve  is  due  to  secondary  meningitis,  with  implication  of  the  nerve, 
or  perhaps  to  secondary  inflammation  of  the  nerve  alone.  Some  rare  cases 
of  congenital  facial  paralysis  have  probably  been  due  to  meningeal  hemor- 
rhage. The  facial  is  apt  to  suffer  outside  the  skull,  in  some  of  its  branches, 
in  operations  about  the  ramus  of  the  jaw.  A  blow  upon  the  nerve  in  the 
parotid  region  has  caused  permanent  paralysis  of  the  face.  Rarely  the  nerve 
of  one  side  has  been  compressed  by  the  blade  of  a  forceps  during  delivery, 
and  very  rarely  such  injury  has  been  bilateral.  Parotid  tumors  and  tuber- 
cular nodes  in  the  neck  occasionally  give  rise  to  facial  paralysis. 

3.  In  children  the  nerve  is  apt  to  suflTer  in  the  temporal  bone.  Otitis 
media,  with  or  without  bone  disease,  is  the  common  cause  of  involvement 
here.  The  nerve  may  be  damaged  in  consequence  of  bone  disease  limited  to 
the  mastoid,  probably  owing  to  extension  of  inflammation  along  the  chorda 
tympani  or  stapedius  branch  of  the  nerve.  In  rare  instances  facial  paralysis 
has  followed  sore-throat. 

4.  The  facial  nerve  is  not  rarely  compressed  at  the  base  of  the  brain  in 
tumors  or  in  meningitis.  Very  rarely  it  is  implicated  in  meningeal  hemor- 
rhage. Owing  to  its  proximity  the  auditory  nerve  is  apt  to  suffer  with  the 
facial  in  this  situation. 


DISEASES  OF  THE  CRANIAL  NERVES.  823 

5.  Withiu  the  pons  the  facial  (nucleus  and  root-fibres)  is  apt  to  sufter 
from  gross  lesions,  especially  acute  softening  and  hemorrhage,  and  occasion- 
ally from  a  patch  of  sclerosis.  The  nerve  may  suffer  alone,  but  commonly 
there  is  implication  of  the  motor  path  to  the  limbs  of  the  opposite  side, 
causing  a  crossed  hemiplegia.  The  sixth  nerve  is  liable  to  suffer  with  the 
facial  in  pons  lesions.  The  nucleus  of  the  facial  is  very  rarely  damaged  in 
acute  myelitis  and  in  chronic  glosso-labio-laryngeal  paralysis.  The  facial 
may  suffer  in  diphtheritic  paralysis,  jjossibly  from  involvement  of  both  cells 
and  fibres.  When  the  facial  suffers  in  alcoholic  paralysis  (it  very  rarely 
does),  the  lesion  is  probably  in  the  trunk  of  the  nerve.  Among  the  rarer 
causes  of  facial  paralysis  may  also  be  mentioned  the  following :  Syphilis, 
which  may  operate  by  involving  the  root-fibres  in  a  meningitis  or  a  gumma, 
or  may  cause  a  neuritis  without  a  considerable  inflammatory  exudate. 
Syphilis  acts  also  by  reducing  the  general  health  and  thus  predisposing  to 
ordinary  neui'itis  of  the  facial.  In  the  rare  cases  of  facial  paralysis,  in  which 
the  onset  is  sudden  and  there  is  no  evidence  of  central  disease,  there  is  prob- 
ably hemorrhage  into  the  nerve-sheath  or  Fallopian  canal  or  thrombosis  in 
a  vessel  of  the  nerve.  In  a  few  cases  emotion  or  fright  has  been  followed 
by  paralysis  of  sudden  onset,  and  it  is  possible  that  the  mechanism  here  is 
thrombosis. 

Double  facial  paralysis  is  of  rare  occurrence.  It  is  observed  as  a  conse- 
quence of  (1)  bilateral  disease  of  the  pons  (as  from  symmetrical  softening 
from  basilar  disease)  ;  (2)  disease  of  nerves  at  the  base  of  the  brain,  other 
nerves  suffering  ;  also  (3)  double  otitis  media  (this  is  perhaps  the  least  infre- 
quent cause)  ;  (4)  neuritis  from  cold  ;  (5)  alcoholic  multiple  neuritis  and 
multiple  neuritis  from  toxic  blood-states  ;  (6 )  nuclear  degeneration  or  sym- 
metrical cortical  disease  (here  the  palsy  is  partial)  ;  (7 )  erysipelas  of  the 
face. 

Symptoms.  In  cases  of  complete  facial  paralysis  there  is  loss  of  power 
and  tone  in  the  muscles  of  the  side  of  the  face  involved.     There  is  loss  of 

Fig.  275. 


Complete  facial  palsy.    Patient  unable  to  close  the  eye  of  the  affected  side. 

emotional  as  Avell  as  voluntary  movements.  Owing  to  the  elasticity  of  the 
skin  in  youth  the  resulting  change  in  the  facial  expression  is  far  less  in  the 
young  than  in  those  in  whom  the  skin  is  wrinkled.  In  the  latter  the  wrinkles 
are  smoothed  out  or  change  their  position.  The  transverse  wrinkles  of  the 
forehead  cease  abruptly  near  the  median  line,  the  lower  eyelid  falls  forward. 


824  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  the  tears  collect  so  that  the  eye  "  waters."  The  loss  of  power  iu  the 
face  renders  the  patient  unable  to  close  the  affected  eye.  (See  Fig.  275.)  It 
remains  somewhat  open  even  during  sleep.  The  inability  to  close  the  mouth 
permits  liquids  to  run  out  of  the  mouth  unless  the  head  is  inclined  to  one  side. 
Whistling  and  accurate  spitting  are  impossible.  Food  is  apt  to  accumulate 
between  the  teeth  and  the  lip  on  the  affected  side  because  the  buccinator  is 
relaxed.  Speech  is  apt  to  be  a  little  muffled.  The  paralysis  of  the  external 
muscles  of  the  ear,  of  the  stylohyoid  and  posterior  belly  of  the  digastric,  and 
of  the  dilator  naris,  does  not  cause  important  symptoms. 

It  was  formerly  believed  that  the  palate  is  sometimes  paralyzed  upon  the 
same  side  as  the  face  in  lesions  of  the  facial  nerve,  but  it  is  doubtful  if  this 
is  so.  The  levator  palati  is  innervated  by  the  spinal  accessory  nerve,  and  it 
is  probable  that  in  the  very  rare  cases  in  which  the  palate  has  actually  been 
paralyzed  coincidently  with  paralysis  of  the  facial  the  palsy  has  depended 
upon  a  lesion  of  the  palatine  branch  of  the  spinal  accessory  or  upon  disease 
of  the  trunk  of  this  nerve.  Mere  deviation  of  the  uvula  must  not  be  mis- 
taken for  paralysis  of  the  palate. 

In  a  small  proportion  of  all  cases  of  facial  paralysis  taste  is  lost  in  the 
anterior  part  of  the  tongue  or  the  side  affected.  In  these  cases  the  facial 
nerve  is  involved  between  the  origin  of  the  chorda  tympani  and  the  genicu- 
late ganglion  of  the  facial.  In  lesions  affecting  other  parts  of  the  facial  the 
sense  of  taste  is  not  lost.  Taste  is  involved  in  a  large  proportion  of  all  cases 
of  facial  paralysis  arising  from  cold.  Sometimes  it  is  lost  where  the  facial 
has  been  damaged  externally  to  the  stylo-mastoid  foramen,  but  in  such  cases 
there  is  doubtless  a  neuritis  extending  along  the  nerve  to  the  chorda.  The 
sense  of  hearing  may  be  impaired  or  lost.  This  occurs  especially  in  the 
facial  paralysis  of  middle-ear  or  mastoid  disease  and  in  lesions  at  the  base  of 
the  brain,  which  implicate  both  auditory  and  facial.  Slight  loss  -of  hearing- 
is  not  rare  in  facial  neuritis  from  cold.  Tinnitus  auriuni  also  may  be  present 
in  these  cases.  When  the  nerve  to  the  stapedius  is  implicated  the  sensi- 
tiveness of  the  ear  to  certain  musical  tones  may  be  increased. 

It  is  stated  that  in  lesions  involving  the  facial  nerve  at  the  geniculate  gan- 
glion there  is  loss  of  lachrymal  secretion  and  of  the  reflex  flow  of  tears  upon 
the  side  of  the  lesion. 

The  changes  in  the  electrical  reactions  in  facial  paralysis  are  identical 
with  those  observed  in  the  paralyses  of  other  peripheral  nerves.  They  merit 
careful  study  in  every  case,  owing  to  their  bearing  upon  prognosis.  In 
severe  cases  the  reaction  of  the  nerve  to  the  faradic  and  galvanic  cuiTents  is 
rapidly  decreased  and  may  be  entirely  lost  in  from  one  to  two  weeks.  While 
the  muscles  lose  their  faradic  irritability,  they  react  more  readily  than  normal 
to  galvanism  at  first,  and  show  a  reversal  of  the  ordinary  formula  of  con- 
traction (the  anodal  closure  contraction  (AnClC)  being  greater  than  the  catho- 
dal closure  contraction  (CaClC)  ). 

In  less  severe  cases  the  irritability  of  the  nerve  to  both  currents  is  re- 
duced but  not  lost,  the  loss  of  faradic  irritability  in  the  muscles  does  not 
occur  so  rapidly,  and  instead  of  the  formula  being  reversed  to  galvanism 
there  may  be  merely  an  equality  in  the  two  contractions.  In  very  slight 
cases  there  may  be  little  or  no  reduction  in  the  irritability  of  the  nerve,  or 
there  may  be  slight  initial  increase  in  irritability  which  is  not  succeeded  by 
a  reduction  of  irritability  below  the  normal.  But  even  in  cases  of  slight  sever- 
ity the  muscles  show  some  reduction  of  faradic  irritability  for  a  time.  As  the 
nerve  recovers  there  is  a  gradual  return  of  the  normal  irritability  of  nerve 
and  muscle.  There  may  be  considerable  recovery  of  power  before  the  full 
irritability  of  the  nei've  is  established. 

Atrophy  of  the  muscles  of  the  face  always  follows  degeneration  of  the 


DISEASES  OF  THE  CRANIAL  NERVES.  825 

nerve,  but  in  most  persons  there  is  enough  subcutaneous  fat  to  prevent  the 
wasting  from  being  noticeable.  In  all  cases  of  severe  type  contracture 
comes  on  in  the  affected  muscles  when  voluntary  power  begins  to  return. 
The  contracture  comes  on  in  the  course  of  five  or  six  months,  increases  for  six 
or  eight  months,  and  then  remains  unchanged  or  lessens  slowly.  It  is  most 
marked  in  the  zygomatici,  which  may  cause  the  naso-labial  fold  to  be  more 
pronounced  than  in  the  normal  side  while  the  face  is  at  rest,  and  thus  lead 
to  the  impression  that  the  paralysis  is  upon  the  side  opposite  the  contracture. 
With  this  contracture  is  associated  overaction  of  the  muscles,  especially  of 
the  zygomatics  and  the  orbicularis,  which  may  contract  the  face  during  vol- 
untary movement.  The  zygomatics  may  be  the  seat  also  of  slight  spas- 
modic involuntary  twitching. 

Pain  in  the  region  of  the  ear  is  very  apt  to  attend  the  onset  of  neuritic 
cases  of  facial  paralysis.  It  may  be  associated  Avith  some  tenderness  to 
pressure  below  the  ear  about  the  ramus  of  the  jaw.  When  the  paralysis  is 
due  to  a  new  growth  from  the  parotid  there  may  be  constant  intense  pain 
back  of  the  ear.  Other  symptoms  which  occasionally  attend  the  onset  are 
swelling  about  the  ear  (due  to  cellulitis),  giddiness,  and  neuralgia  of  the  head, 
face,  or  neck. 

The  onset  of  the  pai-alysis  is  usually  acute,  but  very  rarely  sudden.  In 
some  cases  the  paralysis  does  not  reach  its  height  for  forty-eight  hours.  In 
slight  cases  the  palsy  may  entirely  clear  up  in  a  week  or  ten  days.  Most 
cases  last  from  two  to  four  months,  and  then  recover  entirely.  Where  the 
loss  of  power  lasts  more  than  six  months  ultimate  recovery  is  partial  only ; 
indeed,  it  may  be  said  that  some  permanent  loss  remains  whenever  complete 
paralysis  undergoes  no  improvement  after  a  month's  duration. 

So  far  as  the  facial  paralysis  itself  is  concerned  its  characters  are  essen- 
tially the  same  whatever  may  be  the  position  or  nature  of  the  lesion.  But 
in  cases  of  facial  paralysis  clue  to  disease  of  the  facial  nucleus  the  orbicu- 
laris oris  escapes  entirely.  This  is  because  the  fibres  to  this  muscle  arise  not 
from  the  facial  nucleus,  but  from  cells  near  the  hypoglossal  nucleus,  although 
the  fibres  soon  join  those  of  the  facial  nerve. 

Diagnosis.  The  first  question  in  diagnosis  that  arises  upon  seeing  any 
case  of  paralysis  of  the  face  relates  to  the  position  of  the  lesion  :  Is  the 
paralysis  of  central  (supra-nuclear)  origin  or  is  it  of  nuclear  or  infra-nuclear 
origin  ?  Cases  of  cerebral  origin  are  ruled  out  by  means  of  the  following 
facts:  (1)  cerebral  cases  do  not  show  persistent  paralysis  of  the  eyelid;  (2) 
emotional  movements  are  little  or  not  at  all  impaired ;  (3)  reflex  action  is 
unchanged  ;  (4)  the  electrical  reactions  are  normal  or  slightly  changed  ; 
and  (5)  the  difference  in  the  course  and  associations  of  cerebral  cases. 

Having  determined  that  the  lesion  is  not  central,  it  remains  to  fix  the  seat 
of  the  lesion  in  the  lower  segment  of  the  motor  path.  To  do  this  the  asso- 
ciations of  the  paralysis  must  be  taken  into  account.  If  no  other  nerve 
than  the  facial  is  implicated  and  taste  is  unimpaired,  the  lesion  is  probably 
just  within  the  stylo-mastoid  foramen  or  outside  the  skull.  If  the  sense  of 
taste  is  involved  in  the  anterior  two-thirds  of  the  tongue  on  the  side  of  the 
lesion,  the  seat  of  the  disease  is  in  the  Fallopian  canal  at  some  point  between 
the  junction  with  the  chorda  tympani  and  the  geniculate  ganglion  (where 
the  great  superficial  petrosal  nerve  containing  the  taste-fibres  joins  the  trunk 
of  the  nerve).  Of  course  the  disease  may  have  spread  to  this  region  from 
a  more  peripheral  region.  Disease  of  the  nerve  at  the  geniculate  ganglion 
has  been  thought  to  cause  paralysis  of  the  palate,  but  it  is  extremely  doul^t- 
fiil  if  this  is  so.  Inequality  of  the  two  sides  of  the  palate  has  no  localiz- 
ing value  in  connection  with  facial  paralysis.  If  there  is  complete  deafness 
in  the  ear  on  the  side  of  the  lesion,  and  if  this  deafness  dates  from  the  time 


826  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

of  the  facial  paralysis,  the  disease  is  in  the  trunk  at  the  base  of  the  brain, 
or  (in  rare  cases)  in  the  internal  auditory  meatus.  If  paralysis  of  the  sixth 
nerve  is  associated  with  paralysis  of  the  facial,  the  lesion  is  no  doubt  in  the 
pons,  and  in  all  probability  in  its  posterior  part,  where  the  fibres  of  the 
seventh  pass  around  the  sixth  nucleus.  Crossed  hemiplegia  also  points  to  a 
partial  lesion.  Disease  of  the  facial  nucleus  is  probably  indicated  where  all 
muscles  supplied  by  the  nerve  are  paralyzed  except  the  orbicularis  oris 
(which  is  probably  innervated  by  the  twelfth  nerve).  There  is  one  simple 
point  in  the  diagnosis  of  facial  paralysis,  the  neglect  of  which  sometimes 
leads  to  error.  When  contracture  develops  in  the  paralyzed  muscles  the 
zygomatici  draw  up  the  angle  of  the  mouth  on  the  affected  side.  Hence  an 
error  may  be  made  as  to  the  side  affected,  unless  the  patient  is  made  to  move 
both  sides  of  the  mouth.  Patients  and  their  friends  can  seldom  be  relied 
upon  in  their  statements  regarding  the  side  affected ;  they  usually  think 
the  palsy  is  on  the  side  they  describe  as  "  drawn,"  i.  e.,  the  normal  side,  on 
which  the  features  appear  to  them  distorted. 

Prognosis.  By  far  the  most  important  indications  as  to  prognosis  are  de- 
rived from  the  electrical  reactions,  which  enable  us  to  make  a  forecast  in 
many  cases  before  there  is  any  recovery  in  power.  If  there  is  no  loss  in  irri- 
tability of  the  nerve  to  galvanism  or  faradism  at  the  end  of  ten  days  the  paral- 
ysis will  clear  up  in  a  few  weeks  or  a  month.  If  nerve  irritability  is  much 
lowered,  but  not  lost,  after  the  lapse  of  two  weeks,  there  will  probably  be 
complete  recovery  of  power  in  the  course  of  two  or  three  months  from  the 
onset.  Where  the  excitability  of  the  nerve  is  entirely  lost  by  the  end  of  a 
fortnight,  the  paralysis  will  probably  endure  many  months  at  least.  The 
possibility  of  slight  recovery  is  not  gone  until  both  faradic  and  galvanic 
irritability  in  the  muscles  has  been  lost  more  than  a  year.  There  may  be 
return  of  power  long  before  the  electrical  reactions  become  normal.  There 
is  some  persistent  loss  of  power  in  almost  in  all  cases  where  there  has  been 
complete  paralysis  of  the  face  for  more  than  one  month. 

Occasionally  the  electrical  reactions  are  misleading.  A  severe  facial  paral- 
ysis may  occur  without  any  evidence  of  the  R.  D.,  and  the  R.  D.  may  be 
well  marked  in  mild  cases. 

The  nature  of  the  lesion  causing  the  paralysis  does  not  greatly  affect  the 
prognosis,  with  the  following  exceptions  :  The  prognosis  is  bad  in  the  rare 
cases  where  the  suddenness  of  onset  justifies  the  diagnosis  of  hemorrhage  into 
the  nerve  ;  good  when  due  to  a  syphilitic  lesion,  when  it  is  an  uncomplicated 
palsy,  and  when  the  cause  is  a  multiple  neuritis  (if  death  does  not  occur). 

Treatment.  In  every  case  of  facial  paralysis  an  effort  should  be  made 
to  remove  or  modify  the  pathological  process  on  which  the  loss  of  power 
depends.  In  cases  Avhere  there  is  supj)urative  ear  disease  or  mastoid  dis- 
ease the  pus  should  be  given  free  exit.  In  any  case  where  there  is  even  the 
smallest  likelihood  that  there  has  been  syphilitic  infection,  iodide  of  potas- 
sium should  be  given  freely,  and  if  the  infection  has  been  recent,  mercury 
should  be  added.  In  all  neuritic  cases  of  rapid  onset  the  patient  should  be 
given  a  diuretic  and  a  brisk  purge,  and  a  fly-blister  should  be  placed  over 
the  exit  of  the  nerve  from  the  skull  or  over  the  mastoid.  The  blister  should 
be  followed  by  hot  fomentations  over  the  nerve,  the  applications  being  made 
for  half  an  hour  several  times  daily  for  two  or  three  days.  After  the  patient 
has  been  purged,  salol  should  be  given  in  doses  of  five  grains  hourly  until 
forty  or  fifty  grains  have  been  taken  in  the  course  of  the  day.  This  should 
be  continued,  if  possible,  until  the  end  of  the  first  week.  In  severe  cases 
the  patient  should  remain  in  the  house,  if  possible,  during  the  first  week. 
The  diaphoretic  effect  of  a  hot  bath  daily  during  the  first  days  may  be  of 
service  in  reducing  the  local  inflammation. 


DISEASES  OF  THE  CB AXIAL  NERVES.  827 

There  are  no  facts  to  show  that  the  therapeutic  application  of  electricity 
in  any  form  exerts  any  influence  either  in  checking  the  progress  of  degenera- 
tion in  the  nerve-fibres  or  in  aiding  their  regeneration.  Nevertheless  the 
stimulation  of  the  paralyzed  muscles  by  the  galvanic  current  causes  them  to 
contract,  and  it  is  highly  probable  that  their  nutrition  is  improved  by  such 
stimulation ;  and,  owing  to  this  improved  nutrition  of  the  muscles  they  are 
in  a  condition  more  favorable  to  rapid  repair  when  the  nerve  has  become 
regenerated  than  if  they  had  remained  unstimulated.  It  is  upon  this  ground 
alone  that  the  use  of  electricity  is  to  be  recommended  in  facial  and  other 
peripheral  palsies.  Electricity  should  not  be  employed  from  the  beginning 
in  facial  paralysis,  but  only  after  the  lapse  of  a  week,  when  the  galvanic 
current  may  be  used  for  about  ten  minutes  daily,  or  twice  daily,  in  strength 
just  sufiicient  to  cause  the  muscles  to  contract.  The  positive  electrode  should 
be  placed  below  the  zygoma  over  the  nerve  and  the  negative  electrode 
stroked  over  the  various  paralyzed  muscles  in  turn.  After  a  month  or  six 
Aveeks  the  applications  may  be  reduced  in  number  to  three  or  four  per  week. 
It  is  well  to  continue  the  use  of  the  galvanic  current  after  power  has  begun 
to  return,  but  it  should  be  stopped  when  contracture  begins.  There  is  no 
advantage  in  substituting  faradism  for  galvanism  when  the  muscles  begin  to 
react  to  the  former  current.  When  contracture  sets  in  it  may  probably  be 
lessened  by  means  of  local  massage.  Other  treatment  directed  to  the  con- 
tracture is  useless.  If  the  eye  cannot  be  closed  it  should  be  protected  from 
injury  by  means  of  a  shade.     (For  facial  spasm  see  p.  270.) 


DISEASES  OF  THE   GLOSSO-PHARYNGEAL  NERVE. 

The  functions  of  the  glosso-pharyngeal  nerve  and  the  symptoms  that  result 
from  morbid  processes  involving  it  have  not  as  yet  been  satisfactorily  deter- 
mined. One  reason  for  this  want  of  definite  knowledge  is  that  the  nerve  is 
very  seldom  involved  by  lesions  affecting  it  exclusively. 

The  glosso-pharyngeal  nerve  is  distributed  to  the  back  part  of  the  tongue, 
the  soft  palate,  the  upper  part  of  the  pharynx,  and  the  Eustachian  tube  and 
the  cavity  of  the  tympanum. 

It  has  been  generally  thought  that  the  glosso-pharyngeal  is  the  nerve  of 
taste,  for  the  back  of  the  tongue,  palate,  and  fauces.  But  so  far  as  the  back 
of  the  tongue  is  concerned,  there  is  satisfactory  evidence  that  the  taste-fibres 
which  have  this  distribution  come  not  from  the  root  of  the  glosso-pharyngeal, 
but  from  the  root  of  the  fifth,  though  they  are  distributed  with  the  former 
nerve.  It  is,  moreover,  probable  that  the  sensory  fibres  to  the  anterior  part 
of  the  soft  palate  and  fauces  come  from  the  fifth  and  not  from  the  ninth. 
The  sensibility  of  the  upper  part  of  the  pharynx  and  of  the  tympanic  cavity, 
on  the  other  hand,  is  probably  subserved  by  the  ninth.  A  good  deal  of 
uncertainty  exists  also  as  to  the  motor  functions  of  the  glosso-phar3aigeal. 
The  pharyngeal  plexus,  to  which  the  ninth  contributes,  supplies  the  upper 
pharyngeal  muscles,  but  it  is  not  certain  whether  the  motor  fibres  come  from 
the  ninth  or  the  tenth  nerve.  It  is  likely  that  they  come  from  the  ninth.  It 
is  even  more  doubtful  whether  the  ninth  supplies  any  of  the  fibres  of  the 
palate. 

The  glosso-pharyngeal  nerve  may  be  implicated  by  disease  within  the 
medulla  or  at  the  base  of  the  brain  in  the  posterior  fossa. 

The  chief  intra-medullary  lesions  in  which  it  suffers  are  hemorrhage,  acute 
softening,  and  degeneration,  with  resulting  acute  or  chronic  bulbar  paralysis. 
The  pharyngeal  symptoms  in  such  cases  are  probably  referable  to  the  affec- 
tion of  the  glosso-pharyngeal  nuclei.     At  the  surface  of  the  medulla,  tlae  nerve 


828  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

is  liable  to  suffer  (together  with  the  pneumogastric)  from  meningitis  and  new 
growths. 

Isolated  disease  of  the  glosso-pharyngeal  (especially  if  bilateral)  probably 
causes  difficulty  in  swallowing. 


DISEASES    OF    THE    PNEUMOGASTRIC    AND    SPINAL 
ACCESSORY  NERVES. 

The  vagus  or  pneumogastric  nerve  has  the  widest  distribution  of  any 
cranial  nerve,  supplying,  as  it  does,  the  vocal  and  respiratory  organs,  the 
heart,  the  greater  portion  of  the  alimentary  canal,  and  some  of  the  abdominal 
viscera  (liver,  spleen).  Certain  of  the  functions  pertaining  to  the  trunk  of 
the  nerve  depend  not  upon  the  pneumogastric,  but  upon  the  fibres  which  it 
receives  from  the  accessory  portion  of  the  spinal  accessory  nerve.  Hence,  it 
is  convenient  to  consider  pathological  conditions  pertaining  to  the  accessory 
fibres  in  connection  with  those  affecting  the  root  of  the  pneumogastric,  and  to 
defer  the  consideration  of  disease  of  the  spinal  portion  of  the  eleventh  nerve. 

Owing  to  the  wide  distribution  of  the  pneumogastric  the  symptoms  re- 
sulting from  its  derangement  are  exceedingly  numerous  and  varied.  Very 
often  the  symptoms  of  derangement  of  the  pneumogastric  nerve  generally 
depend,  not  on  demonstrable  lesions  of  the  nerve,  but  uj)on  functional  or 
nutritional  disease.  The  consideration  of  this  very  important  class  of  symp- 
toms belongs  properly  to  the  diseases  of  the  organs  supplied  by  the  pneumo- 
gastric, but  it  is  well  to  touch  upon  certain  of  these  symptoms  in  the  present 
connection.  For  convenience,  we  may  review  the  derangements  of  the 
pneumogastric  generally  before  passing  to  a  more  detailed  description  of  the 
symptoms  of  its  local  derangement. 


AFFECTIONS  OF  THE  PNEUMOGASTRIC  GENERALLY. 

In  spite  of  the  long  course  of  the  j^neumogastric  nerve  it  does  not  suffer 
from  structural  disease  with  great  frequency.  The  nucleus  of  the  nerve  in 
the  medulla  sometimes  is  damaged  by  the  acute  vascular  lesions,  softening 
and  hemorrhage,  or  by  degenerative  processes.  The  adjacent  nuclei  of  the 
glosso-pharyngeal  and  hypoglossal  nerves  regularly  suffer  when  the  vagus 
nucleus  is  involved.  Within  the  medulla  the  root-fibres  may  suffer  from  the 
processes  just  mentioned  and  from  tumor.  At  the  side  of  the  medulla  the 
root-fibres  sometimes  suffer  compression  from  chronic  meningeal  disease  and 
fi'om  growths  from  the  skull,  very  rarely  from  aneurism  of  the  vertebral  artery. 
The  nerve-trunk  in  the  neck  occasionally  suffers  from  deeply-seated  tumors 
and  from  wounds,  including  gunshot  wounds.  The  rare  punctured  wounds 
are  much  more  apt  to  be  recovered  from  than  lacerated  or  incised  wounds, 
which  generally  cause  death  by  injuring  the  carotid  or  jugular.  Sometimes 
the  nerve  suffers  in  surgical  operations ;  it  has  been  included  in  a  ligature  of 
the  carotid  and  cut  in  removal  of  deep  tumors  of  the  neck. 

The  recurrent  laryngeals  are  liable  to  suffer  in  the  operation  for  the 
removal  of  goitre.  In  the  thoi-ax,  aneurisms,  tumors,  and  enlarged  lymph- 
nodes  are  among  the  causes  of  damage  to  the  nerve.  Neuromata  of  the 
nerve  ai-e  very  rare.  It  is  thought  that  exposure  to  cold  may  sometimes 
cause  neuritis  of  the  vagus.  It  is  certain  that  the  trunk  of  the  nerve  is  occa- 
sionally involved  in  the  multiple  neuritis  that  depends  on  tox?emic  states, 
such  as  diphtheria  and  septicaemia.     Rarely  it  is  implicated  in  alcoholic  neu- 


DISEASES  OF  THE  CRANIAL  NERVES.  829 

ritis.  It  is  probable  that  functional  derangement  of  the  nerve,  temporary  in 
duration,  but  pronounced  in  character,  sometimes  depends  on  the  absorption 
of  toxic  substances  from  the  intestinal  tract. 

Symptoms.  The  symptoms  of  pneumogastric  derangement  are  referable 
either  to  paralysis  or  irritation,  or  to  both  combined.  Spasm  of  the  larynx, 
vomiting,  and  slowing  of  the  heart  are  the  chief  irritative  symptoms.  Cases 
have  been  recorded  of  persons  who  could  voluntarily  arrest  the  action  of  the 
heart  for  a  few  seconds  by  pressure  upon  the  vagus.  The  chief  paralytic 
symptoms  are  rapid  heart  action,  with  or  without  slowing  of  respiration,  and 
paralysis  of  the  larynx.  In  some  cases  the  pulse  has  risen  to  200  beats  per 
minute,  while  the  respirations  have  fallen  to  10  per  minute.  In  such  cases 
the  pneumogastric  has  probably  been  implicated  upon  both  sides  ( as  in  cases 
of  multiple  neuritisj,  and  a  fatal  termination  has  usually  taken  place. 

Examples  of  functional  derangement  of  the  pneumogastric  are  seen  in 
Cheyne-Stokes  respiration,  in  the  irregularity  of  the  heart's  action  observed 
in  emotion,  for  instance,  in  anger  and  fear  (this  derangement  being  doubtless 
dependent  on  the  cortical  connections  of  the  vagus),  in  the  "  epigastric  aurse  " 
of  epilepsy,  and  in  the  globus  hystericus  and  laryngeal  spasm  of  hysteria  and 
epileptiform  seizures.  The  close  anatomical  connections  of  the  vagus  nucleus 
with  the  nervous  mechanism  of  equilibrium  explains  the  common  association 
of  vomiting  with  severe  vertigo.  The  relation  of  the  vagus  and  the  equilib- 
ria! portion  of  the  auditory  to  vomiting  is  further  illustrated  by  the  fact  that 
derangement  of  the  vagus  from  gastric  disturbance  may  bring  on  vertigo 
where  there  is  slight  pre-existing  disease  of  the  semicircular  canals. 

Disturbances  Eeferable  to  the  Pharyngeal  Branches  of  the 
Vagus.  Branches  of  the  vagus  take  part  in  the  formation  of  the  pharyn- 
geal plexus,  through  which  the  muscles  and  mucous  membrane  of  the  pharynx 
are  supplied.     The  pharyngeal  muscles  may  be  the  seat  of  paralysis  or  spasm. 

Paralysis  of  the  pharynx  results  from  disease  of  the  vagus  nuclei,  from 
meningeal  disease  of  the  vagus  roots,  from  bone  disease  at  the  base,  and  some- 
times from  diphtheritic  neuritis.  Pharyngeal  paralysis  causes  difficulty  in 
swallowing.  If  the  affection  of  the  nerve  is  one-sided  there  may  be  little 
disability ;  if  bilateral,  food  entering  the  pharynx  from  the  mouth  lodges 
there  instead  of  passing  down  to  the  oesophagus. 

Spasm  of  the  pharynx  is  always  of  functional  origin  and  is  generally  a 
symptom  of  hysteria.  It  is  seldom  the  sole  manifestation  of  the  hysterical 
condition/  During  the  spasms  of  hydrophobia  spasm  of  the  pharynx  usually 
occurs.  £n  pharyngeal  spasm,  as  in  paralysis,  there  is  inability  to  swallow 
food,  but  this  inability  is  transient. 

Disturbances  Referable  to  the  Laryngeal  Branches  of  the 
Vagus.  The  larynx  receives  sensory  fibres  from  the  vagus,  but  its  motor 
fibres  are  derived  exclusively  from  the  accessory  portion  of  the  spinal  acces- 
sory. The  superior  laryngeal  nerve  supplies  the  crico-thyroid  muscle ;  the 
inferior  laryngeal  supplies  all  the  remaining  laryngeal  muscles  which  act  on 
the  glottis.  The  vocal  cords  are  abducted  and  the  glottis  opened  mainly  by 
the  posterior  crico-thyroid  muscle ;  the  cords  are  adducted,  with  closure  of 
the  glottis  by  a  number  of  muscles,  but  chiefly  by  the  lateral  crico-arytenoid. 

Paralysis  of  the  larynx  may  originate  in  many  ways ;  first,  from  organic 
disease  of  the  nerve-centres  or  of  the  nerves  external  to  the  larynx  :  cortical 
disease  of  the  laryngeal  centre  (Semon  and  Horsley),  chronic  nuclear  de- 
generation, growths  or  meningitis  involving  the  nerve-roots,  damage  of  the 
nerve-trunk  by  trauma,  tumors  or  multiple  neuritis,  damage  to  the  recurrent 
laryngeal  by  aneurism,  growths,  or  enlarged  nodes  within  the  chest  or  enlarge- 
ment of  the  thyroid ;  second,  by  paresis  of  the  laryngeal  muscles  not  due  to 
lesions  of  the  vagus  centres  or  nerves  (hysterical  paresis,  weakness  from 


830 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


ansemia  or  prolonged  exhaustion,  local  congestions  and  inflammations)  ;  third, 
from  disease  involving  minute  branches  of  the  nerves  in  the  larynx  and  causing 
paralysis  of  a  single  muscle  ( laryngeal  growths,  cellulitis,  perhaps  multiple 
neuritis) ;  fourth,  without  known  cause. 

Symptoms.  There  are  three  kinds  of  evidence  of  laryngeal  paralysis  :  (1) 
alteration  or  loss  of  voice ;  (2)  derangement  of  the  regulation  of  the  entrance 
of  air  during  respiration  ;  (3)  defects  in  the  movement  of  the  vocal  cords. 

According  to  the  degree  to  which  movement  is  impaired  there  are  three 
main  types  of  laryngeal  paralysis :  (1)  bilateral  abductor  paralysis,  a  dan- 
gerous form  of  palsy  resulting  from  cold,  or  local  catarrh,  or  bilateral  central 
or  nerve  disease ;  (2  i  unilateral  abductor  paralysis,  due  to  pressure  on  one 
recurrent  laryngeal  (often  by  aneurism)  ;  (3 )  adductor  paralysis,  usually 
hysterical  in  character,  though  often  excited  by  laryngeal  catarrh  or  over- 
use of  the  voice. 

The  following  well-known  table  of  Gowers  gives  the  most  important  charac- 
ters of  the  various  forms  of  laryngeal  paralysis : 


Symptoms. 


No  voice ;  no  cough ;  stridor 
only  on  deep  inspiration. 

Voice  low-pitched  and  hoarse ; 
no  cough  ;  stridor  absent  or 
slight  on  deep  breathing. 

Voice  little  changed  ;  cough 
normal ;  inspiration  difficult 
and  long,  with  loud  stridor. 

Symptoms  inconclusive ;  little 
aiFection  of  voice  or  cough. 

No  voice;  perfect  cough;  no 
stridor  or  dyspnoea. 


Signs. 


Both  cords  moderately  abducted  and  motionless. 


One  cord  moderately  abducted  and  motionless, 
the  other  moving  freely,  and  even  beyond  the 
middle  line  in  phonation. 

Both  cords  near  together,  and  during  inspiration 
not  separated,  but  even  drawn  nearer  together. 


One  cord  near  the  middle  line  not  moving  during 
inspiration,  the  other  normal. 

Cords  normal  in  position  and  moving  normally 
in  respiration,  but  not  brought  together  on  an 
attempt  at  phonation. 


Lesion. 


Total  bilateral 
palsy. 

Total  unilateral 
palsy. 

Total  abductor 
palsy. 

Unilateral  ab- 
ductor palsy. 

Adductor  palsy. 


Spasm  of  the  larynx  is  not  an  uncommon  affection  in  children  who  are 
rachitic  or  suffer  from  some  other  disorder  of  nutrition  (tetany,  for  example). 
Occasionally  paroxysmal  attacks  of  laryngeal  spasm  occur  in  adults  (usually 
young  women).  The  seizures  both  in  children  and  in  adults  are  apt  to  be 
nocturnal  and  may  be  accompanied  with  severe  dyspnoea  and  cyanosis.  Seiz- 
ures of  laryngeal  spasm  are  said  occasionally  to  replace  migraine  paroxysms 
(Liveing),  The  "laryngeal  crises"  of  locomotor  ataxia  are  probably  ex- 
amples of  adductor  spasm.  Very  rarely  laryngeal  spasm  is  excited  by 
attempts  to  phonate. 

Amesthesia  of  the  larynx  is  a  rare  condition  sometimes  met  with  in  buU^ar 
disease  and  in  diphtheritic  neuritis.  Occasionally  it  is  seen  as  a  hysterical 
manifestation.  When  it  is  of  functional  origin  reflex  action  is  preserved  ;  in 
central  or  nerve  lesions  reflex  action  is  lost. 

Disturbances  Eeperable  to  the  Pulmonary  Branches.  There  is 
little  positive  information  as  to  the  effects  of  disease  of  the  pulmonary 
branches  of  the  vagus.  The  muscular  fibres  of  the  bronchi  are  supplied  by 
the  vagus,  and  the  paroxysmal  contractions  which  give  rise  to  asthma  are 
thought  to  originate  through  the  agency  of  these  nerves.  There  is  some 
reason  to  think  that  the  pneumogastric  exerts  a  trophic  influence  over  the 
lungs,  and  that  acute  pulmonary  congestion  and  hemorrhage  are  sometimes 
occasioned  in  part  by  its  disease.  Various  disturbances  in  the  rhythm  of 
respiration  are  referable  to  changes  in  the  vagus  centres. 


DISEASES  OF  THE  CRANIAL  NERVES.  831 

Disturbances  Referable  to  the  Cardiac  Branches.  The  fibres 
which  inhibit  and  regulate  the  action  of  the  heart  run  in  the  cardiac  branches 
of  the  vagus.  Instances  are  recorded  in  Avliich  pressure  upon  one  vagus  in 
the  neck  caused  arrest  of  the  action  of  the  heart  for  a  few  seconds  (Czermak, 
Concato).  There  are  also  cases  where  the  heart  could  be  inhibited  for  a  few 
beats  by  an  effort  of  the  will.  Slowing  of  the  heart's  action  has  been  known 
to  follow  ligation  of  one  vagus.  The  slow  heart  of  certain  forms  of  brain 
disease  (meningitis,  rapid  compression)  probably  depends  on  irritation  of  the 
vagus  nuclei.  A  slight  reduction  of  the  frequency  of  the  heart's  action  is 
common  in  disturbances  of  the  digestive  tract,  especially  in  dilatation  of  the 
stomach.  This  slowing  is  thought  by  some  to  often  depend  on  auto-intoxica- 
tion (Jacoby). 

Excessive  rapidity  of  the  heart's  action  is  brought  about  through  paralysis 
of  the  cardiac  branches  of  the  vagus.  This  has  been  noted  in  some  cases  of 
diphtheritic  neuritis  and  in  injury  of  the  nerve  from  various  causes.  Toxic 
influences  acting  upon  the  the  vagi  seem  competent  to  greatly  accelerate  the 
action  of  the  heart  for  a  time.  Loss  of  function  of  one  vagus  may  cause 
only  temporary  disturbance  or  none  at  all.  The  irregularity  of  the  heart's 
action  observed  in  sexual  neurasthenics  and  in  some  cases  of  chronic  alcoholic 
intoxication  depends  probably  upon  a  disturbance  of  nutrition  in  the  vagus 
(trunk,  cardiac  branches  or  centres). 

Sensory  disturbances  referable  to  the  cardiac  branches  are  frequent  and 
varied.  A  tumor  of  one  vagus  has  seemed  responsible  for  anginal  attacks 
(Blondin).  Neuritis  of  one  vagus  has  appeared  to  be  the  cause  of  pseudo- 
anginal  seizures  (Obolonsky).  Nothing  is  known  of  the  relation  of  the  car- 
diac branches  to  angina  pectoris.  Owing  to  the  occurrence  of  fatty  degenera- 
tion of  tlie  heart  after  vagus  lesions,  in  certain  cases,  a  cardiac  ti'ophic  func- 
tion has  been  ascribed  to  the  pneumogastric. 

Symptoms  Referable  to  Qj^sophageal  and  Gastric  Branches. 
The  oesophageal  branches  of  the  vagus  are  rarely  disturbed  in  function.  Oc- 
casionally disease  of  the  vagus  or  its  centre  has  occasioned  difiiculty  in  deglu- 
tition. More  frequently  spasm  of  the  oesophagus,  of  ftinctional  origin,  has 
been  observed.  Vomiting  results  not  merely  from  reflex  stimulation  of  the 
vagus  through  its  gastric  branches,  but  also  by  direct  irritation  of  the  vagus 
roots,  as  in  the  case  of  basal  meningitis.  Gastralgia  is  thought  to  originate 
as  a  pure  neuralgia  in  some  cases ;  in  others  as  a  result  of  direct  irritation  of 
the  peripheral  endings  of  the  gastric  branches.  Hunger  and  thirst  have 
been  lost  as  a  consequence  of  vagus  disease  (Johnson).  Excessive  appetite 
has  been  present,  however,  where  there  was  atrophy  of  both  vagi  (Swan). 

It  is  extremely  probable  that  the  sensation  of  emptiness  experienced  in 
some  digestive  derangements  comes  into  existence  through  the  agenc)^  of  the 
vagus  in  consequence  of  the  imperfect  digestion  and  absorption  of  food. 

Section  of  the  vagi  lessens,  but  does  not  arrest  the  movements  of  the  stom- 
ach. Both  reflex  and  central  irritation  of  the  nei-ves  are  competent  to  in- 
duce vomiting.  Paroxsymal  vomiting  has  resulted  from  intermitting  pres- 
sure of  a  tumor  on  the  pneumogastric  (Gowers).  Pressure  on  one  vagus  in 
the  neck  as  it  lay  exposed  during  an  operation  was  found  to  cause  vomiting 
when  the  pressure  was  being  exerted  (Boinet).  The  gastric  crises  of  loco- 
motor ataxia  are  probably  due  to  the  irritation  of  a  nuclear  lesion.  Intes- 
tinal symptoms  have  not  been  noted  as  the  result  of  vagal  disease. 

Prognosis.  The  prognosis  in  affections  of  the  pneumogastric  depends 
naturally  upon  the  cause  of  the  derangement  of  the  ftinctious  of  the  nerve. 
The  outlook  is  bad  in  all  cases  of  pneumogastric  disease  of  organic  origin. 
In  functional  disturbance  the  prognosis  as  regards  life  may  be  good,  but  may 
be  bad  as  regards  the  comfort  of  the  patient. 


832  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Diagnosis.  The  four  most  characteristic  symptoms  of  vagus  disease  are 
paralysis  of  the  larynx,  slow  respiration,  rapid  or  slow  heart  action,  and  vom- 
iting. In  order  to  determine  the  seat  of  the  lesion,  it  is  necessary  to  take 
into  consideration  the  distribution  of  the  symptoms  and  the  nature  of  the 
associated  symptoms.  Disease' of  the  trunk  is  rare  as  compared  with  disease 
of  the  branches  or  roots  of  the  nerve.  One-sided  laryngeal  palsy  depends 
generally  on  disease  in  the  chest  (with  implication  of  other  cranial  nerves, 
especially  the  hypoglossal).  A  high  degree  of  bilateral  laryngeal  paralysis 
suggests  nuclear  disease ;  a  slight  degree  may  be  peripheral  in  origin.  With 
the  exception  of  chest  tumors,  it  is  usually  not  difficult  to  make  out  the 
existence  and  situation  of  compressing  lesions  of  the  vagus. 

Treatment.  To  remove  the  pathological  process  by  which  the  nerve  is 
damaged  is  the  chief  indication  of  treatment,  but  this  can  be  accomplished 
in  comparatively  few  cases.  Xuclear  disease  is  usually  beyond  the  reach  of 
treatment.     Root  disease  is  often  syphilitic  and  yields  to  mixed  treatment. 

The  laryngeal  divisions  of  the  vagus  often  call  for  special  treatment,  al- 
though the  causes  of  recurrent  laryngeal  paralysis  are  frequently  not  within 
the  range  of  treatment  of  any  kind.  When  tubercular  nodes  are  suspected 
to  be  the  cause,  tonic  treatment,  including  the  use  of  cod-liver  oil,  is  indi- 
cated. The  use  of  electricity  is  of  doubtful  value,  except  in  hysterical  laryn- 
geal paralysis,  where  faradism,  applied  to  the  interior  of  the  larynx,  may 
cause  immediate  improvement.  When  larj^ngeal  j)aralysis  is  secondary  to 
inflammation,  blisters  to  the  exterior  of  the  larynx,  together  with  hypoder- 
matic injections  of  strychnine,  appear  to  do  good. 


PARALYSIS  OP  THE  SPINAL  OR  EXTERNAL  PORTION  OF 
THE   SPINAL  ACCESSORY  NERVE. 

The  large  or  external  portion  of  the  spinal  accessory  nerve  is  essentially  a 
series  of  fibre-bundles  of  the  motor  cervical  nerves  that  ascend  to  the  cranial 
cavity,  only  to  leave  it  again  with  a  cranial  nerve  to  be  distributed  to  the 
trapezius  and  sternomastoid  muscles.  The  nuclei  of  the  nerve  may  be  im- 
plicated in  progressive  degeneration  of  the  motor  nuclei  of  the  cord.  The 
nerve  is  apt  to  be  involved  in  the  exudate  of  basal  meningitis.  It  may  also 
suflfer  in  cervical  caries  from  tumors  outside  the  skull  and  from  wounds  of 
the  neck.     Occasionally  it  is  the  seat  of  "rheumatic"  neuritis. 

Symptoms.  Paralysis  of  one  sternomastoid  is  shown  by  difliculty  in  ro- 
tating the  head  to  the  opposite  side.  The  trapezius  is  supplied  in  part  by 
cervical  nerves,  but  paralysis  of  the  accessory  causes  loss  of  function  in  the 
upper  (occipito-acromion)  portion  of  the  trapezius  and  Aveakness  of  the 
middle  portion.  The  shoulder  drops  a  little,  and  elevation  of  the  arm  is  im- 
paired. 

Treatment.  In  nuclear  disease  nothing  can  be  done.  When  the  paral- 
ysis depends  on  pressure,  the  treatment  consists  in  the  removal  of  its  cause. 
Electricity  and  massage  should  be  employed  in  all  peripheral  cases. 

Spasm  of  the  spinal  accessory  is  considered  in  Chapter  IX.,  p.  272. 


DISEASES  OP  THE  HYPOGLOSSAL  NERVE. 

Paralysis  of  the  Hypoglossal  Nerve. 

Etiology.     Paralysis  of  the  tongue  is  the  chief  result  of  disease  in  the  path 
of  the  hypoglossal  nerve,  and  may  result  from  a  lesion  anywhere  in  the  path 


DISEASES  OF  THE  CRANIAL  NEEVES.  833 

between  the  cerebral  cortex  and  the  tongue ;  i.  e.,  from  a  supra-nuclear, 
nuclear,  or  infra-nuclear  lesion. 

Paralysis  of  the  tongue  from  supra-nuclear  disease — that  is,  from  disease 
an}n^here  in  the  hypoglossal  path,  between  the  nucleus  in  the  medulla  and 
the  lowest  part  of  the  ascending  frontal  and  the  base  of  the  third  frontal 
convolutions — is  by  far  the  most  common  form.  Ordinarily  supra-nuclear 
paralysis  forms  part  of  the  paralysis  of  hemiplegia,  with  which  it  is  fully 
discussed.  The  lesion  is  most  often  hemorrhage  or  acute  softening,  but  may 
be  any  one  of  the  processes  that  give  rise  to  hemiplegia. 

Paralysis  of  the  tongue  from  nuclear  disease  is  the  least  common  of  the 
varieties  mentioned.  The  hypoglossal  nuclei  lie  so  close  to  the  nuclei  for  the 
lips,  pharynx,  and  larynx,  that  some  or  all  of  these  parts  generally  suffer 
with  the  tongue  in  consequence  of  the  implication  of  their  nuclei.  The  hypo- 
glossal nuclei  of  opposite  sides  are  also  so  close  together  that  a  lesion  rarely 
involves  one  nucleus  exclusively.  This  is  true,  not  only  of  chronic  lesions 
like  degenerations,  but  of  acute  lesions  like  hemorrhage  and  softening. 

Infra-nuclear  disease  may  be  located  in  the  medulla,  at  the  base  of  the 
brain,  outside  the  medulla,  or  external  to  the  skull.  Disease  within  the  me- 
dulla is  usually  acute  softening  or  tumor.  The  lesion  usually  involves  also 
the  motor  tract  of  the  same  side ;  hence  a  crossed  hemiplegia  arises  in  such 
cases.  Outside  the  medulla  the  roots  of  origin  of  the  nerve  may  be  damaged 
by  tumors  and  by  the  various  forms  of  meningitis  that  occur  in  this  situa- 
tion. Outside  the  skull  the  hypoglossal  is  occasionally  damaged  by  pene- 
trating wounds  or  deep  tumors  of  the  neck  or  by  vertebral  disease.  The 
spinal  accessory  is  liable  to  be  injured  with  the  hypoglossal  external  to  the 
skull.  Rarely  the  hypoglossal  is  compressed  by  narrowing  of  its  foramen  in 
the  skull. 

Symptoms.  The  chief  effect  of  disease  of  one  hypoglossal  nerve  is  loss  of 
power  in  the  tongue.  When  the  tongue  is  at  rest  in  the  mouth,  its  base  is  a 
little  higher  on  the  paralyzed  than  on  the  unparalyzed  side.  When  the 
tongue  is  moved  within  the  mouth  there  is  imperfect  power  of  motion  to  the 
paralyzed  side ;  whenever  the  tongue  is  protruded,  it  deviates  to  the  2^0^^'cilyzed 
side,  because  it  is  pushed  to  that  side  by  the  fibres  of  the  genio-hyoglossus 
on  the  normal  side.  In  disease  of  both  hypoglossal  nerves  the  tongue  can- 
not be  moved  in  the  mouth  and  cannot  be  protruded.  In  such  cases  articu- 
lation is  very  defective.  There  is  also  difficulty  in  mastication.  In  supra- 
nuclear paralysis  there  is  no  wasting  of  the  tongue ;  in  nuclear  or  infra- 
nuclear  paralysis  the  tongue  wastes  on  one  or  both  sides,  according  as  the 
lesion  is  one-sided  or  bilateral.  The  muscular  tissue  above  suffers,  and  sen- 
sation and  taste  are  essentially  unimpaired.  The  reaction  of  degeneration 
may  be  demonstrated  in  the  wasted  half  of  the  tongue. 

Diagnosis.  The  recognition  of  the  existence  of  hypoglossal  palsy  offers  no 
difficulty,  though  it  should  be  borne  in  mind  that  the  tongue  always  deviates 
toward  the  weaker  side,  being  pushed  over  by  the  genio-hyoglossus.  The  posi- 
tion of  the  lesion  is  shown  by  associated  conditions.  If  there  is  hemiplegic 
weakness  on  the  side  of  the  paralysis  of  the  tongue,  the  paralysis  is  supra- 
nuclear. The  existence  of  nuclear  disease  should  be  suspected  if  there  is 
bilateral  atrophic  paralysis  associated  with  weakness  of  the  lips  and  pharynx. 
Crossed  paralysis — that  is,  paralysis  of  the  tongue  on  one  side  and  of  the 
arm  and  leg  of  the  opposite  side — makes  it  probable  that  the  root-fibres  are 
involved  in  the  medulla.  Unilateral  paralysis  associated  with  corresponding 
unilateral  paralysis  of  the  vocal  cord  and  palate  suggests  disease  at  the  side 
of  the  medulla,  although  a  partial  and  irregular  paralysis  of  the  vocal  cord 

53 


834  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  palate  may  be  associated  with  hypoglossal  palsy  due  to  a  lesion  external 
to  the  skull. 

Prognosis,  There  is  usually  in  time  considerable  or  entire  recovery  of  the 
tongue  palsy  where  the  lesion  is  supra-nuclear  and  the  patient  does  not  die. 
In  nuclear  and  infra-nuclear  paralyses  the  prognosis  is  generally  bad,  owing 
to  the  incurable  nature  of  the  process  that  affects  the  nucleus  or  nerve.  The 
outlook  for  recovery  of  some  power  is  rather  better  in  syphilitic  cases,  but  is 
uncertain  even  then. 

Treatment.  The  treatment  of  hypoglossal  paralysis  is  chiefly  the  treat- 
ment of  the  morbid  process.  If  the  lesion  is  syphilitic  in  nature,  mixed 
treatment  should  be  employed.  In  all  other  conditions  general  tonic  treat- 
ment is  indicated.  In  inflammatory  conditions  counter-irritation  at  the 
occiput  may  be  tried.  The  application  of  electricity  to  the  tongue  involves 
considerable  discomfort  to  the  patient,  and  is  of  such  doubtful  efiicacy  that 
there  is  less  inducement  to  use  it  than  in  peripheral  paralysis  elsewhere. 

Hypoglossal  spasm,  spasm  of  the  tongue,  is  considered  in  Chapter  IX., 
p.  275. 


CHAPTER    XXYIII. 

DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR 
PLEXUSES. 

By  C.  a.  HERTER,  M.D. 

DISEASES   OF   THE    CERVICAL    NERVES. 

Ceevico-occipital  Neuralgia.  In  this  condition  the  pain  is  referred 
to  any  part  or  all  of  the  distribution  of  the  first  four  cervical  nerves,  but  it 
is  the  posterior  branch  of  the  second  cervical  nerve,  the  great  occipital,  that 
is  most  often  affected.  This  nerve  supplies  the  entire  occipital  region  and 
the  posterior  part  of  the  parietal  region,  and  the  pain  may  be  felt  in  this 
entire  area  or  be  limited  to  its  posterior  pai't.  The  pain  is  usually  constant 
and  dull  in  character,  with  occasional  attacks  of  sharper  pain.  Rarely  the 
pain  intermits.  The  scalp  may  be  excessively  tender  to  pressure  and  even 
to  movements  of  the  hairs.  Tender  spots  may  be  found  in  the  following 
positions :  (1 )  At  the  exit  of  the  great  occipital  between  the  mastoid  and  the 
spine;  (2)  in  the  triangle  between  the  trapezius  and  sternomastoid  occupied 
by  the  cervical  nerves ;  ( 3 )  above  the  parietal  boss.  Cervico-occipital  neu- 
ralgia is  very  liable  to  extend  to  the  distribution  of  the  fifth,  either  above 
to  the  branches  of  the  first  division,  or  in  the  neck  to  the  third  division  of 
the  fifth  over  the  lower  jaw.  In  the  latter  case  there  may  be  swelling  of 
the  submaxillary  and  cervical  glands.  This  form  of  neuralgia  has,  further,, 
the  following  characteristics :  It  is  frequently  bilateral,  occurs  especially  in 
those  who  have  had  neuralgia  elsewhere  (Anstie),  generally  follows  exposure 
to  cold,  and  is  apt  to  be  intractable  when  once  established.  Rarely  it  has 
been  clearly  dependent  on  a  carious  tooth,  or  on  pressure  upon  the  neck 
fi'om  a  heavy  load.  It  may  be  associated  with  stiff*  neck  or  with  torticollis. 
In  one  case  it  was  associated  with  symptoms  of  a  destructive  lesion  of  the 
cervical  sympathetic  (Johnson).     It  is  one  of  the  rarer  forms  of  neuralgia. 

It  should  be  remembered  that  occipito-cervical  neuralgia  may  result  from 
caries  of  the  cervical  vertebrae.  In  such  cases  the  pain  only  rarely  extends 
to  the  occipital  region,  and  there  is  early  limitation  of  movement  and  cer- 
vical pain  when  the  patient  drops  heavily  from  the  tip-toes  to  the  sole  of 
the  foot. 

The  prognosis  in  primary  cervico-occipital  neuralgia  is  good  except  where 
the  disease  occurs  in  the  second  half  of  life  and  has  become  established. 

Treatment  is  to  be  carried  out  on  the  principles  described  under  neuralgia 
of  the  fifth.  Counter-irritation  to  the  neck  and  occiput  is  the  most  effective 
local  measure.  The  Paquelin  cautery  should  be  used  over  the  painful  area 
and  on  either  side  of  the  vertebral  spines.  A  fly-blister  may  be  used  instead 
of  the  actual  cautery.  The  general  health  should  receive  careful  attention.  In 
one  case  adhesions  of  the  superior  cervical  ganglion  of  the  sympathetic  and 
the  cord  below  were  freed  by  operation  (Johnson).     The  occipital  and  ver- 


836  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tical  pain,  wliich  had  been  severe,  entirely  ceased  for  six  weeks,  when  it  re- 
turned as  before. 

Affections  of  the  Phre>'ic  Xeeve.  Paralysis  of  both  phrenic  nerves 
causes  entire  inaction  of  the  diaphragm.  Owing  to  this  inaction  the  ab- 
dominal viscera  do  not  descend  with  inspiration,  and  the  ujDper  part  of 
the  abdomen  does  not  advance  or  may  even  be  retracted.  The  action  of  the 
thorax  may  be  increased.  Such  bilateral  paralysis  does  not  embarrass  res- 
piration during  rest  because  of  the  action  of  the  thoracic  muscles,  but  on 
exertion  there  is  dyspnoea  and  weak  voice.  This  paralysis  disposes  to  con- 
gestion of  the  base  of  the  lung  and  renders  an  existent  bronchitis  dangerous. 
One-sided  j^hrenic  paralysis  causes  little  or  no  inconvenience  in  breathing, 
and  the  inactivity  of  one  side  of  the  diaphragm  is  readily  overlooked  owing 
to  the  movement  of  the  normal  side. 

Phrenic  paralysis  Ls  usually  the  result  of  a  lesion  of  the  cervical  spinal 
cord  or  its  nerve-roots.  Sometimes  the  nerve-roots  are  comjDressed  in  bone 
disease.  The  affection  is  bilateral  in  all  such  cases.  The  nerves  themselves 
are  protected  from  injury  by  their  deep  course.  Still,  they  occasionally  suffer 
unilaterally  from  neck  wounds  or  tumors  in  the  neck  or  chest.  They  are 
also  involved  on  both  sides  in  multiple  neuritis,  especially  in  beri-beri  and 
diphtheritic  neuritis.  It  is  said  that  the  phrenic  may  be  the  seat  of  a  simple 
neuritis  the  result  of  cold.  When  due  to  disease  of  the  cord  or  membranes 
phrenic  paralysis  is  associated  with  other  paralyses.  Mistakes  in  diagnosis 
may  arise  if  the  following  facts  are  not  kept  in  mind:  (1)  That  hysterical 
and  nen^ous  persons,  especially  women,  often  breathe  for  a  time  without  using 
the  diaphragm  ("upper  costal  type"  of  breathing)  ;  (2)  that  diaphragmatic 
pleurisy  or  peritonitis  may  cause  inaction  of  the  diaphragm  owing  to  the 
pain  caused  by  motion;  (3)  that  degeneration  of  the  diaphragm  itself  may 
impair  its  power.  The  prognosis  in  phrenic  paralysis  depends  on  the  cause 
and  extent  of  the  paralysis.  When  due  to  diphtheria  or  beri-beri,  paralysis 
of  the  phi'enics  is  usually  fatal.  Treatment  must  be  directed  to  the  cause  of 
the  paralysis.     Electrical  treatment  is  useless. 


DISEASES  OF  THE  BRACHIAL    PLEXUS   AND    OF  ITS 

BRANCHES. 

BPvACHIAL   oSTeUPvITIS. 

Pathology.  The  term  brachial  neuritis  is  used  to  designate  a  primary 
inflammation  of  several  or  all  the  nerves  that  enter  and  make  up  the 
brachial  plexus.  By  a  broader  use  of  the  term  it  might  be  made  to  include 
the  inflammatory  affections  of  individual  nerves  entering  the  brachial  plexus, 
to  be  hereafter  described,  but  it  is  best  to  restrict  it  to  the  condition  above 
indicated. 

The  pathological  process  in  brachial  neuritis  is  an  inflammation  of  the 
nerve-sheaths — a  perineuritis.  Usually  it  involves  in  an  irregular  manner  a 
considerable  part  of  the  plexus.  In  some  cases  the  plexus  is  little  involved, 
the  process  being  located  chiefly  in  the  nerve-roots  that  belong  to  the  plexus. 
Such  a  process  is  known  as  a  radicular  neuritis.  The  existence  of  such  a 
form  of  neuritis  is  inferred  from  clinical  grounds,  and  has  not  been  demon- 
strated. Indeed,  a  satisfactory  description  of  brachial  neuritis  based  on 
pathological  findings  cannot  be  written  at  present  owing  to  the  infrequency 
with  which  autopsies  have  been  made.  The  clinical  grounds  for  the  exist- 
ence of  a  radicular  neuritis  are  very  strong,  and,  as  will  be  seen  from  the 


DISEASES  OF  THE  SPINAL  NEEVES  AND  THEIR  PLEXUSES.     837 

discussion  of  diagnosis,  it  is  of  the  greatest  importance  that  they  should  l)e 
recognized. 

Etiology.  Primary  brachial  neuritis  is  a  rare  disease,  if  we  admit  as 
evidence  of  rarity  the  fact  that  many  neurologists  with  wide  clinical  oppor- 
tunities have  not  met  with  a  dozen  cases  in  as  many  years.  The  liability  of 
women  is  probably  somewhat  greater  than  that  of  men.  The  disease  belongs 
distinctively  to  the  second  half  of  life,  five-sixths  of  the  cases  being  estimated 
to  occur  after  fifty  (Groves).  It  is  a  striking  fact  that  brachial  neuritis  is 
seldom  met  except  in  persons  whose  nutrition  is  to  some  degree  perverted. 
There  is  sometimes  a  history  of  gout  or  muscular  rheumatism,  but  more  fre- 
quently there  is  merely  general  debility  and  digestive  disorder  of  long  dura- 
tion. The  subjects  of  brachial  neuritis  have,  in  a  good  many  instances,  been 
sufferers  from  sciatica  or  lumbago,  and  sciatic  neuritis  has  been  known  to 
precede  the  development  of  the  brachial  affection. 

Symptoms.  The  pain  which  characterizes  neuritic  processes  in  all  sensory 
or  mixed  nerves  is  the  prominent  feature  of  brachial  neuritis  and  renders  it 
one  of  the  most  distressing  of  painful  diseases.  The  seat  of  the  pain  at  the 
commencement  of  the  trouble  is  usually  at  a  distance  from  the  plexus  itself, 
and  affects  especially  the  back  of  the  forearm,  the  wrist  (and  perhaps  with  it 
the  hand),  and  the  region  of  the  scapula.  But  soon,  and  in  some  cases  from 
the  first,  the  chief  seat  of  pain  is  the  region  of  the  plexus  itself,  especially 
the  axilla  or  the  supra-clavicular  region.  As  the  disease  increases  the  pain 
travels  down  the  nerves  of  the  arm,  to  which  the  lines  of  pain  may  accur- 
ately correspond.  In  character  and  intensity  the  pain  varies  considerably  in 
the  same  and  in  different  cases.  At  first  the  pain  is  generally  slight  and 
occasional.  As  the  process  becomes  established  the  pain  grows  more  severe 
and  often  becomes  continuous.  It  is  especially  aggravated  by  movement. 
Usually  the  pain  is  paroxysmal ;  there  is  more  or  less  continual  dull-aching 
pain  with  frequent  or  infrequent  attacks  of  a  sharp,  lancinating,  stabbing 
nature.  When  the  acute  pain  subsides  the  skin  of  the  greater  part  of  the 
arm  may  be  the  seat  of  a  prolonged  burning  or  tingling  sensation.  Usually 
the  paroxysms  of  acute  pain  appear  to  be  spontaneous. 

Hyperalgesia  is  commonly  present  after  the  acute  seizures  in  the  skin  near 
the  plexus.  Slight  temporary  and  limited  anaesthesia  may  be  present  in  the 
skin  near  the  plexus,  but  complete  and  lasting  anaesthesia  is  very  rare  even 
in  the  severest  and  oldest  cases. 

Loss  of  power  in  the  arm,  especially  in  the  hand  and  forearm,  may  occur 
after  a  time,  but  it  is  usually  slight  in  degree.  There  is  frequently  consider- 
able apparent  motor  loss,  owing  to  the  pain  caused  by  motion.  Trophic 
disturbances  in  the  arm  of  the  affected  side  are  seldom  absent.  Wasting  of 
the  muscles  is  present  in  all  severe  cases,  but  is  generally  slight  and  irregularly 
distributed.  The  wasted  muscles  show  the  R.D.  in  various  degrees.  The  skin 
in  places  may  be  glossy  and  thin,  as  in  other  forms  of  neuritis,  and  slight 
local  oedema  is  common.  In  severe  old-standing  cases,  arthritic  changes  in 
the  joints  of  the  fingers  occur  and  cause  serious  deformities. 

Diagnosis.  There  may  be  little  difficulty  in  the  recognition  of  fully  de- 
veloped cases  of  brachial  neuritis,  but  in  some  cases  the  condition  is  frequently 
confounded  with  quite  different  states.  From  brachial  neuralgia  the  chief 
distinctive  features  are  the  presence  in  brachial  neuritis  of  points  of  persist- 
ent local  tenderness  in  the  nerves,  the  marked  increase  of  pain  on  movement, 
especially  abduction  of  the  arm,  and  evidence  of  damage,  even  slight  dam- 
age, to  the  nerve  fibres  of  the  brachial  plexus  (muscular  atrophy,  11.  D.,  and 
trophic  changes  in  the  skin).  In  neuralgia  there  may  be  points  of  tender- 
ness, but  they  are  shifting  and  temp(jrary.     A  history  of  neuralgia  in  the 


838  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

patient  does  not  aid  in  the  diagnosis,  but  a  history  of  gout  favors  the  neuritic 
nature  of  the  trouble. 

Cases  of  slight  neuritis  occur  Avhen  the  region  of  the  plexus  is  not  painful, 
but  when  there  is  pain  refei'red  to  the  extremity,  the  pain  being  paroxysmal 
and  not  constant.  If  occurring  on  the  left  side  such  pain  may  be  mistaken 
for  the  pain  of  angina  pectoris.  The  important  point  of  distinction  is  the 
presence  in  neuritis  of  persistent  tender  points  on  the  nerves.  Sometimes  the 
pain  of  brachial  neuritis  has  led  to  the  suspicion  of  an  aortic  aneurism ;  but 
aneurism  should  be  thought  of  only  when  there  is  intense,  increasing,  and 
constant  nerve-pain  in  the  arm,  ivithout  marked  nerve  tenderness.  The  late 
joint  changes  of  neuritis  may  be  mistaken  for  the  changes  of  rheumatoid 
arthritis,  but  this  can  happen  only  where  the  history  is  not  taken  into  account. 

The  pains  of  radicular  neuritis  may  be  readily  confounded  with  those  of 
bone  disease  or  a  meningeal  tumor  of  the  cervical  region.  Persistent  marked 
tenderness  of  the  nerves  of  the  arm  is  absent  in  both  the  latter.  The  bone 
tenderness  and  slight  deformity  of  bone  disease  are,  of  course,  distinctive  if 
.present.  The  presence  of  rigidity  and  the  symptoms  of  slight  unilateral 
involvement  of  the  cord  cannot  be  misinterpreted  and  should  not  be  over- 
looked. Still,  cases  arise  where  a  diagnosis  can  be  made  with  reasonable 
certainty  only  after  Avatching  the  progress  of  the  case. 

Prognosis.  The  large  majority  of  cases  of  brachial  neuritis  are  of  long 
duration,  pain  and  disability  of  the  arm  lasting  many  months,  and,  in  the 
most  obstinate  cases,  as  much  as  a  year.  The  pain  which  is  suiFered  in  these 
cases  is  apt  to  last  long  after  subsidence  of  the  inflammatory  process  in  the 
plexus,  and  this  post-ueuritic  pain  is  particularly  j^rolonged  in  elderly  persons 
and  those  whose  nutrition  is  bad.  Scarcely  any  movement  of  the  arm  is 
possible  which  does  not  involve  pressure  on  the  sensitive  plexus,  and  hence 
voluntary  movement  of  the  affected  arm  is  greatly  restrained  or  impossible 
for  a  long  period.  Relapses  sometimes  occur.  In  the  severest  cases  the 
nerve-fibres  sustain  permanent  damage. 

In  bad  cases  of  neuritis  a  permanent  reduction  in  the  size  and  form  of  the 
limb  occurs.  Changes  in  the  joints  of  the  shoulder,  elbow,  wrist,  and  fingers 
are  very  apt  to  take  place,  and  lead  to  deformity  and  disability,  often  oT  a 
serious  nature.  Persons  who  have  recovered  from  the  more  acute  troubles  of 
brachial  neuritis  are  prone  to  suffer  from  neuralgia  of  the  arm  and  vasomotor 
disturbances. 

Treatment.  Roughly  speaking,  the  treatment  of  brachial  neuritis  is  that 
of  neuritis  in  general ;  but  in  dealing  with  cases  of  brachial  neuritis  it  is 
necessary  to  bear  in  mind  the  extreme  sensitiveness  of  the  brachial  plexus 
and  the  long  duration  of  the  pain  and  tenderness.  The  first  point  in  every 
case  is  to  secure  immobility  in  the  position  which  causes  least  pain  and  will 
permit  least  deformity  from  contracture.  Immobility  of  the  shoulder  is 
particularly  important.  The  arm  should  be  bandaged  to  the  side  with  the 
forearm  across  the  chest. 

Immobility  increases  somewhat  the  chances  of  joint-stiffness,  but,  notwith- 
standing, this  must  be  employed,  since  the  evil  effects  of  motion  during  the 
acute  stage  are  far  greater.  Absolute  rest  having  been  attained,  the  next 
object  is  to  keep  the  patient  comfortable.  The  pain  may  be  greatly  decreased 
by  mere  rest.  The  spontaneous  pain  which  remains  should  be  combated,  if 
severe,  with  hypodermatic  injections  of  cocaine  in  the  neighborhood  of  the 
most  painful  places.  For  this  purpose  as  much  as  ?  grain  of  cocaine  hydro- 
chlorate  may  be  necessary  twice  daily  during  the  acute  stage.  This  is  an 
efficacious  way  of  relieving  the  pain,  and  is,  on  the  whole,  preferable  to  the 
hypodermatic  use  of  morphine.  But  the  danger  of  a  cocaine  habit  should 
not  be  overlooked,  and  the  evil  constitutional  effects  of  the  drug  must  be 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     839 

avoided.  It  is  scarcely  necessary  to  insist  that  its  use  should  not  be  pro- 
longed a  day  beyond  the  time  the  pain  becomes  bearable.  The  first  dose  of 
cocaine  should  not  be  greater  than  -^-^^  grain. 

When  the  acute  stage  of  inflammation  subsides,  gentle  massage  to  the 
entire  arm  should  be  commenced.  The  massage  should  be  cautiously  in- 
creased, particular  care  being  taken  to  avoid  increasing  pain  in  the  plexus. 
Properly  applied  this  is  the  most  efficacious  measure  that  can  be  employed. 
It  helps  to  relieve  pain,  to  improve  the  nutrition  of  the  muscles,  and  to  pre- 
vent contracture.  The  contractures  should  be  further  combated  by  placing 
the  contractured  muscles  in  hot  water  twice  a  day  for  ten  or  fifteen  minutes, 
and  gently  overcoming  the  deformity  by  passive  motion. 

During  the  period  when  there  is  acute  pain  electricity  should  not  be  em- 
ployed, but  may  be  used  at  a  later  period  for  the  rehef  of  pain  (galvanic 
current)  and  to  help  in  restoring  the  nutrition  of  the  muscles  by  exercising 
them.     For  the  latter  purpose  massage  is  far  more  efficacious. 

Combined  Paralysis  of  the  Brachial  Nerves.  Brachial  palsies,  in 
Avhich  all  or  nearly  all  of  the  branches  of  the  brachial  plexus  are  involved, 
are  of  frequent  occurrence,  being  about  one-fifth  as  common  as  all  single- 
nerve  paralyses  (Dana). 

Etiology.  The  following  are  the  chief  causes  of  combined  brachial  paral- 
ysis from  conditions  external  to  the  spinal  canal : 

1.  Pathological  conditions  in  the  neck,  especially  new  growths,  which  com- 
press the  upper  pai't  of  the  brachial  plexus  or  the  nerve-roots  outside  the 
spinal  canal.  2.  Obstetrical  and  other  mechanical  injuries.  3.  Dislocations 
of  the  humerus.  4.  Fractures  of  the  bones  of  the  arm.  5.  Ascending 
neuritis.  6.  Primaiy  brachial  neuritis  (already  considered).  Taken  as  a 
whole,  the  brachial  palsies  are  much  more  common  in  men  than  in  women, 
and  occiu"  especially  in  adult  life.  To  infancy  belongs  an  important  class  of 
palsies,  those  due  to  injury  during  birth. 

Symptoms.  The  symptoms  of  combined  brachial  paralysis  vary  widely 
with  the  distribution  and  degree  of  the  lesion.  According  to  the  degree  of 
the  lesion  there  may  be  merely  transient  "  heaviness"  and  numbness  of  the 
anil,  the  weakness  disappearing  in  a  few  hours  at  the  longest,  or  the  degree 
of  neuritis  or  pressure  may  be  such  as  to  cause  considerable  weakness  for 
several  months,  or  again  the  nerves  may  be  quite  severed  or  torn.  The 
symptoms  resulting  from  such  damage  are,  of  course,  simply  those  common 
to  nerve  injuries  in  general;  paralysis,  atrophy,  R.  D.,  together  with  vary- 
ing sensory,  trophic,  and  vasomotor  disorders.  While  the  precise  loss  of 
motion  that  is  met  with  varies  much  in  different  cases  there  are  certain  move- 
ments which  are  especially  apt  to  be  affected,  viz.,  abduction  and  elevation 
of  the  arm  (dependent  on  the  circumflex  nerve,  and,  after  elevation  to  the 
horizontal  position,  on  the  lower  cervical,  upper  dorsal,  and  posterior  thoracic 
nerve),  extension  of  the  arm  (dependent  on  the  integrity  of  the  musculo- 
spinal nerve  acting  on  the  triceps),  and  flexion  of  the  forearm  on  the  arm 
(dependent  chiefly  on  the  integrity  of  the  musculo-cutaneous  nerve,  acting 
through  the  biceps  and  brachialis  anticus).  It  is  important  to  recognize  the 
following  forms  of  brachial  paralysis,  which  are  based  partly  upon  the  eti- 
ological facts  already  enumerated,  partly  upon  the  seat  of  the  lesion. 

Brachial  Paralysis  from  Primary  Brachial  JS'euriUs.  The  paralyses  result- 
ing from  this  well-defined  clinical  condition  are  described  elsewhere  (see 
Primary  Brachial  Neuritis). 

Brachial  Paralysis  from  Ascejuling  Xeuritis  (neuritis  "migrans").  Here 
the  paralyses  are  due  to  a  neuritis,  perhaps  due  to  infection,  which  commenc- 
ing in  a  single  nerve  in  consequence  of  an  injury,  ascends  to  the  brachial 
plexus,  where  it  spreads  to  other  nerves,  often  in  an  irregular  way.     Thus 


840  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  inflammation  may  pass  up  the  ulnar,  and  reaching  the  plexus  spread  to 
the  roots  of  the  median.  The  spread  of  the  process  is  usually  slow,  occupy- 
ing many  ^Yeeks,  and  is  generally  accompanied  with  a  good  deal  of  pain  in 
the  sensory  areas  whose  nen^es  are  involved. 

Brachial  Paralysis  from  Fracture  or  Dislocation.  Dislocation  of  the  humerus 
is  a  not  uncommon  cause  of  brachial  paralysis.  When  the  dislocation  is 
subcoracoid  the  head  of  the  humerus  can  hardly  fail  to  compress  the  nei'^'^es, 
which  may  suffer  in  any  degree.  As  a  rule,  the  paralysis  is  severe  and  ex- 
tensive, with  rapid  atrophy  and  R.  D.  Trophic  and  vasomotor  disturbances 
are  likely  to  be  pronounced.  Fractures  of  the  humerus  are  particularly  apt 
to  damage  the  musculo-spinal  nerve,  with  or  without  the  ulnar.  Rarely  the 
median  suffers.  The  median  and  ulnar  may  together  suffer  in  fractures  of 
the  bones  of  the  forearm. 

Brachial  Paralysis  from  Morbid  Processes  in  the  Neck  (malignant  or  tuber- 
cular bone  disease  or  syphilitic  cellulitis)  is  usually  associated,  as  might  be 
expected,  with  irritative  symptoms  in  the  region  of  the  nerve  affected,  especi- 
ally severe  pain,  hypersesthesia,  and  irregular  and  considerable  muscular 
contractures.  Sometimes  a  new  growth  compresses  the  subclavian  artery 
and  so  causes  weakening  of  the  radial  pulse  on  the  same  side. 

Brachial  Paralysis  of  the  Upper-arm  Type  (Erb's  paralysis).  This  pecu- 
liar and  distinctive  type  of  brachial  paralysis  depends  on  injury  to  the  roots 
of  the  cervical  nen^es,  probably  the  fifth  and  sixth,  at  the  side  of  the  neck 
just  in  front  of  the  edge  of  the  trapezius.  The  condition  { which  is  not  com- 
mon) is  met  with  in  adults,  almost  exclusively  men,  and  in  infants.  In 
adults  it  depends  usually  on  downward  pressure  on  the  neck,  as  from  carry- 
ing a  heavy  weight  on  the  shoulder,  but  it  sometimes  arises  from  non-trau- 
matic processes  causing  neuritis.  In  infants  it  is  especially  apt  to  arise  from 
traction  on  the  neck  by  the  finger  during  birth.  It  thus  contributes  a  variety 
of  "  obstetrical  paralysis." 

The  paralysis  regularly  involves  the  deltoid,  biceps,  brachialis  anticus,  and 
supinator  longus,  sometimes  the  supinator  brevis,  and  the  supra  and  infra- 
spinati.  There  is  frequently  anaesthesia  on  the  outer  side  of  the  arm  in  the 
distribution  of  the  circumflex  and  external  cutaneous  nen^es,  and  there  is 
often  much  muscular  wasting.  The  character  of  the  palsy  differs  considera- 
bly in  adults  and  infants.  In  adults  the  loss  of  power  is  often  complete,  sen- 
soiy  symptoms  are  pronounced,  and  the  affection  is  commonly  of  long  stand- 
ing. In  infants  the  paralysis  is  more  apt  to  be  slight  in  degree.  In  fact,  the 
slighter  degrees  of  the  palsy  may  escape  notice  for  some  time  after  the  birth 
of  the  child.  In  well-marked  cases  the  paralysis  cannot  escape  detection  ; 
the  arm  hangs  by  the  side  with  the  forearm  in  extreme  pronation.  Wasting 
cannot  be  detected  until  several  months  after  the  injurj^,  and  may  appear 
very  slight  even  then,  as  it  is  masked  by  the  large  amount  of  fat  over  the 
muscles.  Sensation  is  rarely  impaired  in  infants,  and  may  escape  notice 
when  it  is.  The  palsy  generally  wears  away  in  a  few  weeks  or  months ;  it 
rarely  persists. 

Brachial  Paralysis  of  the  Lower-arm  Type  is  due  to  the  involvement  of  the 
nerves  arising  from  the  seventh  and  eighth  cervical  and  first  dorsal  roots.  In 
this  form  of  paralysis  the  arm  can  still  be  elevated  and  the  forearm  flexed 
and  supinated ;  the  loss  of  power  is  located  in  the  triceps,  the  flexors  of  the 
wrist,  the  pronators,  the  flexors,  and  extensors  of  the  fingers,  and  the  muscles 
of  the  hand. 

Klumpke's  Parlaysis  (paralysis  of  the  lower  roots  of  the  brachial  plexus). 
Lesions  which  involve  the  first  dorsal  root  of  the  brachial  plexus  and  the 
communicating  branch  of  the  second  dorsal  are  characterized  by  atrophic 
paralysis  of  the  thenar,  hypothenar,  and  interossei  muscles,  ansesthesia  in  the 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     841 

ulnar  area  of  the  forearm  and  arm,  and  certain  ocular  symptoms.  These 
ocular  symptoms  comprise  myosis  on  the  side  of  the  lesion,  sluggish  contrac- 
tion of  the  pupil,  diminution  in  the  size  of  the  palpebral  fissure,  and  reces- 
sion of  the  eyeball,  and  are  thought  to  depend  on  implication  of  the  ramus 
communicans  of  the  first  dorsal  nerve  (Klumpke,  Pfeifler). 

This  form  of  brachial  paralysis  is  of  interest,  chiefly  on  account  of  the 
localization  of  the  lesion  to  which  it  must  be  referred.  It  probably  has  no 
claim  to  be  regarded  as  a  distinct  type  upon  pathological  grounds.  It  may 
arise  as  a  primary  neuritis  or  as  the  result  of  pressure  by  a  new  gi'owth 
arising  from  the  chest  or  vertebrae.  In  the  fonner  case  the  lesion  may  spread 
to  the  roots  of  the  plexus,  in  the  latter  case  it  is  apt  to  invade  the  spinal 
cord  and  cause  symptoms  of  pressure  and  destruction  of  the  cord  elements. 

Diagnosis.  The  diagnosis  of  the  seat  of  the  lesion  in  combined  arm  paral- 
ysis is  not  difiicult,  if  the  facts  regarding  the  formation  and  distribution  of 
the  brachial  plexus  be  borne  in  mind.  The  diagnosis  of  the  character  of  the 
lesion  may  be  difficult  if  the  paralysis  be  non-traumatic.  The  process  is 
usually  neuritic  in  character,  but  whether  this  be  primary  or  secondary  to 
some  other  pathological  condition  it  may  be  impossible  to  say  at  first. 

The  distinction  of  peripheral  from  central  brachial  palsy  is  not  usually 
difficult.  Focal  processes  in  the  cervical  spinal  cord  give  rise  to  paralysis, 
wasting,  and  sensory  disturbances  in  the  arm.  But  there  can  be  no  error  if 
the  following  considerations  be  taken  in  account :  in  spinal  cord  disease  there 
is  usually  no  correspondence  between  the  disturbances  of  function  and  the 
ftinctions  of  particular  j^eripheral  nerves ;  there  are  no  local  pathological 
conditions  which  would  explain  a  nerve-lesion,  and,  most  important  of  all, 
there  are  evidences  of  impairment  of  the  conducting  functions  of  the  cord 
(weakness  and  sensory  disturbances  and  alteration  in  reflex  action  below 
the  lesion),  not  rarely  bilateral  in  character. 

Treatment.  There  is  little  to  be  said  of  a  special  nature  regarding  the 
treatment  of  brachial  nem^e  paralysis ;  treatment  consists  in  removing  so 
far  as  possible  the  cause  of  the  paralysis,  whether  this  be  neuritic  or  trau- 
matic. The  treatment  of  neuritis  has  been  already  considered.  Any  source 
of  pressure  must  be  got  rid  of.  Divided  nerves  must  be  sutured,  primary 
suture  always  being  used  when  practicable.  Electrical  treatment  and  mas- 
sage should  be  employed  in  all  cases  where  there  is  serious  damage  to  the 
nerves.  If  electricity  be  employed  to  obtain  muscular  contraction  it  should 
be  applied  at  least  once  daily.  (See  also  Prognosis  and  Treatment  of  Paral- 
ysis of  the  Spinal  Nerves). 

Cervico-brachial  and  Brachial  Neuralgia.  These  terms  are  applied 
to  neuralgic  afiections  of  the  four  lower  cervical  and  first  dorsal  nerves.  The 
pain  is  most  often  in  the  distribution  of  the  ulnar  nei^ve,  but  it  is  not  rarely  most 
marked  in  the  axilla  or  on  the  shoulder.  It  may  be  referred  to  any  part  of 
the  arm  or  hand.  Tender  points  are  commonly  found.  An  axillary,  a  cir- 
cumflex over  the  deltoid,  a  superior  ulnar  at  the  level  of  the  elbow,  and  an 
inferior  ulnar  where  the  nerve  passes  in  front  of  the  annular  ligament  of  the 
wrist,  are  the  chief  painful  points.  As  a  rule,  there  is  some  dull  continuous 
pain  in  addition  to  the  paroxysms  of  sharp  pain.  It  is  very  common  for 
cervico-brachial  neuralgia  to  be  increased  or  excited  by  movement,  and 
some  of  the  severest  cases  are  of  the  nature  of  occupation  neuroses,  and  are 
seen  in  pianists,  violinists,  and  those  who  write  to  excess.  But  of  course  the 
mere  fact  that  a  movement  like  that  of  writing  or  piano-playing  excites  the 
pain  does  not  show  that  the  case  is  an  occupation  neurosis.  The  pain  may 
radiate  to  the  side  of  the  chest  and  thus  suggest  angina  pectoi'is,  or  it  may 
be  associated  with  neuralgia  of  the  fifth.  If  trophic  changes  occur  in  the 
skin  this  is  evidence  of  neuritis. 


842  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Bi'achial  neuralgias  are  not  so  often  associated  with  diathetic  states  as 
neuralgias  elsewhere,  but  are  often  the  consequence  of  injury  (especially 
blows  on  the  shoulder  and  injuries  to  the  ulnar).  An  extensive  neuralgia 
without  neuritis  may  result  from  a  slight  injury  to  the  arm.  Injuries  to  the 
finger-nerves  are  seldom  followed  by  neuralgia.  "Median  cephalic"  neu- 
ralgia is  said  to  have  been  comparatively  common  in  the  days  of  phlebot- 
omy (Anstie).  Carious  teeth  are  said  to  be  an  occasional  cause  of  brachial 
neuralgia  (Salter).  The  prognosis  is  good  Avhere  there  is  a  removable  cause. 
Where  no  such  cause  is  found  the  affection  may  be  very  obstinate.  Rest  for 
the  affected  part  is  often  an  essential  j)art  of  treatment.  Sometimes  immo- 
bilization of  the  arm  by  means  of  a  plaster  bandage  is  of  much  service.  (For 
general  treatment,  see  Neuralgia  of  the  Fifth). 

Paralysis  of  Single  Nerves.     Nerves  of  the  Ujyper  Extremity. 

Paralysis  of  the  Posterior  Thoracic  Nerve.  This  nerve  is  derived  from  the 
fifth  and  sixth  cervical  ner\^es,  and  injury  to  it  causes  paralysis  of  the  serratus 
magnus  muscle.  The  main  eflTects  of  the  paralysis  of  this  muscle  are  :  1. 
Rotation  of  the  scapula  on  its  vertical  axis  when  the  arm  is  put  forward, 
with  recession  of  the  edge  of  the  scapula  from  the  thorax,  so-called  "  winged 
scapula."  2.  Rotation  inward  and  upward  of  the  lower  angle  of  the  scap- 
ula when  the  arm  is  advanced.  3.  ^Yeakening  of  the  power  of  elevating 
the  arm  above  the  shoulder.  There  is  often  severe  pain  in  the  neck  and 
shoulder  during  the  onset  of  the  paralysis. 

The  damage  to  the  nerve  is  generally  in  the  neck,  either  by  direct  pressure 
of  a  heavy  angular  object  on  the  shoulder  or  by  a  violent  muscular  effort, 
as  in  lifting  a  heavy  hammer.  Occasionally  the  nerve  is  injured  by  a  wound 
or  contusion,  and  sometimes  a  neuritis  is  set  up  by  exposure  to  cold.  The 
palsy  is  generally  one-sided ;  very  rarely  it  is  bilateral.  It  is  very  much 
more  common  in  men  than  in  women.  Usually  the  affection  is  right-sided. 
Serratus  paralysis  occurs  in  progressive  muscular  atrophy,  but  then  there 
are  other  muscles  involved.  Paralysis  of  the  posterior  thoracic  nerve  is  of 
long  standing  where  the  loss  of  power  is  complete.  It  should  be  remem- 
bered that  it  is  a  very  rare  form  of  palsy. 

Paralysis  of  the  Supra-Scapular  Nerve.  Damage  to  the  supra-scapular 
nerve  causes  paralysis  of  the  supra-spinatus  and  infra-spinatus  muscles.  The 
paralysis  of  the  former  gives  rise  to  obtrusiA^e  symptoms,  but  paralysis  of 
the  infra-spinatus  causes  a  loss  of  outward  rotation  of  the  humerus.  An 
important  effect  of  this  loss  is  the  inability  to  carry  the  hand  from  left  to 
right  as  in  writing. 

There  is  seldom  isolated  paralysis  of  the  supra-scapular  nerve,  but  it  is 
not  rarely  affected  together  with  the  circumflex,  in  consequence  of  dislocation 
of  the  head  of  the  humerus. 

Paralysis  of  the  Circumfle.v  Nerve  causes  loss  of  power  in  the  deltoid  and 
teres  minor  muscles.  The  paralysis  of  the  former  is  far  more  important. 
Its  chief  sign  is  inability  to  raise  the  arm.  In  some  cases  there  is  loss  of 
sensation  on  the  outside  of  the  upper  part  of  the  arm  over  the  muscles. 
The  deltoid  wastas,  and  this  alters  the  contour  of  the  shoulder.  After  a  time 
trophic  changes  occur  in  the  shoulder-joint  (the  circumflex  sends  filaments 
to  the  joint),  and  adhesions  may  form.  Paralysis  of  the  circumflex  nerve 
is  easily  recognized.  It  is  impossible  to  confound  it  with  the  loss  of  motion 
that  is  seen  in  anchylosis  of  the  shoulder-joint  if  it  is  remembered  that  in 
the  latter  state  passive  motion  of  the  arm  moves  the  scapula  as  well  as  the 
arm.  The  circumflex  nerve  is  often  injui'ed  by  falls  on  the  shoulder  and  by 
dislocations  of  the  head  of  the  humerus.  Rarely  it  is  the  seat  of  "sponta- 
neous" neuritis.     It  is  sometimes  paralyzed  with  other  nerves  belonging  to 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.    843 

the  brachial  plexus  (see  Combined  Paralysis  of  the  Brachial  Nerves)  in  a 
highly  characteristic  manner. 

Paralysis  of  the  Musculo-cutaneous  Nerve  (External  Cutaneous,  Perforans 
Casseriij  causes  loss  of  power  in  the  biceps  and  brachialis  anticus  musclas, 
the  effects  of  which  are  unmistakable  (loss  of  flexion  of  elbow,  especially 
marked  when  the  forearm  is  supinated  and  the  supinator  longus  cannot  act 
as  a  flexor).  There  may  or  may  not  be  anaesthesia  on  the  outer  half  of  the 
forearm  in  front  and  behind,  and  over  the  arm  in  its  lower  part  and  outer 
side.     The  musculo-cutaneous  is  rarely  paralyzed  by  itself. 

Paralysis  of  the  Mumulo-sj^iral  Nerve  in  the  vicinity  of  the  brachial  plexus 
causes  loss  of  power  in  all  the  extensors  of  the  forearm  and  wrist  and  the 
supinators.     Extension  of  the  elbow  is  impossible,  the  wrist  di'ops,  and  the 

Fig.  276. 


Wrist-drop  in  musculo-spiral  paralysis.    (Leube.) 


fingers  are  flexed  at  their  distal  joints.  The  fingers,  can,  however,  l)e  ex- 
tended by  the  interossei  and  lumbricales  if  the  first  phalanges  are  flexed. 
Supination,  though  not  entirely  lost  (the  biceps  being  active),  is  greatly 
weakened.  After  a  time  the  excessive  flexion  of  the  carpus  leads  to  undue 
prominence  of  the  carpal  bones  and  the  synovial  sacs  at  the  back  of  the 
wrist.  When  the  damage  to  the  nerve  is  serious  there  is  in  a  few  weeks  a 
perceptible  diminution  in  the  size  of  the  foi'earm,  due  to  the  atrophy  of  the 
paralyzed  extensors,  and  the  muscles  present  the  R.  D.  in  various  degrees. 

If  the  damage  to  the  nerve  is  in  the  middle  of  the  arm  the  bicejDS  is  gener- 
ally involved.  The  supinator  longus  escapes  only  in  rare  cases  of  musculo- 
spiral  jDaralysis. 

The  loss  of  sensation  in  the  parts  supplied  by  the  musculo-spiral  varies 
considerably  in  different  ca.ses.  In  actual  division  of  the  nerve  above  its 
cutaneous  branches  there  is  usually  loss  of  sensation  in  the  outer  part  of  the 
arm  (about  one-quarter  of  its  circumference)  from  the  level  of  insertion  of  the 
deltoid  to  the  external  condyle  of  the  humerus,  and  on  the  l)ack  of  the  fore- 
arm on  the  outer  side  above,  fiiding  into  normal  sensation  in  the  lower  third 
of  the  forearm.     The  skin  on  the  doi'sal  surface  of  the  hand  is  anaesthetic 


844    ■  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

over  the  thumb  and  metacarpal  bones  of  the  thumb,  index,  and  middle 
fingers.  In  many  cases  of  musculo-spiral  paralj'sis  there  is  no  ansesthesia 
either  in  the  hand  or  arm. 

Musculo-spiral  paralysis  is  of  frequent  occuiTence,  the  course  of  the  nerve 
exposing  it  to  various  kinds  of  injury.  BQgh  up  the  nerve  may  be  damaged 
by  the  pressure  of  a  crutch.  Indeed,  crutch  paralysis  is  usually  due  to 
musculo-spiral  injury.  The  nerve  is  apt  to  be  torn  in  cases  of  fracture  of 
the  humerus,  and  may  be  pressed  upon  by  callus.  The  most  common  cause 
of  the  j)aralysis,  however,  is  damage  to  the  nerve  during  sleep.  The  patient 
lies  on  a  hard  bed  or  on  the  floor  with  the  arm  under  him  and  receiving  liL? 
weight.  The  nerve  suffers  as  it  passes  around  the  humerus  about  the  middle 
of  the  arm.  But  there  is  very  good  reason  to  think  that  the  majority  of 
these  sleep  palsies  of  the  musculo-spiral  are  due  not  to  pressure,  but  to  stretch- 
ing of  the  plexus  from  extension  of  the  arm  above  the  head.  This  is  also 
the  origin  of  the  paLsy  that  occurs  during  extension  of  the  arm  in  some  cases 
where  the  patient  is  ansesthetized.  So  often  does  this  occur  in  patients  who 
have  fallen  asleep  after  excess  in  alcohol  that  it  is  known  as  "  Saturday-night 
paralysis  "  or  "  Sunday-morning  paralysis,"  from  the  times  at  which  the 
paralytic  effects  usually  arise  or  are  detected. 

It  is  necessary  to  distinguish  musculo-spiral  paralysis  ft'om  some  forms  of 
multiple  neuritis — notably  from  lead  paralysis  and  alcoholic  neuritis.  In 
lead  paralysis  the  muscles  supplied  by  the  musculo-spu'al  nerve  are  involved, 
but  the  affection  is  almost  invariably  bilateral  (though  the  two  sides  may 
suffer  very  unequally),  and  the  supinator  longus  muscle  is  almost  exempted 
from  the  palsy.  In  musculo-spiral  paralysis,  on  the  contrary,  the  paralysis 
involves  only  one  nerve  (in  rare  cases  a  cause  of  musculo-spiral  paralysis 
operates  bilaterally),  and  the  supinator  longus  is  almost  invariably  included 
in  the  palsy.  Moreover,  the  onset  of  lead  palsy  is  gradual  and  the  develop- 
ment of  musculo-spiral  paralysis  is  rapid  or  sudden.  The  cause  of  musculo- 
spiral  paralysis  is  usuall}^  readily  elicited.  The  distinction  from  alcoholic 
neuritis  is  usually  extremely  easy  (see  Multiple  IsTeuritis).  The  bilateral 
character  of  the  paralysis,  its  extensive  distribution,  and  the  alcoholic  history 
will  prevent  error  even  when  the  paralysis  affects  chiefly  the  upper  extremities. 

Paralysis  of  the  Median  Nerve.  Severe  damage  to  the  median  nerve  above 
its  muscular  branches  causes  loss  of  poAver  in  the  flexors  of  the  fingers  (ex- 
cepting the  ulnar  half  of  the  flexor  profundus),  in  the  pronators,  in  the 
flexor  carpi  radialis,  in  the  two  outer  lumbricales,  and  in  all  the  muscles  of 
the  ball  of  the  thumb  except  the  abductor  pollicis  and  the  ulnar  half  of  the 
flexor  brevis  polHcis.  In  consequence  of  this  loss  of  power  the  ability  to 
flex  and  pronate  the  forearm  is  greatly  diminished,  but  not  abolished.  Flexion 
at  the  wrist  to  the  ulnar  side  is  still  possible  by  the  action  of  the  flexor  carpi 
ulnaris ;  pronation  is  feebly  performed  by  permitting  the  weight  of  the  hand 
to  rotate  the  forearm  after  it  has  been  supinated,  the  supinator  longus  being- 
capable  only  of  pronating  the  arm  to  a  position  midway  between  supination 
and  pronation.  The  thumb  is  extended  and  abducted  in  a  characteristic 
manner,  and  cannot  be  brought  in  contact  Avith  the  tips  of  the  fingers.  The 
second  phalanges  can  no  longer  be  flexed  on  the  first,  and  in  the  first  and 
second  fingers  there  is  also  loss  of  flexion  of  the  thu'd  phalanges.  The 
first  phalanges  are  flexed  by  the  interossei.  The  most  characteristic  distri- 
bution of  anaesthesia  is  as  follows :  On  the  palmar  surface  loss  of  sensation 
on  the  radial  side  of  the  pahn  and  of  the  thumb,  index  and  middle  finger, 
and  the  radial  side  of  the  ring  finger  ;  on  the  doi*sal  surface,  loss  of  sensation 
on  the  index  and  middle  fingers  and  on  the  radial  side  of  the  ring  finger  for 
a  variable  distance,  and  perhaps  on  the  ulnar  side  of  the  thumb.  (See  Fio;s. 
241  and  242,  p.  747.) 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     845 

The  degree  and  extent  of  the  anaesthesia  vary  much  in  different  cases. 
Sometimes  there  is  no  affection  of  sensation  whatever.  In  a  case  of  severe 
damage  to  the  median  the  appearance  of  the  hand  and  forearm  soon  becomes 
highly  characteristic.  The  forearm  is  much  atrophied  on  the  radial  side  in 
front,  the  wrist  is  inclined  to  the  ulnar  side  and  perhaps  hyper-extended,  the 
ball  of  the  thumb  is  greatly  wasted,  the  head  of  the  metacarpal  bone  is 
prominent,  and  the  thumb  is  usually  rotated  out,  so  that  its  palmar  surface 
is  on  a  plane  with  that  of  the  hand,  as  is  the  case  in  apes. 

The  median  nerve  is  often  injured.  It  suffers  most  frequently  just  above 
the  wrist-joint,  where  it  is  more  superficial  than  in  the  rest  of  its  course,  and 
is  readily  divided.  It  may,  however,  be  damaged  in  almost  any  part  of  its 
course.  In  the  forearm  it  is  not  rarely  injured  in  fractures  of  the  ulna  and 
radius.  In  the  upper  arm  it  is  most  often  invaded  just  above  the  bend  of 
the  forearm.  It  is  said  to  be  in  some  cases  the  seat  of  primary  neuritis. 
Very  rarely  it  is  injured  by  violent  contraction  of  the  pronator  radii  teres. 

Paralysis  of  the  Ulnar  Nerve.  When  the  ulnar  nerve  is  divided  or  severely 
damaged  above  the  origin  of  all  its  branches  there  is  loss  of  power  in  the 
ulnar  half  of  the  flexor  profundus  digitorum,  in  the  flexor  carpi  ulnaris,  in 
all  the  muscles  of  the  little  finger,  in  all  the  interossei,  in  the  two  ulnar  lum- 
bricales,  in  the  abductor  pollicis,  and  in  the  inner  head  of  the  flexor  brevis 
pollicis.  When  this  paralysis  has  lasted  some  time  (three  or  four  weeks  or 
longer),  the  action  of  the  unparalyzed  opposing  muscles  brings  the  hand  into 
a  very  characteristic  position.     (See  Fig.  277.)     The  wrist  is  slightly  bent 

Fig.  277. 


Position  of  wrist,  hand,  and  fingers  in  ulnar  paralysis.    (Lexjbe.) 


backward  and  to  the  radial  side  of  the  forearm  by  the  action  of  the  exten- 
sor carpi  radialis,  extensor  carpi  ulnaris,  and  flexor  carpi  radialis.  The  hand 
is  considerably  thinner  than  normal  owing  to  the  wasting  of  the  interossei 
and  the  muscles  of  the  little  finger,  which  leaves  the  metacarpal  bone  of  that 
finger  very  prominent.  There  are  depressions  between  the  metacarpal  bones, 
but  there  is  a  particularly  marked  depression  on  the  radial  side  of  the  meta- 
carpal bone  of  the  index  finger  on  the  back  of  the  hand,  owing  to  the  wast- 
ing of  the  first  dorsal  interosseus. 

The  paralysis  of  the  interossei  leads  to  a  deformity  which  is  almost  dis- 
tinctive of  ulnar  paralysis.  The  fingers  cannot  be  flexed  at  the  first,  or  ex- 
tended at  the  second  and  third  phalanges,  and,  in  consequence  of  this  the 
extensor  communis  digitorum,  flexor  sublimis  digitorum,  and  part  of  the 


846 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


flexor  profundus  cligitorum  by  their  contracture,  overextend  the  first  pha- 
langes and  flex  the  second  and  third. 

This  deformity  of  the  hand  is  known  as  the  "  bird-claw  hand,"  or  the 
"  claw-like  hand."  (See  Fig.  278.)  The  deformity  is  especially  marked  in 
the  third  and  fourth  fingers ;  the  first  and  second  are  less  afiected  because 
their  lumbricales  escape  paralysis.  This  deformity  occurs  not  only  when  the 
ulnar  nerve  is  damaged  high  up  above  its  muscular  branches,  but  also  in  in- 
juries of  the  wrist,  though  it  is  perhaps  less  extreme  in  the  latter  class  of  cases. 


Fig.  278. 


Position  of  hands  and  fingers  in  ulnar  paralysis  of  long  standing ;  "  bird-claw  hand,"  "main  en 
griffe."  A,  wound  of  the  ulnar  nerve ;  B,  ends  of  the  metacarpal  bones ;  D,  tendons  of  the  flexor 
sublimis  ;  C,  muscles  of  the  ball  of  the  thumb.    (Duchenne.) 

The  state  of  sensation  in  vilnar  paralysis  varies  considerably  ;  in  some  cases 
there  is  no  ansesthesia ;  in  others  of  severe  damage  to  the  nerve  the  loss  in- 
volves, on  the  palmar  surface,  the  little  finger  and  the  ulnar  half  of  the  ring- 
finger,  together  with  the  corresponding  portion  of  the  palms,  on  the  dorsal 
surface,  the  little  finger,  the  ulnar  half  of  the  ring-finger,  and  the  correspond- 
ing region  of  the  dorsum  of  the  hand.     (See  Figs.  243  and  244,  p.  748.) 

The  ulnar  nerve  is  probably  more  often  damaged  than  any  other  spinal 
nerve.  It  is  frequently  injured  in  wounds  of  the  forearm,  especially  in 
wounds  at  the  wrist,  where  the  nerve  is  superficial.  When  the  nerve  is  in- 
jured at  the  wrist  it  is  generally  above  the  origin  of  the  dorsal  cutaneous 
branch.  Higher  up  in  the  forearm  the  nerve  may  be  hurt  by  fractures  of 
the  ulna  and  radius.  At  the  back  of  the  elbow,  just  external  to  the  olecra- 
non, the  nerve  is  very  liable  to  sufier  from  wounds,  and  is  occasionally  injured 
by  pressure  or  contusion.  Long-continued  flexion  at  the  elbow  sometimes 
suffices  to  cause  ulnar  paralysis.  Sometimes  paralysis  arises  in  this  way  dur- 
ing sleep.  The  nerve  is  very  rarely  injured  in  the  arm  above  the  elbow. 
Sometimes  the  symptoms  of  an  apparently  spontaneous  ulnar  neuritis  are 
observed  in  persons  in  reduced  health. 

The  diagnosis  of  ulnar  paralysis  is  simple.  Error  may  possibly  arise  in 
rare  cases  of  disease  of  the  cervical  enlargement,  in  which  the  ulnar  nerve 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     847 

distribution  is  chiefly  affected.     Other  evidences  of  spinal  cord  disease  are 
never  wanting  in  these  cases. 

In  cases  where  nerves  of  the  arm,  and  especially  of  the  forearm,  have  been 
injured,  and  tendons  and  muscles  have  been  injured  with  the  nerves,  it  may 
be  difficult  to  distinguish  the  effects  of  the  nerve  injury  and  the  effects  of 
injury  to  the  tendons  and  muscles.  This  is  because  there  is  often  consider- 
able cicatricial  change  in  muscles  and  tendons,  leading  to  deformity,  which 
may  simulate  closely  that  of  nerve  injury,  and  because  certain  of  the  most 
important  signs  of  nerve  injury,  namely,  changes  in  the  irritability  of  muscles 
and  nerves,  may  be  obscured  by  the  contraction  that  sets  in.  Even  the  most 
careflil  attention  to  every  detail  in  the  history  and  examination  of  such  cases 
may  not  enable  the  observer  to  arrive  at  a  correct  conclusion  as  to  extent 
and  situation  of  the  nerve  damage. 


DISEASES  OF  THE  DORSAL  NERVES. 

The  affections  of  the  dorsal  nerves  are  mainly  sensory.  The  motor  fibres 
of  individual  dorsal  or  intercostal  nerves  sometimes  suffer  in  wounds,  but 
such  localized  damage  does  not  produce  recognizable  symptoms.  When 
there  is  extensive  motor  paralysis  of  the  dorsal  nerves,  it  is  in  consequence 
of  vertebral  or  spinal-cord  disease. 

Intercostal  Neuralgia  (Dorso-intercostal  Neuralgia).  This  rather  com- 
mon form  of  neuralgia  is  especially  frequent  in  women.  Frequently  it  follows 
exposure  to  cold  or  a  contusion  or  other  injury.  It  probably  does  not  occur 
spontaneously,  exce^^t  in  persons  whose  nutrition  is  impaired.  It  may  involve 
one  or  more  of  the  intercostal  nerves,  from  the  third  to  the  ninth,  and  is 
characterized  by  acute  stabbing  pains,  which  shoot  along  one  or  more  spaces. 
In  the  intervals  between  the  exacerbations  there  is  usually  a  dull,  constant 
intercostal  pain.  When  the  neuralgia  has  existed  for  some  time  tender 
points  may  be  found  at  the  exit  of  the  branches  of  the  intercostal  nerve, 
which  is  the  seat  of  pain,  near  the  vertebrae,  near  the  median  line  anteriorly, 
and  in  the  axillary  line. 

Intercostal  neuralgia  of  the  type  just  described  is  often  obstinate  and  of 
long  duration. 

Mammary  Neuralgia  (Mastodynia)  is  a  variety  of  intercostal  neuralgia 
Avhieh  occurs  in  neurasthenic  or  ansemic  women,  with  or  without  disturbance 
of  the  function  of  the  gland.  In  some  cases  it  is  referable  to  over-lactation. 
The  pain  is  most  often  on  the  left  side,  is  sharp  in  character,  and  limited  to 
the  anterior  part  of  the  upper  intercostal  sj^aces.  Another  variety  of  inter- 
costal neuralgia  is  the  trifling  neuralgic  pain  known  as  pleurodynia.  In 
such  cases  the  pain  is  migratory,  and  is  unassociated  with  points  of  tender- 
ness. It  is  necessary  to  distinguish  all  these  forms  of  neuralgia  from  the 
sharp  pleuritic  pains  that  occur  so  often  in  neurasthenics  and  in  those  who 
have  had  pneumonia.  The  pain  in  these  cases  is  apt  to  recur  in  the  same 
positions,  and  is  influenced  by  the  movements  of  respiration.  Probably  it 
depends  on  slight  localized  dry  pleuritis.  It  is  seen  most  often  in  persons 
who  are  free  from  pulmonary  tuberculosis.  In  many  cases  this  pain  varies 
with  extreme  regularity  with  the  well-being  of  the  patient,  often  coming  on 
only  when  he  has  been  fatigued.  In  the  primary  intercostal  neuralgias, 
Avhich  are  comparatively  infrequent,  this  relation  to  the  changing  vitality  of 
the  patient  is  not  so  clearly  seen. 

In  every  case  where  the  diagnosis  of  primary  intercostal  neuralgia  is  made 
great  care  must  be  taken  to  exclude  the  influence  of  organic  conditions  of 
the  chest,  mammae,  vertebrae,  and  spinal  cord. 


848  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Treatment.  Counter-irritation  over  the  affected  space  usually  gives  at 
least  temporary  relief;  sometimes  it  renders  recurrence  of  the  pain  less  fre- 
quent. The  actual  cautery  (Paquelin)  seems  the  most  [effective  means  of 
applying  counter-irritation.  The  point  should  be  applied  superficially  and 
quickly.  If  this  is  not  available,  a  mustard  plaster  or  fly-blister  should  be 
applied.  Chlorodyne  in  small  doses  often  gives  relief,  but  its  repeated  use 
cannot  be  recommended.  It  is  exceedingly  important  to  employ  tonic  treat- 
ment and  rest,  and  to  keep  the  bowels  freely  open.  In  rare  cases  section  of 
the  affected  intercostal  nerve  has  been  resorted  to  and  has  given  relief. 

Herpes  Zoster  (Shingles).  Although  herpes  zoster  occurs  in  various  parts 
of  the  body,  it  affects  with  especial  frequency  the  distribution  of  the  dorsal 
nerves.  The  disease  is  characterized  by  the  rapid  development  of  groups  of 
vesicles  in  the  course  of  a  nerve,  associated  with  neuralgic  pain  in  the  same 
region.  The  development  of  the  vesicles  reaches  its  height  in  about  ten 
days.  The  pain  may  precede  or  follow  the  development  of  the  eruption. 
The  pain  which  precedes  the  eruption  is  usually  moderate  in  severity,  and 
grows  less  as  the  vesicles  develop.  The  pain  that  succeeds  the  eruption  is 
usually  acute,  lancinating,  severe,  and  accompanied  with  tenderness  of  the 
skin.  The  severity  and  persistence  of  this  pain  is  apt  to  be  proportioned  to 
the  age  of  the  patient.  In  the  young  it  is  transient ;  in  those  past  fifty 
there  is  always  a  liability  that  the  pain  will  prove  intractable,  or  at  least  of 
long  duration.  In  rare  cases  intercostal  neuralgia  precedes  for  a  long  period 
the  appearance  of  the  eruption.  The  dermatitis  is  usually  one-sided,  and  is 
generally  located  in  the  lower  intercostal  region. 

There  is  satisfactory  evidence  that  the  eruption  of  herpes  zoster  depends 
on  irritation  of  the  nerve  or  nerves  along  whose  distribution  it  occurs. 
Probably  the  intercostal  nerves  are  always  the  seat  of  neuritis,  and  there  is 
good  reason  tO  think  that  this  neuritis  is  due  to  inflammation  of  the  corre- 
sponding ganglion  of  the  posterior  nerve-roots  (Baerensprung,  Weidner,  Wyss, 
Charcot).     The  neuralgia  is  thus  symj)tomatic. 

Exposure  to  cold,  injury,  and  the  medicinal  use  of  arsenic  have  seemed  to 
account  for  some  cases.  Usually  we  are  wholly  ignorant  of  the  nature  even 
of  the  exciting  cause. 

The  affection  lasts  a  few  Aveeks  in  most  cases.  The  chief  factor  in  the 
prognosis  is  age.  In  some  cases  where  the  neuralgia  subsides  with  the  erup- 
tion it  recurs  from  time  to  time  for'  a  long  period. 

Treatment  is  not  satisfactory. 

Galvanism  relieves  the  pain  of  herpes  zoster,  as  a  rule.  Ointments  of 
opium  and  belladonna  and  dusting  powders  of  camphor  and  morphine  some- 
times give  relief  Internal  medication  appears  to  be  useless,  except  where 
the  general  health  is  much  impaired.  The  vesicles  should  be  protected  from 
irritation. 


DISEASES  OF  THE  LUMBAR  AND  SACRAL  PLEXUSES  AND 
OP  THEIR  BRANCHES. 

With  the  exception  of  sciatic  neuritis,  lesions  of  the  nerves  of  the  lower 
limb  are  considerably  less  frequent  than  those  of  the  upj)er  extremity. 

The  lumbar  jjlexus  (which  is  made  up  of  the  first  three  lumbar  roots  and 
one-half  of  the  fourth)  is  only  occasionally  damaged  by  disease.  Abdominal 
tumors  (ovarian  tumors,  growths,  and  tuberculosis  of  the  abdominal  lymph- 
nodes)  and  psoas  abscess  are  aJmong  the  more  frequent  causes  of  such  dam- 
age.    The  nerve-roots  from  which  the  plexus  arises  may  suffer  pressure  in 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     849 

vertebral  caries  or  malignant  disease  or  from  meningeal  tumors  or  inflamma- 
tions. Very  rarely  the  plexus  is  the  seat  of  an  apparently  primary  neuritic 
process,  and  very  rarely,  also,  a  lumbar  neuritis  is  due  to  upward  extension 
of  inflammation  along  the  lumbo-sacral  cord. 

The  lumbar  plexus  supplies  the  skin  of  the  lower  part  of  the  abdomen,  of 
the  front  and  lateral  aspects  of  the  thigh,  and  of  the  inner  surface  of  the  leg 
and  foot.  Through  its  branches,  the  obturator  and  anterior  crural  nerves, 
it  supplies  the  numerous  muscles,  the  flexors  and  adductors  of  the  thigh,  and 
the  extensors  of  the  knee.  When  the  lumbar  plexus  is  the  seat  of  disease, 
the  s3''mptoms  are  referred  to  the  parts  just  mentioned,  but  it  is  rare  for  all 
parts  of  the  plexus  to  suffer,  and  the  parts  involved  generally  suffer 
unequally. 

Paralysis  of  the  Obturator  Nerve  rarely  occurs  alone.  When  it  does,  it  is 
the  result  of  pressure  during  labor.  The  chief  symptom  of  such  paralysis  is 
loss  of  the  power  of  adducting  the  thigh ;  the  affected  leg  cannot  be  put 
across  the  other.  Most  cases  of  paralysis  of  the  obturator  nerve  depend  on 
damage  to  the  lumbar  plexus. 

Paralysis  of  the  Anterior  Crural  Nerve  causes  loss  of  power  and  atrophy  in 
the  extensors  of  the  knee  and  loss  of  knee-jerk  from  damage  to  the  reflex 
arc.  When  the  nerve  is  damaged  within  the  pelvis  the  branch  to  the  iliacus 
muscle  is  involved  and  there  is  impaired  power  of  flexing  the  hip,  as  well  as 
loss  of  extension  of  the  knee.  Paralysis  of  the  anterior  crural  nerve  also 
causes  anaesthesia,  which  involves  the  entire  thigh,  with  the  exceiDtion  of  a 
strip  of  variable  width  along  the  back  of  the  thigh  (supplied  by  the  sacral 
nerves)  and  the  inner  side  of  the  leg  and  foot.  The  anterior  crural  may  be 
damaged  in  the  thigh  or  groin,  may  suffer  from  pressure  during  parturition 
or  from  dislocation  of  the  hip,  or  may  be  implicated  in  disease  of  the  lumbar 
plexus. 

Paralysis  of  the  Superior  Gluteal  Nerve  causes  loss  of  abduction  and  circum- 
duction of  the  thigh,  from  paralysis  of  the  gluteus  minimus  and  medius.  As 
an  isolated  paralysis,  aj)art  from  affections  of  the  plexuses,  it  is  a  very  rare 
condition. 

Sciatic  Neuritis  (Sciatica).  Sciatic  neuritis  is  an  inflammation  of  the 
gi'eat  sciatic  branch  of  the  sacral  plexus.  The  inflammation  involves  princi- 
pall}^  the  sheath  of  the  nerve,  but  the  pathological  changes  often  extend  to 
the  interstitial  tissue  of  the  nerve.  The  nerve-fibres  themselves  are  damaged 
secondarily.  During  the  acute  stage  the  sheath  is  red  and  swollen  and  may 
be  the  seat  of  minute  hemorrhages.  All  these  inflammatory  changes  (de- 
scribed more  minutely  under  "Neuritis  in  General,"  Chapter  XXV.)  are 
most  pronounced  at  two  points  in  the  course  of  the  nerve,  near  the  sciatic 
notch  and  about  the  middle  of  the  thigh.  The  pathological  changes  may  be 
limited  to  these  spots  or  may  extend  with  less  intensity  to  a  large  part  of  the 
course  of  the  nerve. 

Sciatic  neuritis  gives  rise  to  the  clinical  condition  known  as  sciatica,  and 
is,  indeed,  its  chief  cause.  The  word  sciatica  is,  however,  legitimately  em- 
ployed to  include  cases  of  pain  probably  in  the  sciatic  nerve  due,  not  to 
organic  changes,  but  to  slight  alterations  in  the  nutrition  of  the  nerve — 
sciatic  neuralgia.  The  word  is  less  strictly  used  to  designate  all  painful  con- 
ditions in  the  neighborhood  of  the  sciatic  nerve ;  as,  for  example,  the  sciatic 
pain  due  to  tumor  in  the  pelvis  pressing  on  the  plexus.  It  is  best  that  the 
term  should  be  restricted  to  sciatic  pain  arising  from  causes  within  the  sciatic 
nerve. 

Etiology.  Sciatic  neuritis  is  a  disease  especially  of  middle  adult  life,  but 
is  not  rarely  met  with  between  sixty  and  seventy.  Occasionally  it  is  met 
with  during  adolescence.     It  is  more  than  twice  as  common  in  males  as  in 

54 


850  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

females.  A  disturbance  in  general  nutrition,  inherited  or  acquired,  is 
probably  present  in  all  cases  of  sciatic  neuritis.  The  nature  of  this  disorder 
is  but  imperfectly  known.  In  some  cases  the  sufferers  are  the  subjects  of 
gout  or  the  descendants  of  gouty  persons.  In  other  cases  there  is  a  marked 
disposition  to  rheumatism,  especially  muscular  rheumatism.  In  some  cases, 
probably  in  many,  there  is  an  excessive  excretion  of  uric  acid  as  compared 
with  urea — an  evidence  of  imperfect  digestion  though  there  may  be  no  appre- 
ciable local  digestive  disorders. 

Lumbago  is  sometimes  followed  by  sciatic  neuritis  about  the  ischiatic  notch, 
and  in  these  cases  the  neuritis  arises  probably  by  an  extension  of  interstitial 
inflammation  from  the  muscles  to  the  nerve.  It  is  doubtful  whether  syphilis 
acts  as  a  cause  of  sciatic  neuritis,  excejDt  by  lowering  the  general  health. 

There  is  commonly  an  exciting  cause  for  sciatic  neuritis.  The  most  fre- 
quent exciting  cause  is  exposure  to  cold,  either  local  exposure  (as  from  sitting 
on  wet  grass,  or  a  draughty  water-closet,  or  from  standing  in  the  wet)  or,  less 
frequently,  general  exposure,  as  to  a  draught  of  cold  air.  Mechanical  causes 
are  sometimes  competent  to  start  up  a  sciatic  neviritis.  The  pressure  on  the 
legs  by  the  edge  of  a  hard  seat  is  such  a  cause,  and  a  common  one.  Violent 
muscular  contraction  and  over-exertion  are  much  rarer  causes. 

Symptoms.  The  cardinal  symptom  of  sciatic  neuritis  is  pain  in  the  course 
of  the  nerve- trunk,  and,  less  frequently,  along  the  branches  of  the  nerve  or 
in  its  distribution.  The  onset  of  the  pain  is  usually  gradual,  occasionally 
rapid.  At  first  the  pain  is  experienced  only  upon  motion,  particularly  such 
motion  as  puts  the  nerve  on  the  stretch.  This  pain  grows  more  severe  and 
recurs  from  slighter  causes  until  a  time  may  arrive  when  almost  any  move- 
ment of  the  affected  leg  causes  severe  pain.  While  the  pain  on  movement 
gradually  increases  spontaneous  pain  is  added.  This  spontaneous  pain  is 
most  frequent  and  most  severe  in  two  places,  at  the  exit  of  the  nerve  from 
the  sciatic  notch  and  at  a  spot  about  the  middle  of  the  back  of  the  thigh. 
The  pain  is  not  always  confined  to  the  neighborhood  of  the  nerve,  but  ex- 
tends to  its  areas  of  distribution,  especially  to  the  following  points :  (1)  Just 
above  the  hip-joint,  below  the  posterior  superior  spine  of  the  ileum  ;  (2)  in 
the  popliteal  space ;  (3)  below  the  head  of  the  fibula  ;  (4)  back  of  the  outer 
malleolus ;  and  (5)  on  the  dorsum  of  the  foot.  In  character  the  pain  may 
be  sharp  or  dull.  It  is  often  described  as  burning.  Usually  it  is  aggravated 
at  night.  In  some  cases  the  pain  seems  to  shoot  downward  from  the  upper- 
most part  of  the  nerve.  As  the  pain  grows  more  pronounced,  tenderness  of 
the  nerve-trunk  to  pressure  appears.  This  tenderness  can  be  brought  out 
even  when  it  is  slight  in  degree,  though  stretching  the  sciatic  nerve  slightly 
as  the  patient  lies  on  his  back  by  flexing  the  fiilly  extended  leg  on  the  body. 

Other  disturbances  than  pain  are  met  with  in  the  distribution  of  the  sciatic 
nerve.  Numbness,  tingling,  and  formication  are  of  common  occurrence. 
Areas  of  complete  anaesthesia  occur  only  in  severe  cases.  Somewhat  more 
frequently  irregular  areas  of  partial  anaesthesia  and  analgesia  are  found  on 
the  back  of  the  thigh  or  on  the  leg.  When  the  sensibility  at  the  back  of  the 
thigh  is  affected  this  is  an  indication  that  the  neuritic  process  has  extended 
to  a  point  above  the  origin  of  the  small  sciatic  nerve  or  that  there  is  a  neu- 
ritis of  this  nerve. 

Involvement  of  the  motor  functions  of  the  nerve  is  of  common  occurrence, 
more  common,  probably,  than  is  generally  supposed.  A  large  proportion 
of  all  cases  of  sciatic  neuritis  are  accompanied  with  some  loss  of  power  in  the 
distribution  of  the  sciatic  nerve  or  of  the  branches  of  the  sacral  plexus.  The 
loss  of  power  may  be  slight  or. considerable  and  is  often  associated  with  slight 
wasting  and  flabbiness  of  the  muscles  with  alterations,  which  are  rarely  con- 
siderable in  the  electrical  reactions.      Most  often  the  paresis  involves  the 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     851 

hamstring  muscles  (Mann).  To  elicit  this  weakness  the  patient  should  lie 
upon  the  belly  and  flex  the  leg  on  the  thigh  Avhile  one  hand  of  the  examiner 
resists  the  effort  and  the  other  feels  the  insertions  of  the  muscles.  Much  less 
commonly  there  is  atrophic  paralysis  of  the  calf-muscles,  the  anterior  tibial 
or  peroneal  muscles,  or  of  the  gluteus  maximus.  Paralysis  of  the  latter 
causes  little  or  no  difficulty  in  walking,  but  interferes  with  rising  from  a 
chair  and  with  walking  upstairs.  Occasionally  the  palsy  extends  to  the 
erector  spinse,  with  resulting  typical  scoliosis  (convexity  to  the  side  of  the 
neuritis).  In  rarer  instances  the  pareses  are  not  confined  to  the  side  on 
which  there  is  sciatic  pain. 

Persons  with  sciatic  neuritis  hold  the  leg  stiffly  in  walking  and  slightly 
flexed,  owing  to  the  pain  caused  by  changing  the  tension  of  the  nerve  in 
walking  naturally. 

Slight  fever  may  accompany  the  onset  of  acute  cases  of  sciatic  neuritis ; 
there  is  rarely  any  elevation  of  temperature  when  the  condition  is  estab- 
lished. 

Marked  trophic  or  vasomotor  disturbances  occur  in  some  severe  cases. 
The  most  important  of  these  are  oedema  of  the  leg  and  a  herpetic  eruption  in 
the  distribution  of  the  nerve.  Another  and  more  serious  complication  is  the 
ascent  of  the  neuritic  process  along  the  sciatic  to  the  lumbar  plexus.  The 
anterior  crural  nerve  may  be  thus  involved,  causing  pain  in  the  front  of  the 
thigh  and  weakness  and  wasting  of  the  quadriceps  extensor. 

Diagnosis.  The  diagnosis  of  sciatica  is  based  on  the  presence  of  pain  in 
the  nerve  or  its  distribution,  and  on  tenderness  of  the  nerve-trunk,  and 
usually  is  not  difficult.  The  distinction  from  sciatic  neuralgia  depends  chiefly 
on  the  jDresence  of  marked  and  persistent  tenderness  of  the  nerve- trunk.  The 
characteristics  of  sciatic  neuralgia,  which  is  actually  a  rare  condition  as  com- 
pared with  the  frequency  of  sciatic  neuritis,  are  as  follows :  (1)  The  pain  is 
spontaneous  from  the  start ;  movement  does  not  itself  cause  pain ;  (2)  the 
pain  is  apt  to  be  referred  to  the  branches  rather  than  the  trunk  of  the  nerve ; 
(3)  tenderness  of  the  trunk  is  slight  or  absent ;  (4)  the  patients  are  apt  to 
suffer  from  neuralgia  elsewhere.  Diseases  within  the  pelvis  may  give  rise  to 
severe  sciatic  pain — secondary  sciatica.  The  pain  in  these  cases  is  usually 
referred  more  to  the  branches  than  to  the  trunk  of  the  nerve ;  there  is  also 
little  trunk-tenderness  in  proportion  to  the  pain.  But  the  recognition  of  the 
nature  of  the  pain  may  be  difficult  from  the  symptoms  alone ;  a  rectal  exam- 
ination, w^hich  should  be  made  in  every  case  of  sciatica,  is  of  great  aid  in 
determining  the  nature  of  the  case.  In  sciatic  neuritis  there  may  be  pain 
about  the  hip-joint  (owing  to  the  distribution  of  filaments  from  the  sciatic 
nerve  to  the  joint),  but  there  is  never  any  excuse  for  confounding  such 
widely  different  conditions  as  hip-joint  disease  and  sciatic  neuritis.  Sciatic 
neuritis  is  seldom  double,  hence  double  sciatica  should  direct  suspicion  to 
other  disorders,  especially  disease  of  the  nerve-roots  or  cord.  The  writer  has 
known  double  sciatica  to  be  due  to  extensive  disease  (sarcoma)  of  the  bodies 
of  the  lumbar  vertebrae,  the  first  suspicion  of  the  nature  of  the  sciatica  being 
excited  by  the  appearance  of  lumbar  abscess,  first  one-sided,  later  double. 
The  sciatic  pain  of  locomotor  ataxia  (which  may  be  due  to  neuritis)  is  to  be 
distinguished  by  its  transitory  character  and  its  association  with  cardinal 
tabetic  symptoms. 

Prognosis.  As  regards  the  ultimate  subsidence  of  pain  and  the  restoration 
of  the  function  of  the  nerve,  the  prognosis  of  primary  sciatic  neuritis  is  good 
in  every  case.  The  duration  of  the  symptoms  is  extremely  variable,  lasting 
in  some  cases  for  a  few  weeks  only,  in  others  for  many  months  or  a  year. 
Relapses  are  common  in  severe  cases  and  may  prolong  the  period  of  suffering 
to  one  or  two  years.    In  general  the  more  acute  and  severe  the  symptoms  the 


852  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

longer  the  duration  of  the  period  in  which  there  is  pain.  Most  cases  last  for 
several  months.  It  is  a  good  practical  point  to  remember  that  in  cases  where 
the  nerve-tenderness  is  such  that  the  patient  cannot  get  about,  the  duration 
of  the  trouble  will  be  several  months  at  least.  The  subsidence  of  the  neuritic 
symptoms  may  be  followed  by  obstinate  neuralgia.  Occasionally  a  neui'itic 
process  is  set  up  in  the  nerve  just  as  the  patient  appears  to  be  making  a  re- 
covery. These  statements  apply  to  primary  neuritis  ;  the  cause  and  prognosis 
in  secondary  sciatic  neuritis,  of  course,  depend  upon  the  character  and  posi- 
tion of  the  primary  morbid  process. 

Treatment.  The  first  condition  of  improvement  in  all  cases  of  sciatic 
neuritis  is  rest  for  the  affected  limb,  and  it  is  important  that  this  should  be 
secured  from  the  beginning.  A  week's  thorough  immobilization  at  the  be- 
ginning of  the  trouble  is  probably  more  effective  than  a  month's  rest  when 
the  neuritic  process  has  become  established.  Every  position  or  movement 
of  the  leg  that  causes  pain  should  be  absolutely  avoided.  This  element  of 
rest  in  treatment  is  negative  in  character,  but  it  is,  nevertheless,  of  greater 
importance  than  any  more  positive  measures.  Just  how  the  rest  should  be 
enforced  varies  according  to  the  acuteness  and  severity  of  the  case.  In 
cases  of  mild  degree  it  is  not  essential  that  the  patient  should  go  to  bed ;  it 
suffices  to  keep  the  leg  someAvhat  flexed,  to  avoid  sitting  on  chairs  with  hard 
edges,  and  to  walk  little  and  only  with  crutches.  When  the  nerve-tender- 
ness is  such  as  to  prevent  standing  the  jjatient  should  remain  in  bed  with  the 
leg  extended  upon  a  long  splint  after  the  manner  recommended  by  Weir 
Mitchell,  until  the  tenderness  of  the  nerve  has  much  subsided.  This  is  prob- 
ably the  most  satisfactory  means  of  securing  immobilization  and  gives  excel- 
lent practical  results. 

The  second  cardinal  indication  in  the  treatment  of  sciatic  neuritis  is  the 
relief  of  spontaneous  pain.  This  may  often  be  done  at  the  commencement 
of  a  severe  attack  by  the  application  of  a  hot  poultice,  or  by  the  use  of  ice- 
bags  over  the  course  of  the  nerve  for  several  hours  daily.  The  use  of  cold 
is  particularly  well  adapted  for  use  in  the  cases  where  the  long  heel  and 
axilla  splint  is  employed.  In  the  less  severe  cases  counter-irritation  hj  means 
of  a  mustard-plaster  or  a  fly-blister  may  give  much  relief,  at  least  temporarily. 
But  the  most  effective  form  of  counter-irritation  is  that  obtained  by  means 
of  the  actual  cautery  applied  lightly  without  blistering  over  the  entire  pain- 
ful area.  In  chronic  cases  the  cautery  may  be  used  to  advantage  to  blister. 
The  cautery  is  preferable  to  the  ointments  and  liniments  that  are  often  em- 
ployed. If  the  means  of  alleviating  pain  (and  they  probably  also  exert 
some  inffuence  upon  the  neuritic  process)  have  been  tried  with  little  or  tem- 
porary effect,  it  may  be  necessaiy  to  resort  to  hypodermatic  medication.  The 
hypodermatic  injection  of  distilled  water  sometimes  gives  great  relief,  and 
should  always  be  tried.  If  it  fails,  cocaine  hydrochlorate  should  be  injected, 
bearing  in  mind  the  precautions  mentioned  under  brachial  neuritis.  Injec- 
tions of  morphine  should  be  reserved  for  the  last,  and  should  then  be  used  as 
sparingly  as  possible,  and  should  be  replaced  by  cocaine  when  practicable. 
In  all  cases  where  hypodermatic  medication  is  employed  for  sciatic  neuritis 
the  injection  should  be  made  over  the  most  painful  spot,  at  a  depth  of  about 
two  inches,  and  never  into  the  nerve  itself.  Antipyrin,  antifebrin,  and 
phenacetin  should  be  avoided  entirely,  if  possible.  Simple  acupuncture  in 
the  line  of  the  nerve  may  give  temporary  relief,  but  is  in  itself  a  painful 
proceeding,  and  cannot  be  recommended. 

When  the  neuritis  is  subsiding  galvanism  may  be  cautiously  employed,  l)ut 
probably  its  chief  value  is  the  mental  effect  of  its  use  upon  the  patient.  If 
the  muscles  are  atrophic  or  flabby,  or  if  there  is  any  contracture,  massage 
properly  used  is  exceedingly  valuable.     It  may  also  do  much  to  relieve  pain. 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     853 

Xerve-stretching  has  done  good  in  some  cases.  It  may  be  recommended 
where  everything  else  has  failed  ;  but  under  these  circumstances  it  too  is 
likely  to  fail.  It  acts  probably  by  (1)  breaking  up  adhesions,  (2)  enforcing 
rest,  (3)  as  a  counter-irritant. 

The  possibility  of  doing  good  by  constitutional  treatment  should  never  be 
lost  sight  of.  The  diet  should  be  carefully  studied  and  regulated.  In  rheu- 
matic cases  a  largely  meat  diet  should  be  used  if  the  patient  is  not  reduced 
in  weight.  Where  no  specific  disorder  of  nutrition  can  be  detected  a  tonic 
containing  wine,  quinine,  and  a  little  strychnine  may  be  advantageously 
used  for  a  considerable  period  of  time.  In  the  majority  of  cases  of  sciatic 
neuritis  the  treatment  outlined  is  of  material  benefit ;  only  in  rare  cases  is 
treatment  wholly  unsatisfactory. 

The  sacral  plexus  is  liable  to  suffer  from  various  forms  of  pelvic  disease, 
especially  pelvic  tumors  and  pelvic  cellulitis.  Rarely  the  plexus  suffers 
compression  during  delivery,  and  occasionally  it  is  the  seat  of  neuritis  in 
consequence  of  an  extension  of  inflammation  from  the  sciatic  nerve.  The 
plexus  is  said  to  be  the  occasional  seat  of  a  "primary"  neuritis. 

The  symptoms  of  sciatic  plexus  disease  are  usually  at  first  irritative  in 
character  (pain,  parsesthesia,  etc.)  ;  later  they  are  indicative  of  a  destruc- 
tion (angesthesia,  paralysis,  atrophy).  The  precise  distribution  of  these 
symptoms  naturally  varies  in  different  cases,  since  the  various  muscular  and 
sensory  distributions  of  the  different  elements  of  the  plexus  may  be  vari- 
ously and  very  unequally  affected.  The  manifestations  of  disease  of  the 
plexus  are  rarely  confined  to  the  distribution  of  any  single  nerve  arising 
from  it,  although  a  single  nerve  (as  the  anterior  crural)  may  for  a  time  be 
the  chief  or  exclusive  seat  of  the  symptoms.  Plexus  disease  is  almost  in- 
variably unilateral,  but  in  rare  cases  of  pressure-paralysis  it  is  bilateral.  In 
all  cases  Avhere  plexus  disease  is  suspected  a  careful  rectal  exploration  is  of 
the  utmost  importance,  and  may  reveal  the  presence  of  a  pelvic  tumor,  an 
aneurism,  or  an  abscess  which  exerts  pressure  on  the  sacral  plexus. 

Paralysis  of  the  Sciatic  Nerve  causes  symptoms  which  vary  considerably 
with  the  seat  of  the  lesion.  Damage  to  the  nerve  is  usually  below  the  upper 
third  of  the  thigh,  and,  if  severe,  gives  rise  to  paralysis  of  all  the  muscles 
below  the  knee,  and  ansesthesia  of  the  sole  and  outer  side  of  the  foot  and  the 
outer  side  of  the  leg.  The  gait  in  such  cases  is  much  like  that  observed  in 
many  cases  of  poliomyelitis  in  children.  If  the  lesion  is  above  the  middle 
third  of  the  thigh,  the  flexors  of  the  knee  and  extensors  of  the  hip  are  in- 
cluded in  the  paralysis.  The  sciatic  nerve  external  to  the  pelvis  may  be 
damaged  in  wounds  of  the  thigh,  by  disease  of  the  femur,  by  adjacent  tumors, 
and  occasionally  by  dislocation  of  the  hip.  The  nerve  is  often  the  seat  of 
primary  neuritis. 

Paralysis  of  the  External  Popliteal  {Peroneal)  Nerve  causes  loss  of  power 
in  the  tibialis  anticus,  extensor  longus  digitorum,  extensor  brevis  digitorum, 
and  peronei,  in  consequence  of  which  there  is  loss  of  flexion  of  the  ankle 
and  of  extension  in  the  first  phalanges  of  the  toes.  The  patient  in  such  cases 
has  "  drop-foot,"  and  in  the  course  of  time  talipes  equinus  develops.  In 
cases  of  severe  damage  to  the  nerve  there  is  anaesthesia  on  the  outer  half  of 
the  front  of  the  leg,  and  on  the  greater  part  of  the  back  of  the  foot.  The 
external  popliteal  nerve  is  very  superficial  in  its  course,  and  passes  over  the 
fibula.  It  is  consequently  exposed  to  all  kinds  of  injury  from  wounds,  from 
fracture  of  the  fibula,  from  pressure,  etc.  It  is  also  sometimes  the  seat  of 
primary  neuritis. 

Paralyxis  of  the  Internal  Popliteal  Nerve,  causes  loss  of  power  in  the  pos- 
terior tibial  group  of  muscles  (including  the  tibialis  posticus  and  popliteus) 
and  the  long  flexors  of  the  toes,  and  in  the  muscles  of  the  sole  of  the  foot. 


854  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Extension  of  the  ankle-joint  is  impossible,  and  if  the  branch  to  the  popliteus 
is  involved  there  is  loss  of  inward  rotation  of  the  leg  when  it  is  flexed.  When 
the  damage  to  the  nerve  is  sufficiently  severe  to  cause  ansesthesia  there  is  loss 
of  sensation  over  the  outer  part  and  posterior  aspect  of  the  lower  part  of  the 
leg  and  on  the  sole  of  the  foot.  The  posterior  tibial  nerve  is  rarely  injured 
except  in  fractures  of  both  bones  of  the  leg. 

The  branches  of  the  internal  popliteal  nerve,  the  external  and  internal 
plantar  nerves,  are  rarely  involved  alone. 

Paralysis  of  the  External  Plantar  Nerve  causes  loss  of  power  in  the  muscles 
of  the  little  toe,  the  flexor  accessorius,  the  interossei,  the  two  outer  lumbri- 
cales,  and  the  adductor  of  the  big  toe.  Certain  of  these  muscles  (lumbri- 
cales  and  interossei,  abductor  and  flexor  minimi  digiti)  flex  the  first  pha- 
langes, and  extend  the  second  and  third,  an  action  of  much  importance  in 
walking  in  the  propulsion  of  the  body  forward  just  before  the  foot  leaves  the 
ground.  The  loss  of  this  action  is  a  hindrance  in  walking,  as  is  the  later 
contracture  of  the  opponents  of  the  interossei,  which  leads  to  flexion  of  the 
second  and  third  phalanges.  The  sensory  loss  in  cases  of  external  jilantar 
paralysis  includes  the  skin  of  the  outer  half  of  the  sole  of  the  foot  and  of  the 
little  toe,  and  that  of  the  adjacent  half  of  the  fourth  toe. 

Paralysis  of  the  Internal  Plantar  Nerve  causes  loss  of  power  in  the  short 
flexor  of  the  toes,  the  intrinsic  muscles  of  the  big  toe  (with  the  exception  of 
the  adductor),  and  of  the  inner  lumbricales.  It  gives  rise  also  to  anaesthesia 
on  the  inner  part  of  the  sole  of  the  foot  and  the  plantar  surface  of  the  three 
inner  toes  and  the  adjacent  half  of  the  fourth  toe. 

Paralysis  of  the  Small  Sciatic  Nerve  causes  paralysis  of  the  gluteus  maxi- 
mus,  with  consequent  interference  with  the  power  of  rising  from  a  seat  and 
loss  of  sensibility  in  an  area  of  variable  size  on  the  posterior  surface  of  the 
thigh.  The  small  sciatic  nerve  is  damaged  only  in  disease  of  the  sacral  plexus 
and  is  seldom  the  only  nerve  involved. 

Neuralgias  Involving  Branches  of  the  Lumbar  and  Sacral 
Plexuses.  The  term  lumbo-abdominal  neuralgia  has  been  applied  to  the 
neuralgic  pains  that  aflTect  the  lower  half  of  the  trunk.  The  condition  is 
analogous  to  intercostal  neuralgia.  The  chief  painful  points  are  (1)  an  iliac 
point  near  the  middle  of  the  iliac  crest,  and  (2)  a  hypogastric  point  at  the 
lower  part  of  the  rectus.  Sometimes  in  the  male  there  is  a  scrotal  point  and 
in  the  female  a  labial  point.  The  pain  may  be  mistaken  for  a  girdle  pain 
when  the  affection  is  bilateral,  but  in  the  neuralgic  affection  the  pain  is 
changeable.  Xeuralgic  pain  in  the  side  of  the  head  of  the  penis  is  not  very 
uncommon  in  neurasthenics,  who  excrete  a  large  excess  of  uric  acid.  Such 
pain  is  also  thought  to  result  from  masturbation.  In  women  lumbo-abdomi- 
nal neuralgia  is  sometimes  due  to  pelvic  disease,  habitual  constipation,  or 
straining  at  stool.  It  is  much  rarer  than  myalgic  affections  of  the  same 
region. 

Crural  Neuralgia,  in  which  the  j)ain  involves  the  anterior  aspect  of  the 
thigh,  is  a  rare  form.  It  is  usually  secondary  to  sciatic  neuritis  or  to  a  lesion 
of  the  lumbar  plexus. 

In  Plantar  Neuralgia  the  pain  is  limited  to  the  plantar  region.  It  is  usu- 
ally associated  with  parsesthesi^e  of  the  same  region,  and  appears  to  be  due 
in  some  cases  to  slight  neuritis.  The  pain  of  flat-foot  must  be  borne  in  mind 
in  this  connection. 

Metatarsal  Neuralgia,  or  Morton's  Affection  of  the  Foot,  is  a  not  very  un- 
common disease  of  the  foot  which  has  usually  been  classed  among  the  ill- 
defined  hysterical  or  nervous  disorders  or  among  the  manifestations  of  gout. 
The  pain  is  located  at  the  base  of  the  fourth  toe  and  may  extend  up  the  leg. 
It  may  be  dull,  throbbing,  or  lancinating.  Usually  it  is  spasmodic.  Some- 
times the  severity  of  the  j^ain  interferes  with  walking  for  a  few  minutes. 


DISEASES  OF  THE  SPINAL  NERVES  AND  THEIR  PLEXUSES.     855 

The  pain  is  usually  not  severe  at  night.  It  is  increased  by  pressure  over 
the  head  of  the  metatarsal  bone.  The  trouble  is  often  brought  on  by  ill- 
fitting  shoes.  It  occurs  especially  in  women  and  frequently  in  those  whose 
general  health  or  nervous  tone  is  somewhat  impaired.  The  pain  seems  to  be  due 
to  a  neuritis  of  phalangeal  branches  from  compression  by  the  head  of  the  fifth 
metatarsal  bone.  Pain  of  similar  origin  may  occur  at  the  base  of  the  second 
toe.  In  cases  of  moderate  severity  and  subacute  course  the  pain  may  be  re- 
lieved by  avoiding  all  lateral  pressure  upon  the  toes.  A  specially  con- 
structed shoe  with  a  broad  sole  must  be  worn  and  walking  may  be  restricted 
for  a  time.  In  very  severe  intractable  cases  the  excision  of  the  head  of  the 
fourth  metatarsal  bone  is  necessary. 

Prognosis  and  Treatment  of  Paralyses  of  the  Spinal  Nerves.  It  is  conve- 
nient for  reference  to  group  together  the  chief  practical  facts  relating  to  the 
prognosis  and  treatment  of  paralyses  of  the  spinal  nerves.  In  what  follows 
the  term  paralysis  is  used  to  include  disturbance  or  loss  of  the  sensory  as  well 
as  the  motor  functions  of  nerves. 

Many  elements  enter  into  the  prognosis  of  lesions  of  the  spinal  nerves,  the 
degree  of  damage  to  the  nerve-elements,  the  character  of  this  damage,  the 
presence  or  absence  of  infection,  the  age  of  the  j^atient,  the  general  health, 
and  the  duration  of  the  paralysis.  Where  the  paralysis  is  due  to  pressure 
which  has  been  gradually  exerted,  as  by  an  exostosis,  or  tumor,  or  cicatrix, 
or  aneurism,  the  outlook  depends  on  the  ability  to  remove  this  cause  of 
pressure.  There  is  a  fair  prospect  of  improvement  in  function  even  where 
pressure  sufficient  to  cause  paralysis  has  lasted  a  year,  if  the  pressure  can  be 
removed.  In  the  paralysis  that  results  from  neuritis,  the  intensity  and  acute- 
ness  of  the  symptoms  and  the  degree  of  degeneration  as  shown  by  the  elec- 
trical changes  are  the  chief  guides  to  prognosis.  If  there  is  complete  loss  of 
power  and  entire  loss  of  faradic  irritability  in  the  muscles  at  the  end  of  two 
or  three  Aveeks,  there  will  probably  be  little  recovery  of  power  for  several 
months,  and  many  months  will  certainly  elapse  before  power  begins  to  re- 
turn if  complete  degeneration  (as  shown  by  the  presence  of  complete  R.D.) 
has  occurred,  however  slowly.  Whatever  the  origin  of  the  neuritis  that 
causes  the  paralysis,  pain  is  apt  to  endure  after  the  return  of  power,  and  this 
is  especially  true  of  persons  in  the  second  half  of  life  or  feeble  vitality.  Neu- 
ritis of  infectious  origin  is  particularly  apt  to  cause  persistent  symptoms  ;  the 
outlook  is  worse  in  suppurative  neuritis.  In  traumatic  neuritis  the  prog- 
nosis is  probably  better,  as  a  rule,  than  in  other  forms  causing  the  same  de- 
gree of  change  in  electrical  irritability. 

In  cases  of  peripheral  paralysis  of  acute  development  (acute  neuritis,  com- 
pression, partial  section,  or  laceration)  no  opinion  as  to  the  outlook  can  be 
given  until  the  lapse  of  one  or  two  weeks  if  the  paralysis  be  complete  or  con- 
siderable in  degree.  If  the  muscles  have  lost  their  irritability  to  faradism 
by  the  end  of  a  week  or  ten  days,  considerable  atrophy  will  follow  and  there 
will  probably  be  little  recovery  in  power  until  six  or  eight  months  have 
passed.  If  complete  faradic  loss  occurs,  but  only  after  the  lapse  of  two  or 
three  weeks  or  a  month,  there  will  be  less  atrophy  and  earlier  recovery  of 
power,  but  there  will  be  paralysis  for  several  months.  Where  there  is  merely 
a  moderate  diminution  of  faradic  irritability  or  no  loss  whatever,  recovery  of 
power  will  begin  in  the  course  of  a  few  weeks  or  months.  The  possibility  of 
■■<ome  recovery  in  power  is  not  gone  until  there  is  complete  loss  of  irritability 
to  both  faradism  and  galvanism  in  the  muscles,  and  if  there  is  no  return  of 
faradic  irritability  in  the  muscles  at  the  end  of  a  year,  and  their  atrophy 
has  been  rapid  and  great,  only  slight  improvement,  at  best,  will  occur.  Some 
return  of  faradic  irritability  in  the  paralyzed  muscles  is  usually  to  be  looked 
for  before  recovery  of  power,  but  at  times  there  is  some  motor  recovery,  while 
faradism  is  still  incapable  (in  ordinary  strength)  of  exciting  contraction. 


856  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Occasionally  the  return  of  faradic  irritability  is  not  followed  by  any  distinct 
improvement  in  motor  power.  Musculo-spiral  pressure-paralyses  are  fre- 
quently of  very  short  duration,  with  little  or  no  change  in  the  electrical  irri- 
tability of  the  paretic  muscles ;  recovery  sufficient  to  enable  a  laboring  man 
to  return  to  his  occupation  often  occurs  in  ten  days  or  two  weeks.  A  slug- 
gish, labored  contraction  of  the  muscles  to  faradism  or  galvanism  is  always  to 
be  regarded  as  evidence  of  some  degeneration  in  a  nerve,  but  it  must  be  re- 
membered that  in  muscles  (like  the  gluteus  maximus)  with  coarse  fibres  there 
may  normally  be  some  sluggishness.  When  a  nerve  has  been  divided,  with 
or  without  loss  of  substance,  the  prognosis  depends  largely  upon  the  use  of 
appropriate  surgical  treatment,  although  there  are  exceptional  cases  in  which 
the  nerve-ends  have  reunited  spontaneously  with  recovery  of  function.  The 
primary  nerve-sutures  should  be  employed  whenever  a  nerve  is  completely  or 
partially  severed.  By  this  means  the  conditions  are  rendered  favorable  for 
the  rapid  regeneration  of  the  nerve-fibres.  Union  of  the  divided  ends  by 
first  intention  rarely  occurs,  but  union  in  the  course  of  a  few  days  may  be 
expected.  A  restoration  of  function  occurs  in  a  large  majority  of  cases. 
Motion  usually  returns  in  cases  of  simple  section,  in  the  course  of  three  or 
four  months.  Sensibility  often  returns  much  earlier,  and  may  indeed  be  re- 
established in  the  course  of  a  few  days,  but  this  is  exceptional  and  sometimes 
temporary.  Slight  permanent  defects  in  sensibility  are  not  rare  and  there 
may  be  some  stiffness  of  movement.  The  return  of  touch,  pain,  and  tem- 
perature sense  makes  a  return  of  motor  power  very  probable.  In  some  cases 
the  return  of  motion  is  very  slow,  but  improvement  may  occur  up  to  three  or 
four  years.  The  loss  of  a  small  amount  of  nerve-substance  (say  1  c.cm.) 
makes  little  difference  in  the  prognosis.  The  success  of  primary  suture  is 
considerably  influenced  by  the  age  factor,  the  chances  of  recovery  of  iunc- 
tion  being  far  better  in  the  young  (especially  children)  than  in  those  over 
fifty.  Warm  weather  is  also  distinctly  more  favorable  than  cold.  There 
seems  to  be  a  difference  in  the  inherent  powers  of  different  nerves  to  func- 
tionate anew.  Recovery  is  most  rapid  in  the  musculo-spiral,  rapid,  but  less 
so,  in  the  median,  and  comparatively  slow  in  the  ulnar,  in  which  motion 
probably  never  returns  before  sensation  (Bowlby).  If  primary  suture  fails, 
the  nerve  should  be  re-examined,  freed  from  scars,  and  stretched.  The  sec- 
ondary suture  gives  less  satisfactory  results  than  the  primary  suture,  but  its 
results  are  nevertheless  surprisingly  good.  If  a  secondary  suture  is  done 
after  the  lapse  of  two  years,  the  best  that  can  be  hoped  for  is  a  partial  restora- 
tion of  function,  but  where  the  operation  is  done  in  the  course  of  a  year  re- 
covery is  often  complete  and  a  considei'able  restoration  of  function  can 
generally  be  counted  upon.  Motion  may  return  at  any  time  from  six 
months  to  two  years.  Greatly  atrophied  muscles  may  regain  their  original 
bulk  in  the  course  of  time.  Sensation  may  return  much  earlier,  but  such 
early  recovery  may  be  temporary.  The  prognosis  is  rendered  considerably 
Avorse  in  all  cases  of  nerve-suture  where  the  nerve  wound  has  been  infected. 
In  all  cases  of  motor  paralysis  from  nerve  injury  of  any  kind  electricity 
should  be  employed.  The  affected  muscles  should  be  stroked  for  at  least 
five  minutes  three  times  weekly  with  the  negative  electrode  of  a  galvanic 
battery,  the  weakest  current  being  used  that  will  produce  a  fair  contraction. 
There  is  no  doubt  that  the  proper  use  of  galvanism  hastens  recovery  from 
many  cases  of  pressure-paralysis,  and  it  is  likely  that  it  exerts  a  favorable  in- 
fluence in  the  recovery  of  paralysis  of  other  origin.  Massage  is  of  much 
value  in  preventing  the  occurrence  of  contractures  and  in  reducing  those 
that  have  arisen.  The  immersion  of  the  paralyzed  muscles  twice  daily  in 
warm  water  for  ten  or  fifteen  minutes  also  aids  in  preventing  contractures. 
Careful  attention  to  the  general  health  probably  influences,  in  some  degree, 
the  favorable  progress  of  all  forms  of  peripheral  paralysis. 


CHAPTER    XXIX. 

DISEASES  OF  THE  MUSCLES. 
By  GEOKGE  W.  JACOBY,  M.D. 

SUBACUTE   PROGRESSIVE   POLYMYOSITIS. 

In  marked  contrast  to  the  attention  and  study  which  have  been  bestowed 
npon  the  chronic  forms  of  the  affections  localized  primarily  in  the  muscles, 
stands  the  neglect  with  which  the  acute  and  subacute  disorders,  particularly 
the  inflammatory  ones,  have  been  treated.  A  priori,  it  should  be  supposed 
that  inflammation  of  muscles  (myositis)  would  occur  as  easily  and  as  fre- 
quently as  inflammation  in  other  tissues,  but  as  a  matter  fact  the  occurrence 
of  such  muscular  inflammation  was  universally  believed  to  be  impossible, 
until  Virchow  proved  the  untenability  of  such  an  opinion. 

Even  to-day  many  observers  do  not  admit  the  existence  of  a  primary 
myositis.  This  is  no  doubt  due  to  the  rarity  of  its  occurrence,  so  that  while 
inflammation  of  muscles  due  to  operative  measures,  to  traumatisms  of  varied 
nature,  or  to  propagation  of  the  inflammatory  process  from  neighboring  parts 
is  frequently  encountered,  a  purely  primary  myositis  is  not  often  observed. 
Slight  forms  are  apt  to  be  overlooked  and  the  severe  forms  are  actually  of 
so  infrequent  occurrence  that  when  they  are  encountered  a  disagreement  of 
opinion  concerning  the  diagnosis  and  character  of  the  affection  is  not  sur- 
prising. 

Primary  acute  or  subacute  polymyositis  is  a  disease  so  rarely  observed, 
that  altogether,  including  several  doubtful  ones,  only  21  cases  have  thus  far 
been  described.  These  cases  all  show  the  existence  of  an  acute  inflammation, 
rapidly  and  successfully  affecting  nearly  all  of  the  voluntary  muscles,  char- 
acterized chiefly  by  pain  and  swelling,  and  ending  in  death  in  more  or  less 
short  period  of  time,  or  exceptionally  in  recovery  after  a  prolonged  period 
of  illness. 

As  representative  of  a  typical  myositis  we  may  take  the  inflammation 
occurring  in  the  course  of  trichinosis,  and  although  this  myositis  is  a  secondary 
one,  due  to  the  inflammatory  reaction  produced  by  the  trichina,  it  cannot 
be  a  question  of  doubt  that  many  other  noxious  influences  may  produce  such 
results,  and  that  clinically  they  can  be  differentiated  from  one  another  only 
with  difficulty.  Hence,  every  primary  polymyositis,  due  to  whatsoever 
cause,  will  necessarily  present  clinical  symptoms  closely  analogous  to  those 
encountered  in  trichinosis. 

Of  the  etiology  of  primary  polymyositis  we  know  very  little.  Age  and 
sex  seem  to  be  unimportant  factors  in  the  production  of  the  disease,  although 
of  the  published  cases  two-thirds  occurred  in  males.  The  affection  may  occur 
at  all  ages.  No  cases  have  been  observed  in  childhood  ;  the  youngest  patient 
afflicted  was  seventeen  years,  and  the  oldest  seventy  years  of  age.  Of  the 
cases  here  refei'red  to,  2  occurred  in  patients  under  20,  5  in  the  second 


858  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

decade  of  life,  4  in  the  third,  2  in  the  fou^rth,  3  in  the  fifth,  3  in  the  sixth, 
and  in  2  cases  the  age  is  not  given. 

Occupation,  or  the  influence  of  cold  and  muscular  over-exertion  do  not 
seem  to  be  etiologically  important.  Even  of  those  influences  which  are 
active  in  the  production  of  multiple  neuritis,  with  which  this  disease  may  be 
combined,  particularly  alcohol,  the  same  may  be  said.  Striimpell  has  paid 
particular  attention  to  the  possible  influence  of  tuberculosis  as  a  causal  fac- 
tor without  arriving  at  any  definite  results.  In  three  autopsies  a  tubercular 
process  of  one  pulmonary  apex  was  found,  but  it  is  probable  that  this  was  acci- 
dental and  not  causative. 

Symptomatology  and  Course.  The  onset  of  the  disease  is  usually  a  gradual 
one,  charactei'ized  by  general  disorder.  Occasionally  the  trouble  begins 
acutely  without  any  prodromal  symptoms.  These  symptoms  when  they  are 
present  consist  in  a  feeling  of  malaise  and  fatigue ;  the  appetite  is  disordered, 
and  dizziness  and  headache  are  complained  of.  Gastric  symptoms,  nausea 
and  vomiting,  have  been  noted  in  a  few  cases,  but  in  no  case  was  the  advent 
of  the  disease  heralded  by  a  chill  and  sudden  rise  in  temperature  as  is  the 
case  in  acute  infections. 

Together  with  these  general  symptoms  or  within  a  few  days,  the  local 
symptoms  which  characterize  the  disease  make  their  appearance.  These  at 
first  are  purely  subjective,  and  consist  in  pains  in  the  extremities,  back,  and 
loins.  These  pains  as  they  increase  in  severity  are  accompanied  by  com- 
plaints of  tension  and  cramps  in  the  muscles.  Objective  symptoms  soon 
manifest  themselves,  and  locomotion  becomes  more  and  more  difiicult ;  finally 
the  patient  is  obliged  to  take  to  bed  where  a  condition  of  utter  helplessness 
speedily  supervenes. 

The  muscles  become  afiected  in  a  certain  sequence,  those  of  the  extremities 
being  first  involved  and  at  a  later  period  those  of  the  trunk.  Mobility  is 
impeded  in  accordance  with  the  distribution  of  the  muscular  affection.  Of 
the  extremities,  the  more  distal  parts  retain  their  mobility  longer  than  the 
pi'oximal  ones.  After  the  trunk  muscles  the  abdominal  muscles  and  those 
of  the  neck  become  implicated. 

About  this  time  the  intercostals  are  attacked,  with  the  effect  of  rendering  res- 
piration markedly  diaphragmatic  ;  finally  the  muscles  of  deglutition  become 
involved  and  death  is  generally  due  to  combined  disease  of  these  and  the  re- 
spiratory muscles.  In  the  terminal  stage  of  severe  cases  the  muscles  of  the 
head  and  even  those  of  the  tongue  and  pharynx  are  affected.  Sj^eech  thus 
becomes  indistinct  and  there  is  difficulty  in  protruding  the  tongue  or  even  in 
raising  it. 

The  subjective  symptoms  in  a  developed  case,  therefore,  are  chiefly  pain 
and  disorder  of  voluntary  motion,  but  an  examination  at  once  demonstrates 
the  presence  of  other  symptoms.  Most  marked  and  at  once  noticed  is  the 
painfulness  of  the  affected  muscles  to  pressure  or  to  manipulations  of  any 
kind. 

Inspection  shows  that  the  limbs  have  lost  their  marked  contours,  so  that 
they  seem  to  consist  of  a  single  mass,  the  boundaries  of  the  individual  mus- 
cles being  obliterated.  These  also  are  swollen  and  increased  in  size,  but  this 
swelling  is  lost  amid  the  general  oedematous  infiltration  of  the  skin  and  other 
soft  tissues.  To  palpation  the  muscles  show  a  different  consistency  in  diflfer- 
ent  parts  and  at  different  times,  being  hard  and  distended,  soft  and  doughy, 
and  even  simulating  fluctuation.  This  oedematous  swelling  of  the  skin,  Avhich 
does  not  pit  upon  pressure,  and  is  certainly  also  of  an  inflammatory  nature, 
seems  to  follow  the  affected  niuscles  as  to  time  and  place  of  its  appearance, 
there  always  being  more  oedema  over  those  parts  in  which  the  muscles  are 
most  aifected.     Thus  also  the  skin  of  the  proximal  parts  of  the  extremities 


DISEASES  OF  THE  MUSCLES.  850 

shows  more  oedema  than  that  of  the  distal  parts,  and  the  hands  and  feet  are 
usually  free.  The  face,  while  it  may  show  slight  oedema  generally,  is  not  thus 
affected.  Later,  an  approximation  of  the  attachment-ends  of  the  muscles 
takes  place,  so  that  the  tendons  stand  out  hard  and  unyielding,  and  persis- 
tent flexion  of  the  leg  upon  the  thigh  and  of  the  forearm  upon  the  upper 
arm  may  result.  In  many  cases  atrojjhy  of  certain  muscles  sets  in  during 
the  progress  of  the  case.  Thus  the  vasti,  the  deltoids,  the  trapezii,  and  the 
small  muscles  of  the  hand  were  markedly  atrophied  in  a  case  described  by  me. 

The  oedematous  skin,  wherever  it  is  seen,  at  some  stage  of  the  disease 
shows  a  marked  and  peculiar  redness  which  seems  to  be  characteristic  of 
polymyositis.  The  nearest  approach  to  a  description  of  this  redness  is  to 
say  that  it  resembles  that  seen  in  erysipelas,  so  that  on  account  of  the 
accompanying  oedema  it  may  easily  be  mistaken  for  this  disease.  Sometimes 
the  redness  is  more  erythematous  in  nature,  and  it  is  probable  that  in  some 
cases  the  skin  affection  is  still  different  from  that  just  described,  for  it  has 
been  spoken  of  as  "spotted  redness,"  roseola-like  eruption,  urticaria-like,  etc. 

In  addition  to  this  eruption,  subcutaneous  caj^illary  hemorrhages  along  the 
borders  of  the  disordered  territories  are  of  not  unusual  occurrence. 

It  has  been  claimed  that  the  affection  may  take  an  abortive  course,  simu- 
lating purpura.  It  seems  to  me  to  be  doubtful  whether  such  is  ever  the  fact, 
and  I  am  not  j)repared  to  accept  the  case  upon  which  this  statement  was 
based  as  a  genuine  one.  A  tendency  to  profuse  perspiration  is  also  notice- 
able, and  is  to  a  certain  extent  characteristic,  if  not  of  polymyositis,  at  any 
rate  of  a  severe  acute  affection  of  the  muscles. 

Nervous  symptoms  of  a  marked  kind,  such  as  we  would  expect  to  find 
on  account  of  the  clinical  relationship  between  polymyositis  and  polyneui'itis, 
are  not  present. 

In  consequence  of  the  great  tenderness  of  the  muscles,  it  is  difficult  to  de- 
cide whether  the  nerves  are  painful  to  pressure  or  not.  I  have  paid  particu- 
lar attention  to  this  point,  and  am  sure  that  the  nerve-trunks  are  not  any 
more  sensitive  than  is  normally  the  case.  Disordere  of  sensation  of  any  de- 
cided character  are  not  j^resent  in  the  pure  uncomplicated  cases.  Mechanical 
excitability  of  the  affected  muscles  is  certainly  not  increased,  perhaps  even 
diminished.     Fibrillary  twitchings  do  not  occur. 

The  superficial  reflexes  are  all  present.  The  condition  of  the  deep  reflexes 
will  depend  upon  the  greater  or  less  affection  of  the  muscles,  so  that  the  tendon 
reflexes,  which  in  the  beginning  of  the  disease  are  normal,  will  disappear  as 
the  disorder  progresses.  Hence,  in  one  and  the  same  case  we  may  at  differ- 
ent stages  of  the  disease  find  the  tendon  reflexes  normal,  diminished,  or  ab- 
sent.    There  is  no  valid  reason  why  they  should  ever  be  increased. 

On  account  of  the  pain  produced  by  all  manipulations  it  is  difficult  to 
make  a  careful  electrical  examination,  but  it  is  fairly  certain  that  the  elec- 
trical reactions  correspond  to  what  we  would  a  priori  assume  to  be  the 
case,  which  is  that  the  muscles  gradually  show  diminution  and  finally  aboli- 
tion of  electrical  excitability.  It  is  probable  that  in  the  early  stages  of  the 
disease  qualitative  changes  will  also  be  found. 

Brain  symptoms  are  not  present,  and  consciousness  is  retained  throughout. 
The  headache,  dizziness,  and  insomnia  which  are  present  are  due  to  the  same 
causes  which  produce  such  symptoms  in  other  acute  febrile  diseases.  Of  the 
other  organs  the  spleen  is  markedly  implicated,  and  in  cases  taking  an  acute 
course  it  will  be  found  distinctly  swollen. 

As  pure  complications,  but  having  great  import  upon  the  course  of  the 
disease,  we  must  regard  the  bronchitis  and  pneumonia,  which  frequently 
supervene.  The  paralysis  of  the  soft  palate  and  pharyngeal  muscles  makes 
it  easy  for  mucus  and  particles  of  food  to  be  aspirated  into  the  larynx  and 


860 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


bronchioles.  Thus  we  find  that  bronchitis  and  broncho-pneumonia  consti- 
tute the  direct  cause  of  death  in  the  majority  of  cases.  The  temperature,  as 
well  as  the  pulse,  is  increased  in  all  instances,  independently  of  any  compli- 
cation. The  course  of  the  disease  varies  greatly,  and  in  considering  this  we 
must  be  careful  to  separate  the  acute  from  the  chronic  cases,  and  those  which 
end  fatally  from  the  lighter  cases,  which  may  end  in  recover)^. 

The  duration  in  the  fatal  cases  has  averaged  from  six  weeks  to  three 
months.  The  longest  period  after  which  death  has  occurred  has  been  six- 
teen months.  Of  the  cases  which  ended  in  recovery,  one  lasted  only  seven 
days  and  one  for  two  and  a  quarter  years.  In  the  subacute  and  more 
chronic  cases  the  course  is  not  one  of  constant  progress,  but  remissions  occur 
which  are  apt  to  deceive  the  observer  as  to  the  fiirther  progress  of  the  disease. 
.  Pathology  and  Morbid  Anatomy.  Upon  post-mortem  examination  the  dis- 
eased muscles  seem  swollen  in  toto,  and  show  a  distinctly  spotted  appear- 
ance, pale  gray  spots  alternating  with  dark  red  places.  The  muscle  is  often 
very  friable  and  easily  torn. 

Microscopical  examination  shows  that  marked  changes  have  taken  place 
in  the  muscular  fibres  and  also  in  the  interstitial  connective  tissue.  These 
changes  are  the  anatomical  expression  of  destruction  of  the  fibres.  The 
changes  in  the  interstitial  connective  tissue  are  marked,  and  plainly  show  the 
acute  inflammatory  nature  of  the  process. 

The  perimysium  is  augmented,  has  become  myxomatous  or  fibrous  in 
structure,  contains  fat  globules,  and  in  single  parts  shoAvs  waxy  degeneration. 

Fig.  279. 


M. 


F.F. 


M.  W. 


P.E. 


P.  E, 


N. 


M. 


N. 


Transverse  section.  X  200.  M.  M.  Muscle  fibres  of  average  size  in  partly  transverse,  partly  slightly 
oblique  sections.  P.  E.  P.  E.  Perimysium  externum,  with  numerous  capillaries.  N.  N.  Nuclei, 
some  in  centre,  some  at  periphery  of  muscle.  W.  Muscle  fibre  in  waxy  degeneration,  holding  three 
protoplasmic  bodies.  M.  W.  Cluster  of  medullary  corpuscles  in  waxy  degeneration.  F.  F.  Muscle 
fibre  in  waxy,  possibly  combined  with  fatty  degeneration. 


Not  all  the  muscle  fibres  of  a  single  bundle,  but  only  a  limited  number, 
are  afiected.    These  affected  fibres  are  either  transformed  into  an  apparently 


DISEASES  OF  THE  MUSCLES. 


861 


homogeneous  or  into  a  waxy  mass.  Partly  homogeneous  and  partly  waxy 
fibres  are  not  uncommon.  The  nuclei  are  markedly  increased  in  number, 
not  only  at  the  periphery,  but  are  also  found  scattered  throughout  the  body 
of  the  muscle ;  indeed,  there  may  be  so  great  an  increase  of  nuclei  that  the 
fibres  assume  the  asjDCct  of  a  so-called  giant  cell,  the  regular  arrangement  of 
the  sarcous  elements  being  lost  and  the  granulations  having  become  irregu- 
lar. In  this  case  the  sarcolemma  sheath  is  still  present,  and  the  boundary 
of  each  muscle  fibre  is  clearly  defined ;  in  other  parts  can  be  seen  how  the 
muscle  fibre  breaks  up  into  a  number  of  indifferent  corj)uscles,  losing  its  dis- 
tinct boundary  and  blending  with  the  perimysium,  so  that  no  line  of  demar- 
cation can  be  drawn  between  the  two.  We  can  clearly  see  how  the  original 
muscle  tissue  loses  its  specific  structure  and  becomes  transformed  into  con- 
nective tissue.  The  muscle  fibre  is  not  from  the  start  affected  in  its  entirety 
by  the  myositic  ^Drocess,  but  the  various  parts  are  attacked  progressively. 
This  is  shown  by  the  presence  of  muscular  fibres,  which  in  part  are  un- 
changed, but  in  part  are  transformed  into  a  coarsely  granular  mass,  the  sar- 
colemma still  being  present.  All  in  all,  then,  we  clearly  have  a  hyperplastic 
perimyositis,  together  with  a  parenchymatous  myositis. 

The  terminations  of  this  myositic  process  are  either,  as  already  indicated, 
transformation  of  the  contractile  matter  into  connective  tissue  or  fatty  and 


F  4 


p.  I 


F.2. 


F.  1. 


Transverse  section.  X  800.  F.  1,  Muscle  tibre,  with  central  nuclei.  F.  2.  Muscle  fibre,  with  aug- 
mented peripheral  nuclei,  showing  indication  of  breaking  up  into  muscle  plates.  F.  3.  Muscle  fibre, 
holding  five  central  nuclei,  each  one  corresponding  to  a  muscle  plate,  the  whole  resembling  a  mye- 
loplax;  the  sarcous  elements  enlarged  and  crowded.  F.  4.  Muscle  fibre  transformed  to  a  great 
extent  into  partly  nucleated,  partly  non-nucleated  protoplasm.  P.  I.  Perimysium  internum  almost 
unchanged. 


waxy  degeneration.  The  latter  termination  is  undoubtedly  the  most  com- 
mon. All  the  changes  which  the  muscles  undergo  may  be  clearly  followed 
upon  the  accompanying  cuts. 

The  nerve  fibres  in  all  specimens  which  I  have  examined  were  also  the 
.seat  of  an  inffammatory  process,  but  the  large  number  of  normal  fibres  pres- 


862 


NEBVOUS  DISEASES  AND  THEIR  TREATMENT. 


ent  convinces  me  that  the  process  in  the  nerves  is  entirely  secondary  to  that 
in  the  muscles.  Brain,  spinal  cord,  and  peripheral  nerve  trunks  are  normal. 
Microscopically,  also,  it  has  been  noted  that  even  those  muscles  appear  dis- 
eased which,  macroscopically,  seem  to  be  normal,  thus  corroborating  the 
clinical  symptoms  which  point  to  an  involvement  of  the  entire  muscular 
system. 

"  As  regards  the  pathogeny  of  the  disease  we  know  very  little ;  still  it  seems 
probable  that  the  trouble  is  an  infectious  one,  and  that,  as  Striimpell  has 


Fig.  281. 


R.  N. 


P.  I. 


F. 


W.  M. 


F.P. 


P.E. 


V. 


Longitudinal  section.  >(  200.  P.  E.  Perimysium  externum,  considerably  augmented,  composed  of 
coarse  bundles  of  fibrous  connective  tissue.  V.  Vein,  engerged  with  blood.  F.  P.  Fat  globules  in 
external  perimysium.  P.  I.  Perimysium  internum,  slightly  augmented.  R.  N.  Rows  of  nuclei.  F. 
Row  of  fat  globules  (?)  in  centre  of  muscle  fibre.  TI'.  M.  Clusters  of  medullary  corpuscles  in  waxy 
degeneration.  In  the  vicinity  of  this  cluster  the  gradual  transformation  of  the  muscle  tissue 
jnto  inflammatory  corpuscles  and  the  consequent  destruction  of  the  muscle  tissue  is  marked.  W. 
Peripheral  portion  of  the  muscle  fibre  in  marked  waxy  degeneration. 


suggested,  the  action  of  this  infection  is  not  specifically  local  (muscular),  but 
that  by  its  agency  poisons  have  been  introduced  into  the  circulation  and 
thus  brought  into  contact  with  all  the  tissues,  of  which  in  this  case  the  mus- 
cular ones  are  alone  susceptible  to  its  noxious  influence.  Whether  these 
cases  bear  any  relationship  to  the  chronic  forms  of  primary  progressive  mus- 
cular atrophy  is  a  question  which  cannot  yet  be  answered.  It  seems  to  me 
quite  possible  that  some  cases  of  primary  dystrophy  may  be  the  outcome  of 
light  cases  of  polymyositis.  If  this  is  so,  then  we  would  not  be  wrong  in 
looking  upon  these  cases  as  closely  allied,  pathogenetically,  to  cases  of  pri- 
mary muscular  atrophy. 

Diagnosis.  The  diagnosis,  bearing  in  mind  the  marked  clinical  symptoms, 
should  not  be  a  difficult  one. '  The  main  difficulties  will  arise  in  making  a 
differential  diagnosis  between  polymyositis  and  trichinosis,  but  the  marked 
gastric  and  intestinal  troubles,  the  earlv  occurrence  of  facial  cedema  and  of 


DISEASES  OF  THE  MUSCLES. 


863 


pains  in  the  region  of  the  ocular  and  laryngeal  muscles,  as  well  as  the  impli- 
cation of  the  muscles  of  mastication,  should  direct  our  attention  to  trichinosis 
rather  than  to  polymyositis.  The  exposure  to  trichinosis  invasion  is,  of 
course,  most  important. 


C.I. 


..t 


Fig.  282, 


"\    '1 


?^  i^ 


w. 


W.  M. 


1  -- 


Longitudinal  section.  X  800.  P.E.  Perimysium  externum,  broadened,  composed  of  coarse  bundles 
of  fibrous  connective  tissue  freely  vascularized.  P.  I.  Perimysium  internum,  transformed  into 
inflammatory  or  medullary  corpuscles.  J.  /.  Groups  of  inflammatory  corpuscles,  obviously  arisen 
from  previous  contractile  tissue.  N.  Nucleated  inflammatory  corpuscles  imbedded  in  muscle  tissue. 
C.  J.  Clusters  of  inflammatory  corpuscles  in  bay-like  excavations  of  the  contractile  tissue,  in  part 
spindle-shaped,  in  transition  to  fibrous  connective  tissue ;  the  medullary  tissue  traversed  by  a 
large,  probably  newly -formed  capillary  bloodvessel. 

Against  a  multiple  neuritis  and  in  favor  of  myositis  we  must  regard  the 
localization  of  pain  to  the  muscles  themselves,  the  occurrence  of  marked 
oedema,  and  the  implication  of  the  skin  in  the  inflammatory  process,  together 
with  the  absence  of  extended  disturbances  of  sensation. 

It  must  not  be  forgotten  that  in  some  cases  an  association  of  the  two  affec- 
tions may  occur. 

Prognosis.  The  prognosis  of  the  affection  is  a  very  dubious  one ;  of  the 
twenty-one  published  cases,  including  those  in  which  the  diagnosis  is  doul)t- 
ful,  only  nine  ended  in  recovery.  Recovery,  when  it  occurs,  takes  place 
gradually,  and  is  very  much  retarded.  In  only  one  of  the  non-fatal  cases 
were  the  muscles  of  deglutition  and  respiration  afiected,  while  in  nearly  all 
of  the  fatal  ones  this  was  the  case.  It  is  thus  clear  that  such  a  complication 
is  one  which  renders  the  prognosis  absolutely  bad. 

Treatment.  Treatment  of  all  kinds  does  not  appear  to  exercise  any  influ- 
ence upon  the  course  of  the  disease.  Medication  will,  therefore,  necessarily 
be  restricted  to  an  alleviation  of  symj^toms.  Salicylate  of  sodium,  colchicum, 
and  antipyrin  may  be  tried  early  in  the  disease  and  some  relief  from  pain 
and  general  malaise  obtained.  When  the  pains  are  most  severe  morphine 
seems  to  be  the  only  remedy  which  Avill  alleviate  the  sufferings  of  the  patient. 

Prolonged  hot  baths,  or  the  envelopment  of  the  limbs  in  hot  cloths,  are 


864  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

gratefully  received  by  tlie  patient,  up  to  such  a  time  when  every  movement 
is  avoided  on  account  of  the  pain  thereby  produced. 

All  mechanical  remedies,  as  massage  and  electricity,  are  absolutely  contra- 
indicated  while  symptoms  of  progression  are  present. 


THE  PROGRESSIVE  MUSCULAR  DYSTROPHIES. 

The  above  designation  has  been  given  to  progressive  muscular  atrophy  not 
due  to  disease  of  the  sjDinal  cord  or  peri^oheral  ners^es.  The  disease  is  located 
exclusively  in  the  muscles  themselves,  and  leads  to  marked  atrophy  and  corre- 
sponding impairment  of  function.  To  Erb  distinctly  belongs  the  credit  of 
creating  a  clear  division  between  the  spinal  and  myopathic  forms  of  progres- 
sive muscular  atrophy. 

The  clinical  distinctions  between  these  two  forms  are  mainly  that  in  the 
myojjathic  forms  young  jDersons,  often  children,  are  the  subjects,  and  that 
several  members  of  the  same  family  are  frequently  attacked,  while  in  the 
spinal  forms  the  reverse  is  the  case. 

It  seems  probable  that  the  affection  is  a  congenital  one,  that  is  to  say,  that 
it  is  due  to  the  subsequent  development  of  a  faulty  embryonal  disposition  of 
the  muscular  tissue. 

In  some  cases  this  faulty  disposition  shows  itself  by  a  gradual  disappear- 
ance of  the  muscular  fibres,  due  to  a  simple  defect  in  their  growth,  in  others 
there  is  in  addition  to  this  an  increase  of  connective  tissue  with  or  without 
the  formation  of  fat.  All  of  these  cases  show  loss  of  muscular  power  corre- 
sponding to  the  disappearance  of  the  muscle  fibres ;  but  objectively  the  cases 
will  vary  according  to  the  presence  or  absence  of  hyjDerplasic  connective  tissue 
and  according  to  the  localization  of  the  atrophy. 

Based  upon  such  differences,  a  number  of  so-called  types  have  been  de- 
scribed. While  it  is  certain  that  all  of  the  forms  actually  constitute  a  unity, 
it  is  well  for  convenience  of  description  to  retain  certain  characteristic  types. 
These  are : 

1.  Pseudo-muscular  hypertroj^hy. 

2.  Erb's  juvenile  type. 

3.  Landouzy-Dejerine  type. 

4.  The  peroneal  or  leg  type,  Avhich  has  been  classed  with  the  dystrophies, 
for  convenience'  sake,  but  is  probably  of  neurotic  origin.  | 

The  clinical  entity  of  the  various  forms  is  shown  by  a  more  or  less  com- 
plete correspondence  of  the  majority  of  prominent  characteristics,  by  the  fact 
that  transitional  forms  from  one  type  to  another  are  noted,  as  when  pseudo- 
hypertrophy is  found  in  other  forms  than  the  pseudo-hypertrophic  type,  or 
when  the  affection  takes  the  course  of  the  pseudo-hypertrophic  form  without 
hypertrophy  being  present,  and  by  the  fact  that  various  types  occur  in  dif- 
ferent children  of  one  and  the  same  family.  The  occurrence  of  indefinite 
cases  which  cannot  be  classed  in  any  of  the  knoAvn  forms  also  goes  far  to 
su23port  this  view. 

Pseudo-muscular  Hypertrophy  (atrophia  musculorum  lipomatosus). 
The  affection  in  this  class  of  cases  begins  in  childhood,  is  often  present  in 
several  members  of  the  same  family,  and  is  characterized  by  progressive  dis- 
order of  function  associated  with  an  increase  in  size  of  single  parts  of  the 
body,  due  to  an  interstitial  deposit  of  fat  which  obscures  the  existing  atrophy 
of  the  muscular  fibres. 

Symptoms.  The  disease  manifests  itself  gradually,  and  the  first  abnor- 
mality noted  by  the  parents  in  the  hitherto  apparently  healthy  child  is 


DISEASES  OF  THE  MUSCLES. 


865 


weakness  of  the  legs,  particularly  manifested  in  running,  jumping,  or  going 
upstairs.     The  child  stumbles  easily,  and  falls  frequently. 

Somewhat  later  an  enlargement  of  certain  muscles  is  observed,  that  is 
to  say,  the  muscles  appear  large  in  comparison  with  other  muscles  of  the 
part.  The  muscles  of  the  calf  are  usually  the  first  to  become  hypertrophied, 
the  extensors  of  the  knee  and  the  muscles  of  the  back  and  loins  are  also 
aflfected  early.     Of  the  muscles  of  the  upper  part  of  the  body,  the  infra- 


FlG.  283. 


Fig.  284. 


Typical  pseudo-muscular  hypertrophy. 


Pseudo-muscular  hypertrophy  in  brothers.  (Infirmary 
for  Nervous  Diseases,  Philadelphia.) 


spinati,  are  earliest  and  most  markedly  enlarged.  The  supra-spinatus  and 
the  deltoid  are  usually  increased  in  size,  but  the  serratus  rarely,  and  the  pec- 
toralis  never.     In  the  arm  the  triceps  and  biceps  may  be  either  enlarged  or 

55 


866  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

wasted,  but  the  muscles  of  the  forearm  and  the  small  muscles  of  the  hand 
are,  as  a  rule,  unaffected.  Together  with  this  enlargement  a  wasting  of  cer- 
tain groups  of  muscles  takes  places,  and,  after  a  time,  the  originally  hyper- 
trophied  muscles  also  become  atroj^hied. 

Weakness  of  the  muscles  goes  hand-in-hand  with  their  involvement,  but  it  is 
not  always  the  most  wasted  muscle  which  is  the  weakest.  In  the  legs  the  weak- 
est muscles  are  usually  the  flexors  and  extensors  of  the  hip,  and  the  extensors 
of  the  knee.  The  calf  muscles  generally  give  out  before  the  anterior  tibials. 
Corresponding  to  the  involvement  of  these  muscles  of  the  legs  there  is  limi- 
tation of  movements  which  leaves  its  impress  by  characteristic  symptoms. 
On  account  of  weakness  of  the  extensors  the  patients  have  great  difficulty 
in  going  upstairs,  so  that  they  make  use  of  the  guard-rail  to  pull  them- 
selves from  one  step  to  another.  The  gait  has  a  peculiar  waddling  char- 
acter, and  the  power  of  getting  up  unaided  from  the  floor  becomes  lost. 
The  manner  in  which  such  patients  arise  from  the  floor  is,  as  has  been  pointed 
out  by  Gowers,  very  characteristic.  The  child,  if  not  totally  unable  to  rise, 
does  so  by  supporting  himself  upon  all  fours,  stretching  out  his  legs,  and  then 
with  his  hands  climbing  up  his  own  thighs. 

Contractions  occur  late  in  the  affection  in  those  muscles  which,  through  weak- 
ness of  their  opponents,  habitually  overact.  In  this  way  is  produced  a  tahpes 
equinus  and  permanent  flexion  of  the  legs  upon  the  thighs,  the  thigh  upon 
the  hip,  and  of  the  forearms  upon  the  arms.  Curvature  of  the  spine,  antero- 
posteriorly  with  the  concavity  backward  (lordosis),  is  also  one  of  the  early 
symptoms  of  the  disease.  This  lordosis,  which  is  due  to  a  weakness  of  the 
extensors  of  the  hip,  may  be  so  marked  that  a  vertical  line  drawn  from  the 
scapula  falls  far  behind  the  sacrum.  Upon  sitting,  this  curvature  disap- 
pears and  is  often  replaced  by  a  curvature  with  the  concavity  forward. 
Lateral  curvature,  when  present,  is  due  to  weakness  of  the  spinal  muscles. 

The  electric  excitability  of  the  muscles  is  quantitatively  reduced  to  both 
currents  in  proportion  to  the  wasting  of  their  fibres.  Qualitative  changes 
are  not  present.  Fibrillary  twitchings  do  not  occur.  Sensation  is  unim- 
paired and  the  reflexes  remain  normal  until  such  a  time  when  the  reflex  arc 
is  interrupted  by  the  muscular  disease. 

The  central  nervous  system  is  not  involved. 

The  course  of  the  disease  is  a  chronic  one,  but  its  progress  and  duration 
vary  greatly.  Until  power  of  walking  becomes  lost  the  progress  of  the  dis- 
ease is  usually  slow,  but  after  that  an  increase  seems  to  take  place.  Death 
occurs  in  from  ten  to  twenty-five  years,  and  is  usually  due  to  some  complica- 
tion, the  respiratory  organs  becoming  affected  in  consequence  of  the  lessened 
action  of  the  respiratory  muscles. 

Erb's  Juvenile  or  Scapulo-Humeral  Form.  The  juvenile  form  of 
Erb  is  a  chronic  progressive  atrophy  and  weakness  of  numerous  voluntary 
muscles,  beginning  in  childhood  and  early  youth,  somewhat  later  than  in 
pseudo-hypertrophy,  and  frequently  occurring  as  a  family  disease.  It  is 
characterized  by  the  early  and  marked  selection  of  the  muscular  affection 
for  the  upper  part  of  the  body.  The  pectoral,  the  trapezius,  the  latissimus, 
the  rhomboids  and  other  shoulder  muscles  are  first  affected,  and  later  the 
muscles  of  the  arm  become  attacked.  Here  it  is  the  flexor  group  of  the 
upper  arm  which  is  first  involved,  then  the  triceps  becomes  affected,  but  the 
muscles  of  the  forearm  and  hand  are  not  implicated.  To  this  rule  the  supi- 
nator longus,  which  is  usually  affected  together  with  the  muscles  of  the  upper 
arm,  forms  an  exception. 

In  the  lower  half  of  the  body  the  lumbar  muscles,  part  of  the  abdominal 
muscles,  the  glutei,  the  thigh  muscles  to  a  great  extent,  and,  ultimately,  the 
calf  muscles  and  part  of  the  peronei  become  affected. 


DISEASES  OF  THE  MUSCLES. 


867 


Pig.  285. 


While,  as  a  rule,  wasting  of  the  muscles  is  present  from  the  first,  such  is 
not  always  the  case.  Some  muscles,  and  in  all  instances  always  the  same 
muscles,  exceptionally  show  a  true  or  false  hypertrophy.  These  enlarged 
muscles  are  the  deltoid,  the  infra-spinatus,  the  sartorius,  and  the  gastroc- 
nemius. While  the  changes  may  for  a  long  time  be  confined  to  the  muscles 
here  mentioned,  ultimately  the  entire  muscular  system  becomes  involved. 

The  changes  produce  peculiarities  in  the  appearance  of  the  body  which 
are  very  characteristic.  The  abnormal  position  of  the  scapula,  the  lumbar 
lordosis,  and  particularly  the  thinness 
of  the  upper  arms  and  thighs,  in  dis- 
tinction to  the  well-developed  forearms 
and  the  hypertrophic  legs,  are  peculiar 
to  this  form  of  the  disease. 

The  relationship  between  pseudo- 
hypertrophy and  juvenile  atrophy  is  so 
close  that  in  many  cases  the  line  of  de- 
marcation between  the  two  is  not  clearly 
defined. 

The  Landouzy-Dejerine  or  Fa- 
cio-scAPULO-HUMERAL  Type.  This 
form;  which  was  known  to  Cruveilhier 
and  was  described  by  Duchenne  under 
the  name  of  infantile  progressive  mus- 
cular atrophy,  was  in  1884  for  the 
first  time  correctly  recognized  as  a 
myopahtic  affection  by  Landouzy  and 
Dejerine. 

The  muscular  affection  here  begins  in 
early  childhood,  but  may  occasionally 
develop  late. 

The  characteristic  feature  of  this  form 
is  that  the  face  is  first  and  markedly 
attacked.  The  affection  of  the  face, 
consisting  in  a  mask-like  smoothing 
and  immobility,  gives  rise  to  a  peculiar 
appearance  known  as  the  "  facies  myo- 
pathique.'*  The  orbicularis  oris  be- 
comes very  weak,  so  that  the  lips  are 
habitually  separated  and  protruded. 
This  symptom  is  known  as  the  "  tapir 
mouth."  The  articulation  of  labials 
becomes  indistinct  and  the  ability  to 
whistle  is  lost.  The  eye  muscles  and 
those  of  mastication  and  deglutition  re- 
main unaffected.  The  muscles  of  the  rest  of  the  body  become  affected  later 
and  in  the  manner  described  in  the  preceding  form. 

The  electric  excitability  of  the  muscles  in  both  of  these  forms  is  decreased 
in  direct  proportion  to  the  amount  of  actual  atrophy  of  the  muscle  fibres. 
Reaction  of  degeneration  does  not  occur,  and  fibrillary  twitchings  are  usually 
but  not  always  absent.  Mechanical  excitability  of  the  affected  muscle  is 
generally  decreased  or  lost.  Sensibility  is  normal,  and  symptoms  of  disease 
of  the  brain  or  spinal  cord  are  not  present.  Deformities  of  the  body,  due 
to  the  shortening  of  the  less  affected  muscles,  take  place  as  the  disease  pro- 
gresses. All  kinds  of  transitions  occur  between  this  form  and  the  preceding 
one.     Cases  of  juvenile  atrophy,  with  late  involvement  of  the  face,  are  not 


Erb's  juvenile  or  scapulo-humeral  form  of 
muscular  atrophy.  (Marie  and  Guinon.) 


868  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

very  rare,  so  that  the  main  difference  between  this  form  and  the  juvenile  one 
is  to  be  sought  in  the  primary  or  secondary  facial  involvement. 

Etiology.  Of  the  actual  causes  which  produce  pseudo-hypertrophy  we 
know  nothing.  Boys  are  affected  much  more  frequently  than  girls,  and  as 
the  disease  often  occurs  in  several  members  of  one  family,  it  is  not  unusual 
to  find  the  boys  of  the  family  affected,  while  the  girls  are  exempt.  When 
heredity  can  be  traced,  and  this  can  be  done  in  one-half  the  cases,  the  heredi- 
tary influence  emanates  from  the  mother's  side.  Indirect  influences,  such  as 
neuropathic  constitution,  syphilis,  alcoholism,  consanguinity,  do  not  appear 
to  have  any  influence  in  the  causation  of  the  diseases,  although  in  such  fami- 
lies occasionally  a  history  of  nervous  disease,  as  hysteria,  epilepsy,  idiocy, 
etc.,  is  obtainable. 

The  age  at  which  the  disease  manifests  itself  is  usually  that  of  early  child- 
hood, so  that  in  three-fourths  of  the  cases  the  symptoms  become  apparent 
before  the  tenth  year.  Beyond  the  congenital  hereditary  tendency  common 
to  all  foi'ms  of  dystrophies,  we  know  nothing  of  the  producing  causes  of  the 
juvenile  or  Landouzy-Dejerine  types.  Both  sexes  suffer  about  equally,  so 
that,  in  affected  families  there  is  not,  as  in  pseudo- hypertrophy,  affection  of  one 
sex  to  the  exclusion  of  the  other.  The  disease  may  manifest  itself  very 
early,  but  as  a  rule  the  onset  takes  place  in  late  childhood  and  the  beginning 
of  adult  life.  The  facial  type  seems  to  begin  at  an  earlier  age  than  the 
shoulder  type. 

The  action  of  any  direct  exciting  cause  in  the  development  of  the  disease 
is  unknown,  and  while  the  affection  has  become  manifest  soon  after  an  attack 
of  acute  disease,  or  exposure  to  cold,  it  is  unwarrantable  to  assume  any  causal 
connection  between  the  two. 

Pathological  Anatomy.  In  all  forms  of  primary  dystrophies  there  is  a 
correspondence  of  the  main  anatomical  changes.  The  differences  encoun- 
tered are  rather  those  of  extent  than  of  character  and  may  be  noted  in  dif- 
ferent muscles  of  the  same  individual  to  the  same  degree  as  in  muscles  of 
different  individuals,  and  vary  as  much  in  different  cases  of  the  same  form 
as  in  cases  of  different  types.  Hence  it  is  not  possible  from  a  microscopical 
examination  of  a  specimen  of  muscle  to  say  from  which  form  it  has  been 
taken. 

The  changes  found  may  be  divided  into  two  classes,  those  of  the  muscle 
fibres  and  those  of  the  connective  tissue.  The  principal  changes  are  those 
of  the  muscular  fibre,  and  those  which  consist  of  changes  in  volume ;  hyper- 
trophy and  atrophy  must  be  considered  the  primary  and  important  ones. 

This  is  at  variance  with  the  old  view,  which  is  still  held  by  some  observers, 
that  the  change  in  the  connective  tissue  is  the  primary.  It  is  now  certain 
that  the  muscular  fibres  are  first  affected  and  the  connective  tissue  second- 
arily, or  that  j)ossibly  they  both  become  affected  together. 

Hypertrophic  fibres  may  be  found  in  nearly  all  specimens  taken  from  early 
stages,  but  their  number  varies  from  a  single  one  here  and  there  to  a  great 
many  in  each  transverse  section. 

These  hypertrophic  fibres  are  thought  to  be  characteristic  of  primary  myop- 
athies in  contradistinction  to  the  spinal  atrophies.  The  atrophy  also  varies 
quantitatively  and  qualitatively,  only  single  atrophic  fibres  being  found  or 
all  muscular  fibres  having  disappeared.  The  fibres  become  rounded  by  losing 
their  sharp  corners. 

An  increase  of  muscle  nuclei  is  always  noticed,  those  of  the  periphery 
being  augmented  in  number,  and  nuclei  appearing  in  the  centre  of  the 
muscles.  Here  and  there  long  rows  of  nuclei  are  present.  Constant  also  is 
the  Assuring  and  fibrillation  of  the  muscles.  Vacuoles  also  are  encountered  at 
times,  but  their  formation  is  not  so  constant  nor  so  characteristic  as  the 


DISEASES  OF  THE  MUSCLES. 

Fig.  286. 


869 


Quadriceps  femoris  from  pseudo-hypertrophy.    X  300.    Longitudinal  section :  a,  artery ;  v,  vein 
1 1,  tendon-lilie  formation  of  fibrous  connective  tissue  ;  f,  fat  globules. 


Fi(4   287. 


Pe 


Pi 


Quadriceps  femoris  from  pseudo-hypertrophic  muscle,  X  300.    Transverse  section :  Pe,  Pi,  peri- 
mysium externum  and  internum    T,  tendon-like  formation  ;  F,  fat  globules. 


870  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

changes  just  noted.      The  transverse  striation  becomes  indistinct ;  fatty  or 
waxy  degeneration  in  the  fibres  is  rare. 

The  connective  tissue  changes  consist  in  a  gradual  proliferation,  with  an 
increase  of  nuclei,  an  increase  and  thickening  of  the  vessels  and  a  deposit 
of  fat.  These  changes  may  vary  in  diiferent  muscles  so  that  all  degrees  and 
combinations  of  muscle  fibre,  connective  tissue  and  fat  may  be  seen.  The 
increase  in  connective  tissue  stands  in  inverse  proportion  to  the  changes  in 
the  muscular  fibres. 

The  above  changes  have  been  noted  chiefly  in  pieces  of  muscle  excised 
during  life.  Autopsies  have  been  made  in  a  number  of  cases  and  muscles 
thus  obtained  have  shown  the  same  changes. 

The  motor  nerves,  the  anterior  nerve-roots,  and  central  nervous  system 
have,  with  but  single  exceptions,  been  found  normal.  In  these  exceptional 
cases,  changes  of  a  pathological  nature  were  found  in  the  gray  anterior  horns 
or  deviations  from  the  normal  were  observed  which  were  so  slight  as  to  be 
unimportant. 

That  any  of  these  changes  have  had  a  direct  bearing  upon  the  production 
of  the  dystroj)hy  is  doubtful. 

Pathologically  it  would,  considering  the  symmetrical  distribution  of  the 
atrophy,  seem  that  we  were  dealing  with  a  disorder  of  the  trophic  centres 
which  preside  over  muscular  nutrition,  but  the  changes  found  all  jDoint  to 
the  existence  of  a  primary  muscular  affection.  The  spinal  changes  which 
have  been  observed  in  a  few  cases  were  so  different  from  those  found  in  true 
spinal  atrophy  that  for  the  present,  at  any  rate,  they  may  be  disregarded ;  at 
the  same  time,  on  account  of  the  insufficiency  of  our  methods  of  investiga- 
tion, we  cannot  be  absolutely  certain  that  the  trophic  centres  are  not  involved. 
Erb,  Knoll,  Moebius,  Liebermeister,  and  others  are  adherents  to  this  neurotic 
theory  of  j)roduction,  believing  the  trouble  to  be  a  trophoneurosis  ;  the  great 
majority  of  investigators,  however,  consider  the  affection  to  be  primarily  of 
muscular  origin. 

Diagnosis.  The  diagnosis  of  progressive  muscular  dystrophy  is  not  diffi- 
cult if  the  essential  features  of  the  entire  group  and  the  special  characteris- 
tics of  the  single  forms  are  borne  in  mind.  In  pseudo-hypertrophy  the  wad- 
dling gait,  the  manner  in  which  the  children  arise  from  the  floor  and  climb 
stairs,  the  enlargement  of  the  calf  muscles,  often  together  with  contracture, 
the  hypertrophy  of  other  muscles  in  connection  with  wasting  of  neighboring 
ones,  are  all  symptoms  which  render  a  mistake  between  pseudo-hypertrophy 
and  any  other  disease  impossible. 

In  all  the  forms,  the  affection  of  several  members  of  a  family,  the  onset  of 
the  disease  in  youth,  the  distribution  of  the  atrophy  to  certain  parts  of  the 
body  are  almost  sufficient  to  correctly  diagnosticate  the  disease. 

Differentially  the  affections  must,  above  all,  be  separated  from  the  spinal 
form  of  muscular  atrophy.  If  Ave  remember  that  the  latter  rarely  shows  any 
heredity,  that  the  onset  is  usually  late  in  life  after  adult  age  has  been  reached, 
that  it  usually  commences  in  the  small  muscles  of  the  hand,  progresses  to  the 
forearm,  upper  arm,  and  body,  affecting  the  lower  extremities  only  very  late, 
that  hyjDertrophy  is  never  present,  and  fibrillation  nearly  always,  and  that 
the  atrophied  muscles  show  reaction  of  degeneration,  then  muscular  and 
spinal  atrophies  will  only  rarely  be  confounded.  The  affection  of  the  facial 
muscles  in  the  dystrophic  form  can  hardly  be  mistaken  for  the  bulbar  paralysis 
often  met  with  in  the  spinal  disorder.  The  absence  of  pains  and  sensory  dis- 
orders, the  absence  of  reaction  of  degeneration,  and  the  presence  of  h}'3)ertrophy 
will  serve  to  differentiate  tlie  dystrophies  from  chronic  multiple  neuritis. 

The  differentiation  of  one  type  from  another  is  rather  a  question  of  classi- 
fication than  of  diagnosis. 


DISEASES  OF  THE  MUSCLES.  871 

The  distinction  from  the  peroneal  type  will  be  spoken  of  later  on. 

Prognosis.  Inasmuch  as  the  disease  is  progressive  in  nature,  the  prognosis 
must  be  a  serious  one.  In  cases  in  which  the  disease  develops  late,  the  pro- 
gress of  the  affection  is  slower,  and  the  duration  may  extend  over  very  many 
years.  As  a  rule,  patients  afflicted  with  the  pseudo-hypertrophic  forms  do 
not  live  beyond  the  middle  of  the  second  decade. 

In  all  forms  as  the  affection  progresses,  more  and  more  muscles  become  in- 
volved until  finally,  after  the  patients  have  become  helpless,  the  respiratory 
muscles  are  attacked,  the  diaphragm  becomes  involved,  and  death  occurs 
through  asphyxia  or  some  intercurrent  disease. 

Treatment.  As  we  would,  from  the  developmental  nature  of  the  affection, 
expect,  medicinal,  and  mechanical  agents  of  all  kinds  have  failed  to  pre- 
vent the  progress  of  the  disease.  At  the  same  time,  if  anything  is  to  be 
accomplished  therapeutically  it  must  be  done  in  the  direction  of  stimulating 
the  growth  of  the  muscular  fibres.  For  this  purpose  we  may  use  electricity, 
massage  and  gymnastics,  and  it  is  fairly  certain  that  while  no  case  has  been 
cured  by  these  agents,  the  two  latter,  at  any  rate  decrease  the  tendency  to 
contractures,  and  to  an  extent  retard  the  progress  of  the  disease.  The  ques- 
tion of  preventive  treatment  is  also  one  which  must  be  mentioned.  While 
it  is  hardly  rational  to  endeavor  in  anyway  to  medically  influence  the  par- 
ents of  dystrophic  children,  and  thus  prevent  the  appearance  of  the  disease 
in  future  offsj^ring,  we  should,  however,  counsel  against  the  marriage  of  even 
the  healthy  women  belonging  to  such  families,  and  thus  avoid  the  possibility 
of  transmitting  the  family  taint. 


PROGRESSIVE  NEUROTIC    ATROPHY. 

This  form  of  atrophy,  Avhich  was  first  recognized  by  Charcot  and  Marie  in 
1886,  and  shortly  afterward  described  by  Tooth  under  the  name  of  the 
"  peroneal  type"  has  been  most  carefully  studied  by  Hoffmann  in  Germany 
and  Sachs  in  this  country. 

The  affection  occupies,  so  to  say,  an  intermediary  position  between  pro- 
gressive muscular  atrophy  of  spinal  origin  and  the  progressive  muscular 
dystrophies,  and  shows  marked  differences  from  these  well-known  forms  of 
muscular  atrophy. 

Etiology.  All  that  is  known  of  the  etiology  of  this  form  is  that  most  cases 
are  developed  upon  a  family  basis,  so  that  several  members  of  a  family  be- 
come affected.  Occasionally  a  history  of  the  affection  in  the  ascendants  has 
been  obtained.  Males  seem  to  be  affected  more  frequently  than  females,  but 
these  are  not  by  any  mean  exempt.  In  some  families  the  male  members 
only  are  affected.  The  onset  of  the  affection  may  take  place  during  infancy, 
in  childhood,  and  also  in  later  life.  The  usual  period  of  development  is  before 
the  twentieth  year. 

Symptoms  and  Course.  The  marked  peculiarity  in  the  symptomatology 
of  this  form  is  that  the  distal  parts  of  the  extremities  are  affected  first,  and 
that  it  usually  commences  in  the  lower  extremities,  while,  therefore,  the 
ordinary  form  is  the  leg-type  or  peroneal  form,  the  commencement  occasion- 
ally takes  place  in  the  upper  extremities,  or  all  four  are  affected  simultane- 
ously. The  small  muscles  of  the  foot  are  usually  first  attacked,  but  the  early 
involvement  of  these  muscles  is  very  apt  to  be  overlooked ;  when,  therefore, 
the  affection  of  the  foot  is  observed  at  a  later  period,  it  is  generally  errone- 
ously assumed  that  the  disease  started  in  some  other  part  of  the  body.  After 
the  foot  muscles  the  peronei,  the  extensor  communis  digitorum,  the  tibialis 
anticus,  and  the  calf  muscles  become  affected. 


872  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  disease  progresses  to  the  muscles  of  the  thighs,  particularly  to  the 
vastus  internus,  and  usually  at  the  same  time  the  small  muscles  of  the  hands, 
the  thenar,  hypothenar,  interossei,  and  lumbricales,  and,  somewhat  later,  the 
muscles  of  the  forearm  become  affected. 

The  muscles  of  the  upper  arm,  neck,  and  body  remain  unaffected  for  years, 
but  may  eyentually  become  diseased.  So,  also,  the  final  involyement  of  the 
face  is  not  unknown. 

As  a  rule,  the  atrophy  is  symmetrical,  but  occasionally  this  is  not  the  case, 
as  in  a  girl  seen  by  the  writer,  in  whom  the  atrophy  involved  first  the  small 
muscles  of  one  foot,  then  the  muscles  of  the  lower  leg  upon  the  same  side,  and 
together  with  this  the  muscles  of  the  upper  leg  of  the  opposite  side. 

In  the  loAver  extremities  a  paralytic  club-foot  is  early  developed,  which, 
especially  in  children,  is  a  characteristic  symptom,  and  is  distinguishable 
from  congenital  club-foot  only  by  the  electrical  reactions.  In  the  upper  ex- 
tremities the  wasting  of  the  small  hand-muscles  causes  first  flexion  of  the 
fingers  and  then  claw-like  deformity.  The  presence  of  this  main  en  griffe, 
together  with  double  club-foot,  in  early  life,  is  in  itself  sufficient  for  a  recog- 
nition of  the  disease.  Paralysis  and  atrophy  go  hand  in  hand.  Hyper- 
trophy, true  or  false,  does  not  occur.  ^luscular  spasms  are  not  observed, 
but  slight  fibrillary  twitchings,  tremor,  and  restlessness  in  single  muscles  are 
not  uncommon.  Mechanical  excitability  is  reduced  in  the  wasting  muscles, 
and  becomes  abolished  in  the  wasted  ones. 

The  tendon  reflexes  also  become  weaker  and  weaker,  and  are  finally  lost 
as  the  muscles  upon  whose  integrity  they  depend  become  more  and  more 
atrophied. 

Of  very  great  import  are  the  changes  produced  in  the  electrical  excita- 
bility of  muscles  and  nerves.  This  electrical  irritability  is  diminished  early 
and  shows  complete  or  partial  reaction  of  degeneration.  AnClC  precedes 
CaClC,  and  the  contraction  becomes  slow  and  languid.  Later  a  complete 
loss  of  excitability  to  both  faradic  and  galvanic  currents  occurs. 

It  should  be  noted  that  changes  in  the  electrical  excitability  of  muscles 
and  nerves  may  be  found  in  certain  territories  before  any  signs  of  atrophy 
or  impairment  of  voluntary  motion  are  present. 

It  is  also  important  to  recognize  the  presence  of  sensoiy  disturbances  when 
they  exist.  Although  many  cases  show  no  disorder  of  cutaneous  sensibility, 
in  a  number  it  is  either  reduced  or  absent  in  those  territories  which  are  most 
invaded  by  the  atrophy,  and  a  number  of  others,  while  showing  no  objective 
sensory  disorder,  give  evidence  of  subjective  ones,  such  as  well-defined  pains 
and  paraesthesias.  Vasomotor  disturbances  strictly  limited  to  the  atrophic 
territories  are  not  uncommon,  and  consist  in  a  marbled  cyanosis  or  redden- 
ing of  the  skin  combined  with  coldness. 

Diagnosis.  From  the  spinal  forms  of  progressive  muscular  atrophy  these 
cases  show  marked  differences;  at  the  same  time  their  commencement  in  the 
distal  parts  of  the  extremities,  the  gradual  involvement  of  the  more  proximal 
parts,  and  the  final  involvement  of  the  body  itself,  the  restlessness  of  the 
muscles,  which  is  similar  if  not  identical  with  fibrillation,  the  occurrence  of 
reaction  of  degeneration  in  the  atrophied  and  paralyzed  muscles,  the  absence 
of  hypertrophy,  etc.,  establish  a  close  resemblance  to  these  spinal  forms. 
So,  also,  even  greater  difficulty  may  be  experienced  in  differentiating  this 
neurotic  atrophy  from  poliomyelitis  anterior  chronica  and  from  chronic  poly- 
neuritis. From  chronic  poliomyelitis,  which  is  retrogressive  in  its  course, 
the  hereditary  and  progressive  nature  will  serve  to  distinguish  it.  The  differ- 
entiation from  chronic  multi'ple  neuritis  is  the  most  diflicult  on  account  of 
the  close  connection  between  the  two ;  the  course  of  the  disease  and  the  con- 
stant progression  will  serve  as  important  diagnostic  points ;  the  age  of  the 


DISEASES  OF  THE  MUSCLES.  873 

patient  is  also  of  value,  for  polyneuritis  is  usually  a  disease  of  adult  life ;  in 
neuritis,  furthermore,  we  expect  to  find  etiological  causes  which  are  not 
present  in  this  form  of  atrophy.  On  the  other  hand,  the  marked  family  char- 
acter of  the  ailment,  and  its  occurrence  at  an  early  age,  approach  it  to  the 
progressive  dystrophies,  from  which  the  entire  absence  of  hypertrophy  and 
the  more  marked  qualitative  changes  of  electrical  excitability  will  serve  to 
differentiate  it. 

Pathological  Anatomy.  There  have  in  all  been  only  three  autopsies  in 
cases  of  this  kind,  those  by  Virchow,  Friedreich,  and  Dubreuilt.  In  these 
degeneration  of  the  peripheral  nerves,  fatty  and  parenchymatous  degenera- 
tion of  the  muscles,  with  simple  atrophy  of  the  fibres,  together  with  spinal- 
cord  changes,  degeneration  of  the  fibres  of  Goll,  have  been  found.  Whether 
these  changes  in  the  spinal  cord  are  of  a  primary  or  secondary  nature  cannot 
yet  be  stated,  but  judging  from  a  clinical  point  of  view  the  primary  changes 
are  undoubtedly  those  in  the  peripheral  nerves. 

The  Prognosis  and  Treatment  of  these  cases  become  plain  as  soon  as  we 
recognize  the  constantly  progressive  character  of  the  disease.  That  this  pro- 
gressive course  can  be  arrested  or  delayed  by  any  known  method  of  treatment 
is  more  than  doubtful.  Whatever  methods  of  treatment  are  to  be  tried  must 
be  carried  out  upon  the  general  lines  employed  in  diseases  of  the  muscles 
and  of  the  peripheral  nerves. 

MYOTONIA   CONGENITA  (Thomsen's  Disease). 

This  disease,  which  is  named  after  the  physician  who  (himself  afflicted) 
first  attracted  general  attention  to  it  by  his  careful  description,  is  a  peculiar 
disorder  of  the  voluntary  movements  characterized  by  motor  inhibition,  due 
to  a  stiffness  and  rigidity  of  the  muscles,  occurring  after  a  period  of  inactivity. 
This  rigidity  passes  away  in  a  short  time  and  does  not  return  while  the  mus- 
cles are  being  used. 

History.  In  1876  the  disease,  as  it  occurred  in  himself  and  in  four  gene- 
rations of  his  family,  twenty-three  cases  in  all,  was  first  described  by  Dr.  J. 
Thomsen.  The  title  employed  in  his  description  was  "  Tonic  Spasms  in 
Voluntarily-moved  Muscles."  The  only  references  to  this  class  of  cases  prior 
to  1876  are  one  by  Sir  Charles  Bell  and  another  by  Leyden.  Since  Thom- 
sen's pubhcation  reports  of  similar  cases  have  been  received  from  nearly  all 
countries.  Many  of  these  cases  have  only  certain  symptoms  in  common  with 
the  affection  described  by  Thomsen,  while  others,  in  addition  to  the  charac- 
teristic symptoms,  present  phenomena  which  point  to  the  existence  of  central- 
nerve  disorder.  The  most  complete  publication  upon  the  subject,  which 
contains  an  analysis  of  all  the  positive  and  doubtful  cases  published  prior  to 
1876,  is  Erb's  monograph  on  Myotonia  Congenita.  The  number  of  positive 
cases  analyzed  in  this  book  is  twenty-eight ;  this  number  does  not  include 
the  cases  occurring  in  Thomsen's  own  family,  two  of  which  only  have  been 
described,  and  these  without  any  objective  examination.  The  case  described 
by  me  is  the  twenty-ninth,  and  since  then  the  histories  of  a  few  more  have 
been  published. 

Etiology.  The  etiology  of  the  affection  demonstrates  that  the  most  impor- 
tant factor  in  its  production  is  heredity.  In  the  majority  of  cases,  it  is  a 
family  disease,  and  in  nearly  all  the  affection  was  noticed  in  early  childhood 
as  soon  as  the  child  was  obliged  to  make  systematic  use  of  its  muscles.  In  a 
number  of  cases,  in  addition  to  the  presence  of  the  same  affection  in  other 
members  or  in  collateral  branches  of  the  family,  other  neuropathic  disorders 
were  present.     Thus,  Weidmann  gives  the  history  of  a  patient  of  whom  one 


874  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

brother  was  an  epileptic,  and  of  whom  another  had  died  in  consequence  of  a 
meningitis.  Knud  Pontoppidan  describes  a  case  in  whose  family  numerous 
neuropathic  disorders  were  found,  and  in  the  family  of  a  patient  of  Bern- 
hardt a  number  of  consanguineous  marriages  had  occurred. 

Both  sexes  suffer,  but  males  seem  to  be  more  frequently  affected  than 
females.  Of  the  influence  of  other  causes,  particularly  psychic  emotions,  we 
know  little  ;  cases  have  been  described  by  Seeligmiiller,  Peters,  and  Engel, 
in  which  the  origin  of  the  affection  is  attributed  to  fright.  Engel's  L?  prob- 
ably not  a  genuine  case  of  Thomsen's  disease.  Climate  and  country  may  have 
some  influence  upon  its  production ;  the  affection  seems  to  be  more  common 
in  Scandinavia  and  Germany  than  in  France  and  England,  and  is  exceed- 
ingly rare  in  the  United  States. 

Symptomatology.  The  disease  is  characterized  by  an  inhibition  and  awk- 
wardness of  voluntary  movements,  due  to  tonic  spasm,  occurring  particularly 
after  a  period  of  rest,  and  remaining  absent  as  long  as  the  muscles  are  in  use. 

This  peculiar  disorder  of  motion  is  already  noticeable  in  childi'en  when 
they  first  begin  to  play ;  they  are  awkward  in  their  movements  and  cannot 
compete  with  their  playmates  in  such  games  as  require  full  and  rapidly 
changing  control  of  different  muscles. 

Every  period  of  rest  is  followed  by  fresh  spasm,  which  is  stronger  the 
longer  the  muscles  have  not  been  used.  After  such  a  peri<Dd  of  rest  the 
spasm,  in  consequence  of  any  muscular  exertion,  will  occur  in  full  force  ;  the 
muscles  then  become  entirely  stiff,  and  movements  can  be  executed  only  with 
the  greatest  difficulty,  if  at  all. 

In  a  severe  case,  a  slight  cause,  such  as  stubbing  the  toe  while  walking, 
will  make  the  patient  fall,  and  he  will  be  unable  to  rise  from  the  ground 
until  the  spasm  has  subsided. 

These  spasms  always  pass  off  soon,  and  during  the  intervals  the  patients 
do  not  differ  subjectively  from  normal  individuals. 

A  patient  who,  upon  getting  out  of  bed  in  the  morning,  cannot  walk  at  all 
on  account  of  the  spasm,  will,  after  repeated  attempts,  succeed  in  walking  a 
few  steps,  and  will  then  be  able  to  walk  for  hours  without  any  trouble ;  the 
next  period  of  rest  will,  however,  prepare  the  way  for  a  fresh  spasm. 

Various  grades  of  severity  are  found  in  different  patients.  The  lower 
extremities  are  usually  more  affected  than  the  upper  ones,  and,  as  a  rule,  all 
the  voluntary  muscles  of  the  body,  with  the  exception  of  those  of  the  face, 
tongue,  and  eyeballs,  are  more  or  less  affected.  In  a  case  reported  by  me 
these  muscles  were  also  affected.  Certain  influences  seem  to  increase  the 
severity  of  the  symptoms.  Above  all,  Ave  must  here  place  prolonged  rest, 
even  standing ;  cold  and  damp  weather,  cold  batlis,  and  even  great  heat, 
psychical  excitement  and  sudden  sensory  impressions  are  important  in  pro- 
ducing this  result.  Moderately  active  exercise  serves  to  ameliorate  this  ten- 
dency to  spasm. 

In  every  other  way  the  patients  appear  normal,  no  other  symptoms  of 
nervous  disorders  are  present,  and  nutrition  is  usually  perfect. 

The  muscles  themselves  are  well  nourished,  and  are  often  abnormally 
large,  in  most  cases  presenting  a  truly  athletic  development ;  their  strength 
is,  however,  always  less  than  their  size  would  lead  us  to  believe. 

Fibrillary  twitchings  and  disorders  of  sensation  are  not  present ;  the  ten- 
don reflexes  are  usually  normal,  though  sometimes  reduced,  and  may  even 
vary  at  different  times  in  one  and  the  same  individual. 

Peculiar  changes  in  the  mechanical  and  electrical  excitability  of  the  mus- 
cles are  found,  which  have  beeli  most  carefully  studied  by  Erb,  and  given  the 
designation  myotonic  reaction.      (MyR.) 

The  mechanical  excitability  is  increased  so  that  thev  show  overaction  to 


DISEASES  OF  THE  MUSCLES. 


875 


such  stimulation.  A  quick  localized  blow,  as  with  a  percussion  hammer, 
produces  a  coutraction  of  the  irritated  fibres,  causing  a  distinct  groove  in  the 
muscle,  which  lasts  for  fifteen  seconds  or  more.  Firm  pressure  causes  tonic 
contraction  of  the  entire  muscles  with  similar  persistency. 


Fig.  288. 


Normal  muscle.    Quadriceps  femoris.    Transverse  section.    X  300. 

The  faradic  excitability  of  the  muscles  is  also  increased  and  altered,  a 
slow  tonic  persistent  contraction  being  produced  by  medium  currents.  Single 
opening  shocks  always  produce  normal  quick  contractions. 

Fig.  289. 


Myotonia  congenita.    Quadriceps  femoris.    Transverse  section.    X  300. 

To  the  galvanic  current  the  muscles  show  an  increased  excitability  with 
qualitative  change.  The  cathodal  and  auodal  closure  contractions  are  about 
equal,  or  the  AnClC  is  stronger  than  the  CaClC.  Marked  local  furrows  are 
formed  under  the  excitative  electrodes.  Erb  has  described,  as  occurring  in 
his  cases,  undulating  rhythmical  contractions,  starting  at  the  kathode  and 
passing  to  the  anode,  where  they  ceased. 


876  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  mechanical  or  electrical  excitability  of  the  nerves  is  not  changed.  In 
all  cases  the  affection  once  developed  seems  to  continue  during  life,  though  it 
may  at  times  become  so  much  lighter  that  it  seems  to  have  disappeared. 

Pathology.  No  autopsy  has  yet  been  made  in  this  disease,  and  it  is  doubt- 
ful whether  any  important  results  will  be  gained  by  an  examination  of  the 
central  nervous  system.  In  a  number  of  cases  pieces  of  the  muscles  have 
been  either  excised  or  removed  by  means  of  the  harpoon,  intra  vitam.  The 
changes  thus  found  by  Erb,  and  corroborated  by  myself  and  others,  were 
marked  hypertrophy  of  all  fibres  and  great  proliferation  of  nuclei,  with  al- 
tered appearance  of  the  minute  structure.  The  hypertrophy  of  the  muscle- 
fibres  is  so  great  that  they  are  twice  or  three  times  as  large  as  normal  fibres. 
That  this  h}^ertrophy  is  not  due  to  excitation  and  contraction  caused  by 
the  process  of  excisions  is  shown  clearly  in  the  accompanying  cut  (Fig.  288), 
showing  a  transverse  section  of  a  normal  muscle  removed  intra  vitam  from 
a  perfectly  healthy  individual,  from  the  same  locality  and  prepared  in  pre- 
cisely the  same  manner  for  microscopical  examination  as  was  the  piece  of 
mviscle  removed  from  the  case  of  Thomsen's  disease,  a  transverse  section  of 
which  is  also  shown.  (Fig.  289).  In  addition  to  the  hypertrophy,  the  fibres 
differ  in  shape  from  the  normal,  being  more  circular,  with  somewhat  rounded 
corners,  and  not  polygonal.  The  nuclei,  greatly  augmented  in  numbers,  are 
not  only  found  along  the  periphery  of  the  fibres,  but  also  here  and  there  in 
its  interior. 

The  connective  tissue  around  the  muscle  bundles  and  that  around  the  sin- 
gle fibres  is  distinctly  augmented. 

The  changes  seen  in  the  minute  structure  of  the  muscle  are  indistinct 
transverse  striation,  irregular  non-parallel  edges  of  the  fibres,  splitting  up  of 
fibre  into  minute  fields,  with,  in  many  instances,  wide  gaps  between  them, 
homogeneous  appearance  on  transverse  section,  and  formation  of  vacuoles. 

The  clinical  manifestations  of  the  disease  being  limited  to  disordered  func- 
tions of  the  voluntary  muscles,  and  the  anatomical  examinations  also  show- 
ing changes  in  the  minute  structure  of  these  muscles,  it  seems  natural  that 
we  should  argue  post  hoc,  propter  hoc,  and  consider  the  clinical  manifesta- 
tions dependent  upon  the  anatomical  disorder.  Whether,  however,  the  mus- 
cular changes  are  the  primary  ones,  or  whether  these  are  secondary  to  some 
disorder  in  the  central  nervous  system,  is  a  question  which  cannot  as  yet  be 
decided.  The  absolute  functional  and  trophic  dependence  of  the  muscles 
upon  the  central  nervous  system,  the  fact  that  the  myotonic  disorder  has 
been  noted  in  diseases  of  the  central  nervous  system,  the  hereditary  tendency 
to  nervous  diseases  occurring  in  some  of  the  families  with  Thomsen's  disease, 
the  occasional  etiological  influence  of  fright,  and  the  influence  of  psychic 
excitement  upon  the  condition  of  the  sufferer,  are  facts  which  make  it  im- 
possible to  assert  that  the  disease  is  a  myopathic  one.  It  is  clearly  possible 
that,  primarily,  the  nervous  system  is  at  fault,  and  that  we  are  dealing  with 
a  tropho-neurosis  of  the  muscles  dependent  upon  disorder  of  the  central 
trophic  apparatus. 

On  the  other  hand,  the  reaction  of  the  muscles  to  direct  mechanical  and  elec- 
trical excitation,  while  the  reaction  from  the  nerve-trunks  remains  unchanged, 
is,  to  say  the  least,  a  powerful  argument  in  favor  of  the  myopathic  theory. 

Diagnosis.  The  diagnosis  of  this  affection  presents  no  difficulty  on  ac- 
count of  the  characteristic  features  of  the  disease.  The  family  tendency,  its 
manifestations  in  early  childhood,  together  with  the  "  myotonic  reaction " 
will  serve  to  dispel  all  doubts.  The  myotonic  reaction  of  itself  is,  how- 
ever, not  characteristic  of  Thomsen's  disease,  as  it  is  found  occasionally  in 
acquired  disorders,  the  precise  nature  of  which  is  still  in  doubt.  Simula- 
tion can,  as  Erb  tei"sely  puts  it,  always  be  detected  by  a  few  blows  with  the 


DISEASES  OF  THE  MUSCLES.  877 

percussion  hammer  and  a  few  anodal  and  cathodal  closures  with   the  gal- 
vanic current. 

Treatment  and  Prognosis.  No  treatment  seems  to  exert  any  influence 
upon  the  disease.  Patients,  in  time,  learn  to  avoid  certain  influences,  such 
as  cold,  damp  air,  psychical  excitement,  etc.,  and  to  encourage  others,  as 
muscular  exercise,  and  are  thus  enabled  to  lead  a  fairly  comfortable  life. 
The  disease  lasts  during  the  entire  life  of  the  patient,  and  death,  when  it 
occurs,  is  due  to  some  other  disease. 


ARTHRITIC    MUSCULAR  ATROPHY. 

It  is  well  known  that  muscles  surrounding  diseased  joints  rapidly  waste, 
and  that  this  atrophy  bears  no  relation  to  the  nature  nor  to  the  cause  of 
the  joint  affection.  Chronic  and  acute  affections,  spontantaneous  or  trau- 
matic ones,  are  equally  followed  by  this  atrophy.  The  muscles  chiefly 
affected  are  the  extensors  of  the  diseased  joints.  The  atrophy  is  of  very 
common  occurrence,  and  presents  the  following  clinical  features  :  The  pri- 
mary joint  trouble  is,  after  a  more  or  less  short  interval,  followed  by  a  weak- 
ness in  the  affected  extremity,  chiefly  characterized  by  an  inability  to  en- 
tirely or  partially  extend  the  distal  portion  of  the  limb.  Frequently  the 
patient  still  complains  of  pain  in  the  joint. 

Upon  examination  we  find  that  the  joint  itself  is  either  normal  or  that  it 
is  still  implicated  to  so  slight  a  degree  as  to  be  entirely  disproportionate  to 
the  amount  of  functional  disturbance.  The  proximal  portion  of  the  limb, 
however,  shows  marked  atrophy  of  its  muscles.  If  the  ankle  joint  is  affected 
the  calf  muscles  are  wastecl ;  if  the  knee,  the  quadriceps ;  if  the  hip,  the 
glutei ;  if  the  wrist,  the  extensor  muscles  of  the  forearm  ;  if  the  elbow,  the 
triceps,  and  if  the  shoulder  joint,  the  deltoid,  supra-spinatus,  infra-spinatus, 
and  teres  minor  are  affected. 

In  arthritis  of  the  finger-joints  this  wasting  is  marked  in  the  interossei. 

Thus,  as  a  rule,  almost  without  exception,  the  extensors  of  the  joint  alone 
are  affected,  but  occasionally  the  flexors  also  are  implicated,  but  always  to  a 
slighter  degi'ee  than  their  opponent.  Even  other  muscles  of  the  proximal 
part  of  the  extremity  may  be  affected,  but  it  is  very  unusual  to  find  any 
muscles  of  the  distal  part  atrophied.  Characteristic  of  this  kind  of  atrophy 
is  that  it  occurs  very  soon  after  the  injury  to  the  joint,  and  that  it  affects  the 
muscles  in  toto.  Thus,  in  a  week  after  the  injury  a  difference  in  the  circum- 
ference of  the  limb  may  be  detected  by  measurement,  and  the  wasting,  while 
it  may  vary  as  to  degree,  always  affects  the  muscle  throughout  its  entire 
length.  The  atrophy  increases  during  a  time,  and  then  becomes  stationary 
and  does  not  begin  to  improve  until  the  joint  trouble  has  disappeared.  Oc- 
casionally the  atrophy  may  persist  for  a  long  time  after  disappearance  of  the 
joint  affections.     Atrophy  and  loss  of  functions  go  hand-in-hand. 

The  electrical  excitability  of  the  affected  muscles  is  either  normal  or 
quantitatively  reduced,  so  that  they  respond  to  strong  currents  only.  Never 
is  there  any  qualitative  change,  thus  proving  that  the  atrophy  is  simple  in 
nature  and  not  degenerative. 

Mechanical  excitability  is  usually  increased  in  the  affected  muscles,  and  an 
excessive  knee-jerk  may  be  obtained  if  the  muscles  of  the  thigh  are  affected, 
and  a  foot-clonus  if  the  ankle-joint  is  involved. 

Sensory  symptoms  are  not  present  in  the  pure  forms  of  arthritic  atrophy. 

Pathology.  Microscopical  examination  shows  the  atrophic  muscles  to  be 
paler,  more  flaccid,  and  less  elastic  than  is  normally  the  case. 

Microscopically  the  muscular  fibers  are  narrowed,  but  do  not  present  any 


878  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

other  deviation  from  the  normal.  Neither  in  transverse  nor  longitudinal 
sections  can  any  degenerated  fibres  be  found ;  their  striation  is  regular  and 
granular ;  breaking  down  of  the  fibers  does  not  occur.  The  nuclei  of  the 
periphery  niay  be  increased  and  the  interstitial  connective  tissue  is  aug- 
mented. Such  fibres  in  various  stages  of  atroj^hy  are  found  throughout  the 
entire  muscle.  Examination  of  the  nervous  system  has  failed  to  reveal- any 
change  in  either  the  central  or  peripheral  parts  except  in  the  articular 
nerve  endings  in  the  joint.  The  changes  here  found  are  undoubtedly  due 
to  direct  extension  of  the  joint  affection,  and  do  not  in  any  way  explain  the 
atrophy  of  the  muscles. 

The  Cjuestion  of  the  manner  in  which  these  arthritic  atrophies  are  produced 
is  one  which  has  given  rise  to  a  great  deal  of  discussion.  The  oldest  and 
most  simple  explanation  ascribed  these  atrophies  to  functional  inactivity  of 
the  limb  ;  but  this  theory  is  not  tenable,  inasmuch  as  the  atrophy  occurs  even 
if  the  limb  is  left  movable  and  the  joints  are  not  fixed ;  furthermore,  the 
rapidity  with  which  the  atrophy  occurs  invalidates  this  theory,  for,  while  we 
know  that  inactivity  may  lead  to  a  certain  wasting  of  the  entire  limb,  we 
also  know  that  never  does  an  immobilized  limb  in  which  there  is  no  joint 
affection  atrophy  in  the  manner  here  described. 

That  the  atrophy  is  due  to  an  insufficient  blood  supply,  that  it  is  the  result 
of  a  secondary  myositis,  or  that  it  is  caused  by  an  ascending  neuritis,  are  all 
theories,  which,  for  a  time,  were  advocated  by  various  observers,  but  whose 
correctness  has  been  disproved. 

The  only  theory  which  satisfactorily  explains  the  condition  is  the  reflex 
hypothesis  of  Vulpian  and  Charcot.  According  to  this  hypothesis  the  irri- 
tation w^hich  is  produced  in  the  articular  nerve-endings  by  the  arthritic 
trouble  is  centripetally  propagated  to  the  spinal  centres  of  the  motor  nerves 
supplying  the  Avasting  muscles,  and  here  produces  a  molecular  change,  which 
is  the  direct  cause  of  the  atrophy. 

The  correctness  of  this  theory  has  been  experimentally  proved  by  Ray- 
mond and  Deroche.  These  investigators,  assuming  that  if  the  atrophy  is 
actually  a  reflex  one,  interruption  of  the  reflex  arc  must  prevent  its  occur- 
rence, cut  through  the  posterior  spinal  roots,  wdth  the  result  of  preventing 
the  occurrence  of  the  atrophy  after  an  experimentally-produced  arthritis, 
Hoffa  has  repeated  these  experiments  in  a  large  number  of  dogs,  and  was 
enabled  to  corroborate  the  statements  of  the  above-mentioned  observers.  In 
a  dog  in  Avhom  the  third,  fourth,  and  fifth  lumbar,  and  first  sacral  posterior 
nerve-roots  of  one  side  had  been  previously  divided,  a  purulent  inflammation 
of  both  knee-joints  was  produced.  Upon  the  side  on  w^hich  the  nerve-roots 
had  been  divided  no  atrophy  occurred,  while  upon  the  other  side  there  was 
atrophy  of  the  quadriceps  so  marked  that  a  difference  of  nearly  1  cm.  existed 
in  the  measurements  of  the  two  limbs.  There  can  hardly  be  any  reasonable 
doubt  that  this  experiment  proves  the  correctness  of  the  reflex  theory. 

The  reason  why  only  the  extensors  of  a  joint  are  affected  in  this  reflex 
manner  must  be  sought  in  the  direct  anatomical  connection  which  the  artic- 
ular nerves  have  with  the  nerves  which  supply  the  extensor  muscles  of  the 

Diagnosis.  The  diagnosis  will  be  based  upon  the  preceding  joint  affection, 
upon  the  Avide  extent  of  the  atrophy,  and  the  reduction  in  the  electrical  ex- 
citability Avithout  any  reaction  of  degeneration.  The  course  of  the  affection 
AA'ill  serve  to  differentiate  it  from  any  of  the  progressive  muscular  atrophies. 

Prognosis.  In  acute  joint  affections  the  atrophy  is  usually  of  short  dura- 
tion, and  restoration  of  function  may  be  speedily  hoped  for  as  soon  as  the 
joint  is  restored  to  its  normal  condition.  If  the  joint  trouble  is  chronic  the 
wasting  Avill  last  for  a  long  time,  eA'en  after  cure  of  the  joint  affection. 


DISEASES  OF  THE  MUSCLES.  879 

Treatment.  The  prirpary  point  in  the  treatment  of  these  atrophies  is  the 
removal  of  the  joint  affections.  As  long  as  any  disease  exists  here  no  in- 
crease in  bulk  of  the  muscle  is  to  be  expected.  As  soon  as  the  joint  is  in  a 
normal  condition  the  muscles  usually  begin  to  improve  of  themselves,  but 
this  is  not  always  the  case,  and  in  many  instances  the  improvment  only  takes 
place  up  to  a  certain  point,  and  then  remains  stationary.  It  is  in  such  cases 
that  local  treatment  is  of  the  greatest  importance.  Electricity,  galvanism 
or  faradism,  of  sufficient  strength  to  produce  good  contractions  of  the  muscles, 
massage,  superficial  and  deep  active  movements,  with  and  without  opposi- 
tion, together  with  hydrotherapeutic  procedures,  are  the  remedies  which  in 
nearly  all  cases  will  enable  us  to  completely  restore  the  muscles  to  their 
normal  conditions. 


CHAPTER    XXX. 
THE  TROPHO-^EUROSES. 

By  JOSEPH  COLLINS,  M.D. 

Ukder  the  title  of  tropho-ueuroses  are  included  a  number  of  diseases  in 
which  anomalies  of  nutrition  depending  on  nervous  origin  is  the  one  striking 
feature  of  the  disease.  The  number  of  these  diseases  is  gradually  increasing. 
The  question  of  whether  or  not  there  exist  specific  trophic  nerves  is  to-day 
quite  as  unsettled  as  it  was  a  quarter  of  a  century  ago.  There  is  any  amount 
of  clinical  evidence,  and  that  of  a  convincing  kind,  to  prove  the  existence  of 
trophic  nerves,  and  there  have  not  been  lacking  writers  and  investigators 
who  have  claimed  the  discovery  of  such  nerves,  but  experimental  physiology 
still  fails  to  reveal  any  clue  of  their  presence.  The  truth  is  that  it  gives  a 
negative  answer.  Many  trophic  disturbances  are  probably  due  to  vasomotor 
changes,  and  it  is  not  possible  to  separate  by  any  sharply-defined  lines  the 
vasomotor  and  the  tropho-neuroses.  At  the  same  time  it  should  be  dis- 
tinctly stated  that  there  exists  tropho-neuroses  in  which  there  are  no  appre- 
ciable vasomotor  disturbances,  as  in  many  cases  of  acromegaly  and  hyper- 
trophies ;  and,  on  the  other  hand,  there  are  any  number  of  vasomotor  dis- 
turbances which  are  in  no  sense  trophic.  Still  there  is  the  closest  relation- 
ship between  vasomotor  and  tropliic  disturbances,  and  it  is  not  improbable 
that  further  research  into  the  domain  of  experimental  physiology  will  reveal 
that  this  intimacy  is  dependent  on  the  relationship  existing  between  the  spinal 
ganglia  and  the  sympathetic  system.  Recent  investigation  in  this  direction 
tends  to  postulate  the  spinal  ganglia  as  responsible  for  trophic  conditions, 
and  the  sympathetic  ganglia  for  the  vasomotor,  and  the  theory  that  may  be 
constructed  on  this  supposition  explains  better  than  any  heretofore  the  inter- 
lationship  and  partial  dependence  of  one  upon  the  other. 

It  Ls  not  my  purpose  to  consider  here  the  physiology  of  the  vasomotor 
nerves,  no  more  is  it  to  give  in  detail  the  arguments  that  have  been  advanced 
to  prove  the  existence  of  trophic  nerves  and  centres.  These  subjects  belong 
properly  to  text-books  on  physiology  and  experimental  medicine,  and  in 
them  may  be  found  any  amount  of  facts  and  theory  bearing  on  these  subjects. 

Some  of  the  diseases  which  are  considered  in  this  chapter  are  of  recent 
recognition,  but  so  assiduously  have  they  been  studied  that  their  morbid 
anatomy  and  clinical  course  are  quite  as  well  understood  as  those  of  much 
older  date. 

RAYNAUD'S  DISEASES. 

Synonyms.  Symmetrical  Gangrene ;  Local  Asphyxia ;  Asphyxie  Local 
Symmetrique  ;  Neuropathic  Gangrenous  Trophoneurosis. 

In  1862  Maurice  Raynaud  described  a  variety  of  dry  gangrene  which  he 
had  observed  in  twenty-eight  cases,  and  which  he  characterized  as  a  neurosis 
dependant  on  an  exaggeration  of  the  excito-motor  power  of  the  cord  pre- 
siding over  the  vasomotor  nerves ;  a  kind  of  gangrene  which  owns  for  its 


THE  TROPHO-SEUEOSES.  881 

cause  some  error  of  innervation  of  the  capillary  vessels.  He  showed  that  in 
many  instances  there  were  three  stages  in  its  development :  The  first,  accom- 
panied by  icy  coldness  and  pallor,  the  dead-finger  stage,  and  this  he  termed 
local  syncope,  the  affection  heing  usually  paroxysmal;  the  second  stage  that 
in  which  the  blood  is  unfitted  to  the  nutritive  requirements  of  the  parts,  stag- 
nates in  the  extremities,  he  called  local  aspln'xia ;  the  thii'd  stage,  that  of 
gangrene,  when  mortification  occurs.  In  1874  Raynaud  contributed  a  sec- 
ond paper  which  contained  a  record  of  thirty-one  cases.  Since  that  time, 
and  particularly  since  Barlow's  translation  of  Raynaud's  article  into  English, 
many  cases  have  been  reported,  although  the  disease  may  be  said  to  be  ex- 
tremely rare.  The  term  symmetrical  gangrene,  which  the  discoverer  himself 
gave  to  the  disease,  is  not  entirely  appropriate,  for  I  have  been  able  to  find 
in  the  literature  no  fewer  than  eleven  cases  in  which  the  condition  was 
manifest  in  one  extremity  only,  and  in  many  cases  the  disease  does  not  go  on 
to  gangrene,  so  although  eponyms  should  be  discouraged,  the  most  fitting 
name  for  the  disease  is  as  given  above. 

Etiology.  Raynaud's  disease  occurs  very  frequently  in  patients  who  are 
the  possessors  of  other  nervous  diseases,  such  as  hysteria,  epilepsy,  tabes, 
myelitis,  syringomyelia  and  neurasthenia.  It  is  not  uncommonly  seen  in 
insane  asylums,  particularly  in  patients  who  have  acute  mania. 

It  occurs  about  twice  as  often  in  females  as  in  males.  In  a  hundred  cases 
taken  from  the  literature  sixty-one  were  females  and  thirty-nine  males.  It 
may  occur  at  any  age,  but  is  much  more  frecj^uent  during  adult  Hfe,  from 
twenty  to  forty.  Cases  have  been  reported  in  children  under  two  years,  and 
early  childhood  furnishes  a  goodly  proportion  of  the  cases.  Xo  cases  have 
been  recorded  as  occurring  for  the  first  time  after  sixty  yeai^.  Raynaud 
attributed  great  etiologic  weight  to  disturbances  of  menstruation  ;  but  statis- 
tics since  his  time  have  not  corroborated  him  in  this.  Syphilis  was  a  direct 
etiological  factor  in  one  case  ;  this  was  proven  to  be  a  fact  by  the  prompt  dis- 
appearance of  the  symptoms  under  antiluetic  treatment  (Baidow :  Lancet, 
July  6,  1889),  and  in  a  few  others  it  is  possible  to  get  an  inherited  or  ac- 
quired syphilitic  history.  A  neuropathic  diathesis  is  to  be  made  out  in  a 
large  proportion  of  the  cases.  Anaemia  and  all  conditions  of  impoverished 
blood,  whether  due  to  malaria,  excesses,  or  intercurrent  diseases,  are  strong 
predisposing  factoid.  Cases  of  Raynaud's  disease  are  sometimes  seen  asso- 
ciated with  urticaria,  scleroderma  and  telangiectasis.  The  exciting  causes 
are  fright,  exposure  to  cold,  frost  bite,  acute  fatigue  and  trauma,  especially  to 
the  sympathetic  system,  through  blows  or  injuries  over  the  solar  plexus  and 
splanchnic  ganglia.  The  disease  has  come  on  in  a  few  cases  after  the  acute 
infectious  diseases,  including  mfluenza,  in  one  case  after  dog  bite,  and  in 
another  after  a  poisonous  dose  of  chloral.  By  some  writers  the  original 
cause  of  the  disease  is  considered  to  be  of  a  toxic  nature. 

Symptoms.  The  local  symptoms  generally  precede  any  subjective  symp- 
toms, and  the  patient  remarks  that  the  fingers  or  toes,  or,  more  rarely,  the 
nose,  after  or  without  having  been  exposed  to  the  cold,  looks  pale  and  glossy, 
and  presents  the  characteristics  of  a  local  sjmcope  or  regional  ischtemia. 
AVith  this  there  is  a  feeling  of  tingling  and  itchiness,  a  sensation  as  if  the 
parts  had  been  stung  by  nettles,  and  a  feeling  of  numbness  and  loss  of 
dexterity  and  tactile  sensibility.  This  condition  may  persist  for  some  time ; 
gradually,  or  paroxysmally,  the  parts  affected  become  more  blanched  and 
the  local  syncope  more  exaggerated.  The  end  or  the  entire  finger  may  be- 
come apparently  completely  exsanguinated,  waxy,  and  colorless,  the  so-called 
digiti  mortui.  To  the  touch  they  are  cold  and  pulseless,  although  the  pulse 
at  the  worst  may  be  demonstrable.  A  needle  plunged  through  the  skin  into 
the  tissues  does  not  cause  a  drop  of  blood.     With  this  stage  there  may  be 

56 


882 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


some  constitutional  symptoms,  such  as  in  the  beginning  a  chill,  nausea, 
anorexia,  constipation,  a  general  feeling  of  hypothermia,  lack  of  energy, 
pain  in  various  parts  of  the  body,  and  a  sense  of  tingling  in  other  extremi- 
ties which  are  not  the  seat  of  local  syncope.  If  the  symptoms  persist,  the 
skin  either  preserves  its  glassy,  waxen  look  or  it  becomes  shrivelled  and 
puckered.  This  stage,  after  lasting  from  a  few  minutes  to  several  hours  or 
days,  may  pass  off  without  leaving  a  trace,  or  it  may  pass  into  the  second 
stage,  that  of  local  asphyxia. 

In  the  stage  of  local  asphyxia  or  regional  cyanosis,  the  tips  of  the  fingers, 
the  toes,  or  any  part  affected  begins  to  assume  a  bluish-black  appearance.  The 
nails  especially  look  as  if  they  had  been  dipped  in  ink.  If  the  affected  parts  are 
pressed  upon  the  anaemia  produced  takes  a  long  time  to  disappear.  Occa- 
sionally in  this  stage  of  regional  cyanosis,  the  fingers  are  swollen,  of  a  vivid- 
red  color,  extremely  hot,  covered  with  a  profuse  perspiration,  the  capillaries 
and  all  the  vessels  fully  distended,  and  ansemia  caused  by  pressure  disap- 
pears rapidly.  In  both  forms  the  integrity  of  the  circulation  is  interfered 
with,  and  the  results  are  the  same.  Simultaneously  with  the  appearance  of 
this  stage  the  patient  begins  to  complain  of  pain  generally  of  a  neuralgic 


Fig.  290. 


Gangrene  of  fingers  in  Raynaud's  disease.    (Dehio.) 

character,  and  generally  in  proportion  to  the  cyanosis  so  is  the  pain.  The 
fingers  of  both  hands  or  the  toes  may  be  involved  at  the  same  time,  but  fre- 
quently the  appearance  in  one  hand  slightly  antedates  that  of  the  other. 
After  continuing  in  these  parts  for  a  time  it  is  not  uncommon  to  find  the 
ears  and  even  the  tip  of  the  nose  beginning  to  be  similarly  affected.  Lead- 
ing up  to  the  third  stage,  the  epidermis  over  the  affected  parts  may  show 
small  blisters,  and  in  some  cases  these  contain  a  small  quantity  of  blackish 
blood.  After  several  hours  or  longer  the  skin  over  the  black  portion  of  the 
fingers,  especially  over  the  bulbs,  separates  from  the  adjacent  parts,  the  derma 
becomes  extensively  destroyed  and  small  ulcers  can  be  seen  eroding  the 
deeper  tissues,  or  the  gangrene  takes  a  deeper  hold,  and  the  terminal  pha- 
langes or  even  the  entire  finger  becomes  shrivelled  and  mummified  (Fig.  290). 
If  the  gangrenous  process  is  limited  to  the  formation  of  small  necrotic  areas, 
these  heal  slowly  after  the  attack  has  passed  off,  and  the  only  evidence  re- 


PLATE  VII, 


Local     asphyxia    of     hands,     nose    and     ears,     and     gangrenous     patch     iq 

left  ear,      (Henry.) 


THE  TROPHO-NEUROSES.  883 

maining  is  a  slight  scar  in  the  pulpy  part  of  the  finger.  A  number  of  these 
scars  may  tell  of  many  previous  attacks.  If  the  gangrenous  process  is  of  the 
severer  form,  the  skin  of  the  end  of  the  fingers  becomes  black,  dry,  and 
shrivelled,  while  adjoining,  in  the  healthy  tissue,  may  be  seen  forming  the 
line  of  demarcation  from  which  a  reactive  process  is  to  be  set  up  which  sep- 
arates the  dead  part,  and  from  which  the  reparative  process  develops.  The 
process  may  be  so  severe  that  spontaneous  amputation  of  extremities,  such  as 
the  feet,  may  occur.  The  process  of  separation  and  cicatrization  is  a  very 
slow  one  and  frequently  extends  over  many  months.  In  the  majority  of 
cases,  however,  the  gangrene  does  not  go  on  to  this  extent. 

The  disease  may  show  itself  in  other  parts  of  the  body  than  the  fingers, 
toes,  ears,  and  nose,  but  in  these  it  is  most  common.  (See  Plate  VII.)  It 
is  not,  however,  uncommon  to  find  patches  over  the  heels,  deltoid  muscles, 
calves,  maleoli,  nates,  cheeks,  and  lips,  and  on  the  abdomen  especially  on 
each  side  of  the  umbilicus.  When  it  involves  any  of  these  parts  it  does  not 
ordinarily  go  on  to  complete  gangrene.  The  tongue,  the  penis,  and  the  vulva 
are  unusual  seats  of  the  lesion. 

The  constitutional  symptoms  of  this  disease  vary,  and  are  not  altogether 
constant.  The  absence  of  fever  is  characteristic  of  its  entire  course,  and  dur- 
ing the  stage  of  local  asphyxia  the  temperature  of  the  skin  of  parts  affected 
may  be  very  much  lowered.  The  most  interesting  symptom,  as  was  empha- 
sized by  Barlow,  is  intermittent  hsemoglobinuria.  This  may  occur  dur- 
ing an  attack,  or  it  may  seemingly  take  the  place  of  an  attack.  The 
causes  of  hsemoglobinuria  occurring  apart  from  Raynaud's  disease  are  not 
well  understood ;  but  unlike  the  latter  disease  it  occurs  preponderatingly 
in  males,  and  particularly  in  those  who  sometimes  in  their  lives  have  suf- 
fered from  malarial  infection.  And,  furthermore,  the  symptoms  attend- 
ing hsemoglobinuria  sui  generis  are  much  more  severe  than  those  of  Ray- 
naud's disease.  Psychical  disturbances  sometimes  occur  at  the  beginning  or 
during  the  course  of  the  attack,  and  consist  of  a  feeling  of  malaise,  irrita- 
bility and  depression,  transient  attacks  of  aphasia  (Weiss),  loss  of  motor 
power  (Raynaud),  unconsciousness  (Englisch),  convulsions  (Southey),  all  of 
which  may  be  attributed  to  ischsemia  resulting  from  spasm  of  the  arteries  of 
the  representative  parts  of  the  brain,  analogous  to  that  occurring  in  the 
arteries  of  the  fingers  and  extremities.  Disturbances  of  vision  during  a 
paroxysm  is  not  uncommon.  It  may  be  a  simple  dimness  or  obscuration  de- 
pendent upon  a  narrowing  of  the  calibre  of  the  central  artery  of  the  retina 
and  its  branches,  and  which  can  be  demonstrated  ophthalmoscopically,  or  it 
may  be  associated  with  profound  hebetude,  bluntness  of  hearing,  noises  in 
the  ear,  perversion  of  taste,  and  other  symptoms  that  point  to  vascular  de- 
pravity in  the  brain.  Occasionally  the  disturbance  of  vision  may  be  due  to 
pupillary  conditions,  such  as  iridoplegia  (Hutchinson),  and  these  cases  point 
to  an  involvement  of  the  sympathetic. 

Fortunately  these  severer  symptoms  do  not  occur  in  the  majority  of  cases. 
Trophic  disturbances,  such  as  atrophy  of  the  muscles  of  the  hands,  prolifera- 
tion of  the  epidermis,  urticaria,  chilblains,  changes  in  the  nails,  and  even 
scleroderma  may  occur.  Very  rarely  synovitis  and  evidences  of  involve- 
ment of  one  or  more  of  the  joints  are  seen.  In  those  cases  in  which  neuritis 
and  lepra  nervorum  are  present  there  will  be  striking  defects  of  sensibility  and 
motion,  and  changes  in  electrical  irritability. 

The  duration  of  the  disease  is  a  variable  one.  The  first  and  second  stages 
last  from  a  few  hours  to  several  days,  and  the  third  stage,  depending  if  it 
goes  on  to  mummification,  or  if  limited  to  the  formation  of  local  necrotic 
spots  in  the  form  of  ulcers,  is  a  variable  one.  If  the  former  occurs,  three  or 
four  months  will  elapse  before  recovery  sets  in,  and  in  the  latter  case  the  same 


884  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

number  of  weeks  may  suffice.  The  first  attack  may  be  the  only  one,  but  in 
the  great  proportion  of  cases  the  disease  returns  after  a  variable  intermission, 
during  which  time  other  vasomotor  phenomena,  such  as  urticaria  and  angeio- 
neurotic  oedema,  may  show  themselves. 

In  children  the  disease  runs  a  very  rapid  course  and  frequently  there  is 
nothing  paroxysmal  about  the  attack  ;  the  symptoms  progress  uninterruptedly 
and  the  child  may  die  within  two  days  from  the  time  when  the  disease  first 
showed  itself. 

The  pathology  of  the  disease  is  obscure,  and  very  little  can  be  said  with 
absolute  certainty.  Most  observers  of  the  disease  since  the  time  of  Raynaud 
have  corroborated  his  opinion  that  the  local  syncope  is  produced  by  a  con- 
traction or  spasm  of  the  vessels,  the  arteries  and  veins,  in  the  parts  afiected. 
The  local  asphyxia  occurs  when  the  spasms  cease  in  the  veins  and  capillaries, 
but  still  continues  in  the  arteries,  such  is  the  condition  when  the  second  stage 
is  characterized  by  a  black  appearance  of  the  parts.  When  they  are  of  a 
vivid-red  color,  as  has  previously  been  described,  it  is  probable  that  there  is 
a  paresis  of  the  vaso-constrictors,  or  more  probable  an  irritation  of  the  vaso- 
dilators, which  retards  the  circulation  through  the  parts.  Attempts  have 
been  made  to  associate  the  disease  with  certain  pathological  conditions  of  the 
arteries  resulting  from  syphilis,  Bright's  disease,  etc.,  but  if  these  conditions 
are  present  they  can  only  be  regarded  as  intercurrent  or  accidental.  That 
the  disease  does  occur  with  certain  diseases  of  the  spinal  cord,  such  as  tabes, 
syringomyelia,  and  myelitis,  is  beyond  cavil.  In  a  few  cases  neuritis  has  been 
found  in  the  nerves  distributed  to  the  affected  parts  (Pitres  and  Vaillard : 
Archives  de  Physiologie,  1885),  (Wigglesworth  :  Trans.  Path.  Soc,  1887,  Lon- 
don, vol.  xxxvii.),  (Affleck:  Brit.  Med.  Journ.,  1888,  vol.  ii.  p.  1269),  but 
it  is  probable  that  these  changes  were  secondary.  The  same  may  be  said  of 
those  cases  where  endarteritis  and  endophlebitis  have  been  found,  as  in  the 
cases  reported  by  Dehio  and  by  Goldschmidt.  Raynaud's  disease  may  attack 
people  whose  vessels  are  not  healthy,  but  in  such  individuals  spasm  of  the 
bloodvessels  and  not  degeneration  of  their  walls  is  at  the  bottom  of  the 
disease ;  back  of  all  this  is  some  derangement  of  the  sympathetic  nerv- 
ous system  and  that  part  of  the  central  nervous  system  from  which  the 
sympathetic  has  its  origin.  It  may  be  due  to  affection  of  the  local  vaso- 
motor system,  as  in  cases  where  exposure  to  cold  is  directly  the  cause  of  the 
attack.  It  may  be  due  to  affection  of  the  sympathetic  ganglia,  as  in  a  case 
reported  by  Collier  (Manchester  Med.  Chronicle,  1889),  where  irritation  of 
the  great  abdominal  sympathetic  from  an  ancient  and  recent  peritonitis  was 
clearly  the  cause.  Again,  it  may  be  due  to  lesion  of  the  vasomotor  centres  or 
conducting  paths  in  the  spinal  cord,  syringomyelia,  tabes,  etc.,  or  of  the 
vasomotor  centimes  and  areas  in  the  medulla  and  brain ;  and  finally  it  may 
be  called  into  being  through  physical  or  psychical  reflexes. 

Diagnosis.  When  the  affection  is  well  developed  it  is  scarcely  possible  to 
mistake  it  for  any  other  disease.  The  symmetry  of  development,  the  distri- 
bution, the  sensory,  motor,  and  trophic  changes  coming  on  in  regular  order, 
and  the  absolute  lack  of  dependence  of  these  symptoms  on  constitutional 
disease,  are  characteristic.  Other  forms  of  gangrene  can  be  differentiated 
by  their  etiology,  and  it  is  only  necessary  to  mention,  senility,  ergot,  constric- 
tion, which  have  not  only  these  etiological  peculiarities,  but  cause  gangrene ' 
having  very  different  appearance  and  distribution.  Erythromelalgia  may  be 
confounded  with  Raynaud's  disease  when  local  erythema  occurs  in  the  second 
stage,  but  it  may  be  diffe^'entiated  by  its  mode  of  onset  and  the  fact  that 
erythromelalgia  never  goes  on  to  gangrene.  Diabetes  and  nephritis  can  be 
quickly  ruled  out  by  an  examination  of  the  urine.     It  should  not  be  forgot- 


THE  TBOPHO-NEUROSES.  885 

ten,  however,  that  both  of  these  conditions,  particularly  the  latter,  may  com- 
plicate Eaynaud's  disease. 

Prognosis.  Generally  speaking  the  prognosis  may  be  said  to  be  good.  The 
pro2:)ortion  of  cases  that  terminate  fatally  is  not  easy  to  calculate.  Numer- 
ous cases  in  which  death  occurred  are  on  record,  but  as  a  rule  the  cause  of 
death  was  some  complicating  or  intercurrent  disease,  such  as  phthisis.  The 
prognosis  is  bad  when  the  disease  develops  in  individuals  who  are  already 
afflicted  with  some  incurable  disease,  such  as  tabes  or  syringomyelia.  Except 
in  children  an  attack  probably  never  eventuates  in  death.  When  the  dis- 
ease goes  on  to  the  formation  of  gangrene  en  masse  the  general  health  may 
become  so  depraved  that  the  body  becomes  an  easy  victim  of  infectious  dis- 
ease, particularly  tubercle,  which  in  turn  shortens  the  patient's  life. 

Treatment.  The  most  important  factors  in  the  treatment  of  this  disease 
are  to  increase  the  patient's  nutrition,  to  counteract  the  neuropathic  diathesis 
from  which  so  many  of  these  patients  suffer,  and  to  render  him  immune  to 
causes  that  are  known  to  excite  attacks,  such  as  exposure  to  cold,  mental 
shocks,  and  the  like.  Measures  that  contribute  to  the  patient's  general 
health,  and  which  are  consistent  wdth  bodily  and  mental  quietude,  such  as 
change  of  climate,  regular  and  systematic  exercise,  and  avoidance  of  fatigue, 
should  be  taken.  During  an  attack,  if  the  pain  is  very  severe,  it  may  be 
necessary  to  give  an  anodyne,  such  as  morphine,  which,  however,  should  never 
be  injected  into  the  seat  of  the  pain,  for  any  irritation  to  those  parts  tends 
to  increase  the  liability  to  gangrene  and  amount  of  destruction  if  the  gan- 
grenous stage  does  occur.  The  affected  parts  should  be  wrapped  in  cotton 
and  placed  in  a  position  most  favorable  for  the  circulation,  the  temperature 
of  the  part  maintained  by  a  moderate  degree  of  artificial  heat,  either  dry 
heat  or  occasional  lukewarm  hand  and  foot  baths.  The  administration  of 
nitroglycerin  and  nitrite  of  amyl  has  been  warmly  recommended  by  some, 
but  the  consensus  of  opinion  is  that  use  of  either  one  is  usually  disappoint- 
ing. Electricity  has  been  used  extensively  since  Raynaud  first  recommended 
it,  but  its  therapeutic  value  in  this  affection  is  very  small.  Peter,  of  Paris, 
recommends  the  use  of  the  galvanic  current,  the  positive  pole  applied  over 
the  cervical  enlargement  and  the  negative  pole  in  a  basin  of  warm  salt 
water.  Each  of  the  four  extremities  are  bathed  in  turn  for  five  minutes, 
while  the  number  of  elements  used  is  increased  from  4  to  8,  10,  and  even  16 
for  each  member,  the  intensity  of  the  current  being  from  2  to  3  milliamperes. 
It  has  also  been  recommended  to  apply  one  pole  of  the  galvanic  current  to 
the  cervical  region  and  the  other  to  the  lumbar  and  send  the  current  through 
the  spine,  and  likewise  a  mild  galvanic  current  to  the  sympathetic  in  its 
various  portions,  but  the  truth  is  that  this  method  of  treatment  is  of  very 
little  use.  When  gangrene  sets  in  it  should  be  treated  according  to  the  prin- 
ciples of  modern  surgery. 


ANGIONEUROTIC   CEDEMA. 

Synonyms.  Acute  Circumscribed  CEdema ;  Acute  Idiopathic  GEdema  ; 
Periodic  Swelling ;  Urticaria  Tuberosa,  or  Giant  Swelling ;  Acute  Non- 
inflammatory CEdema. 

Angioneurotic  oedema  is  a  disease  characterized  by  the  appearance  of  cir- 
cumscribed swellings  on  different  parts  of  the  body,  by  preference  the  face, 
throat,  and  extremities,  without  apparent  cause  or  premonition,  and  non- 
inflammatory in  natui'e.  Reference  to  the  disease  can  be  found  in  medical 
literature  dating  back  as  far  as  1827,  but  it  is  only  since  1882,  when  Quincke 
and  his  pupil,  Dinkelacker,  gave  a  critical  description  of  the  disease,  that  it 


886  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

has  been  thoiiglit  anything  more  than  an  intercurrent  symptom.  The  term 
angioneurotic  oedema,  under  which  the  disease  is  most  commonly  described 
in  this  country,  is  not,  considering  our  ignorance  of  the  pathology  of  the  dis- 
ease, an  entirely  justifiable  one,  as  it  takes  for  granted  certain  factors  in  the 
genesis  of  the  disease  which  are  not  demonstrable.  The  term  acute  circum- 
scribed non-inflammatory  oedema  is  the  term  which  best  expresses  the  clini- 
cal characteristics  of  the  disease. 

Etiology.  The  most  important  predisposing  causes  are  heredity,  disor- 
dered health,  overwork,  and  exhaustion.  In  a  large  proportion  of  the  cases 
that  have  been  reported  there  is  evidence  of  a  strong  neuropathic  taint,  mani- 
festing itself  as  hysteria,  hystero-epilepsy,  neurasthenia,  or  some  evidence  of 
degeneration.  Direct  heredity  is  one  of  the  most  important  and  interesting 
elements  in  the  production  of  the  disease.  It  has  been  pointed  out  with 
remarkable  accuracy  by  Strubing  (Zeitschr.  f.  Min.  Med.,  ix,  p.  389)^ 
Quincke  ( Monatschrifl  f.  prakt.  Dermatol.,  1882,  i.),  Falcone  (Rivista  Veneta, 
Veneza,  1887,  vii.  ^,  Osier  {American  Journal  of  the  Medical  Sciences),  and 
others.  In  the  latter's  case  the  author  was  able  to  trace  the  hereditary  influ- 
ence through  five  generations,  in  which  time  no  less  than  twenty  individuals 
were  afflicted  with  the  disease.  In  the  fourth  generation  eight  people  were 
affected.  In  cases  that  are  directly  hereditary,  male  and  female  seem  to 
furnish  about  an  equal  number  of  cases. 

The  sinister  influence  of  psychical  and  physical  exhaustion  can  be  traced 
in  some  cases,  although  the  greater  number  of  these  patients  considered 
themselves  in  good  bodily  health.  In  some  cases  the  disease  develops  while 
the  individual  is  doing  exhausting  bodily  and  mental  labor,  as  was  the  case 
in  a  physician  under  the  writer's  observation. 

The  period  of  early  adult  life  fiirnishes  the  greatest  number  of  cases,  the 
average  age  being  about  about  twenty-seven  years.  Childhood  is  by  no 
means  exempt.  Dinkelacker  has  reported  a  case  in  a  child  three  months 
old,  in  whom  the  disposition  to  the  disease  was  inherited.  It  rarely  occurs 
for  the  first  time  in  individuals  upward  of  sixty  years,  although  it  does  occa- 
sionally, as  is  shown  by  a  case  reported  by  Goltz  {Deutsch.  med.  Wochenschrift, 
1880,  No.  17).  An  examination  of  ninety  cases,  to  determine  which  sex  is 
most  frequently  affected,  shows  that  it  occurs  about  twice  as  often  in  females 
as  in  males  in  Germany  and  in  France,  while  in  this  country  and  in  Eng- 
land the  occurrence  in  the  sexes  is  about  equal. 

Among  the  exciting  causes  that  may  be  mentioned  as  having  been  found 
in  several  cases  are  exposure  to  cold,  gastric  irritation,  the  onset  of  puberty, 
the  climacteric,  masturbation  during  the  unstable  time  of  adolescence,  trauma, 
fright,  and  the  influence  of  certain  toxic  substances,  j)articularly  tobacco, 
malaria,  and  alcohol.  The  causative  influence  of  the  last  three  mentioned  is 
frequently  seen  when  they  have  been  intercepted  for  a  time  and  then  renewed. 
Such,  for  instance,  as  excesses  in  alcohol  and  tobacco  after  a  period  of  cessation, 
and  return  to  a  malarial  district  after  a  period  of  prolonged  absence.  Of 
the  exciting  causes  exposure  to  cold  is  one  of  the  most  potent,  and  is  shown 
in  cases  reported  by  Starr,  Widonitz,  Kirsch,  Jamieson,  and  myself.  In  one 
of  Starr's  patients  the  hands  swelled  every  time  she  put  them  in  cold  water, 
and  in  winter  exposure  of  the  face  and  hands  when  out  of  doors,  or  of  the 
buttocks  in  a  cold  water-closet,  was  sure  to  be  followed  by  an  appearance 
of  the  swelling. 

The  time  of  the  appearance  of  the  swellings  has  been  in  some  cases  very 
regular  ;  such,  for  instance,  as  in  a  case  reported  by  Matas  (Neiv  Orleans  Med. 
Journ.,  Oct.  1887);  but  in  these  cases  the  periodicity  is  to  be  attributed  to  ma- 
larial poisoning.  In  the  great  number  of  cases  the  swellings  may  appear  at 
any  time  during  the  twenty-four  hours ;  the  time  when  attacks  are  most 


THE  TROPHO-NEUROSES.  887 

liable  to  show  themselves,  however,  is  between  2  and  6  a.  m.,  a  period  when 
the  tide  of  life  is  at  its  lowest  ebb  and  the  parts  least  resistant. 

Attacks  are  more  frequent  in  summer  and  winter  than  during  the  other 
two  seasons.  In  the  summer,  for  the  reason  that  it  is  during  this  period 
that  sudden  cooling  is  apt  to  take  place. 

It  has  been  previously  mentioned  that  this  disease  is  seen  in  those  who  are 
handicapped  through  some  inherited  or  acquired  neurotic  taint,  but  it  must 
be  mentioned  that  it  occurs  in  those  from  whom  no  neurotic  history  can  be 
obtained,  who  have  no  bad  habits,  and  who  are  in  comfortable  circumstances 
in  life.  In  fact,  it  may  be  said  that  in  a  considerable  number  of  cases  the 
closest  search  will  not  reveal  an  attributable  cause. 

Symptoms.  The  manifestations  of  the  disease  generally  present  them- 
selves without  warning  and  most  commonly  on  the  face,  the  lips,  the  tongue, 
pharynx,  forehead,  and  genital  organs.  In  some  cases  the  patient  may 
complain  a  short  time  before  the  appearance  of  the  swelling  of  a  feeling  of 
malaise  or  depression,  associated  with  ill-defined  gastro-intestinal  symptoms. 
The  oedema  reaches  its  full  development  in  from  one-half  to  two  hours,  and 
gives  the  patient  very  little  discomfort,  except  by  its  mere  presence.  There 
is  a  feeling  of  stifihess  and  unwieldiness  and  a  sensation  of  tension,  but  no 
subjective  sensation  of  inflammatory  swelling,  such  as  a  sense  of  throbbing 
and  pulsating  pain.  The  swelling  varies  in  color,  is  clearly  circumscribed, 
and  is  closely  diflerentiated  from  the  surrounding  surface.  Ordinarily  the 
color  is  whitish,  with  a  little  rose  tinge,  but  in  some  cases  the  skin  over  the 
swelling  is  of  a  dull  roseate  hue,  Avith  a  whitish  shading  near  the  centre  of 
the  swelling.  The  swelling  does  not  pit  on  pressure,  or,  if  it  does  slightly, 
the  indentation  is  quickly  effaced.  The  amount  of  swelling  varies  in  each 
case ;  sometimes  it  is  so  slight  that  it  is  scarcely  noticeable,  while  in  other 
cases  the  patient  is  quite  unrecognizable  when  the  swellings  occur  on  the 
face.  It  lasts  from  a  few  hours  to  a  few  days,  but  in  the  vast  majority  of  the 
cases  no  trace  of  the  swellings  can  be  found  after  twenty-four  hours.  It  may 
occur  in  separate  parts  of  the  body  simultaneously,  but  frequently  its  disap- 
pearance from  one  part  of  the  body  is  the  signal  for  its  manifestation  in 
another,  which  may  have  no  relation  to  the  part  previously  affected ;  for 
instance,  it  will  jump  from  the  forearm  to  the  eyelids,  or  from  the  lips  to  the 
crest  of  the  ilium,  or  from  the  cheeks  to  the  stomach — that  is,  to  parts  hav- 
ing no  apparent  anatomical  or  physiological  connection.  As  a  rule,  it  does 
not  show  itself  in  more  than  two  or  three  localities  at  one  visitation,  and 
frequently  in  only  one.  After  its  disappearance  from  an  area,  a  heavy  wooden 
sort  of  a  feeling  is  complained  of,  although  the  responses  of  the  different 
sensations  are  unimpaired. 

The  subjective  sensations  are  a  sense  of  scalding  or  burning  as  the  swelling 
is  showing  itself,  and  due  probably  to  the  tension  under  which  the  skin  is 
suddenly  placed.  Occasionally  there  is  a  feeling  of  itchiness,  not  only  in 
the  parts  that  are  swollen,  but  in  the  neighboring  skin,  and  if  the  skin  is 
scratched  an  artificial  urticaria  is  the  result.  Aside  from  these  if  the  swell- 
ing does  not  encroach  upon  any  organ,  such  as  the  eye,  the  stomach,  the 
penis,  and  testicles,  or  if  it  does  not  block  up  the  conductivity  of  a  passage, 
such  as  the  mouth,  pharynx,  the  larynx,  or  intestine,  as  it  sometimes  does, 
there  will  be  scarcely  any  other  subjective  symptoms.  There  are  two  symp- 
toms or  conditions  which  sometimes  occur,  but  which  must  be  regarded  as 
complications,  viz.:  hsemoglobinuria  and  albuminuria,  and  effusion  into  the 
joints. 

The  mucous  membrane  of  the  larynx,  the  pharynx,  stomach,  and  intes- 
tines are  sometimes  affected,  and  when  any  of  these  parts  is  the  seat  of  the 
swelling  the  symptoms  may  become  very  distressing,  and  even  inimical  to 


888  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

life.  When  the  swelling  appears  in  the  larynx  the  symptoms  are  those  of 
obstruction,  and  are  in  proportion  to  the  amount  of  encroachment  that  it 
makes.  This  is  often  so  great  that  distressing  symptoms  of  suffocation  are 
produced,  and  in  some  instances  death  has  taken  place  in  consequence  of  the 
oedema,  as  in  two  of  the  cases  reported  by  Osier.  In  some  cases  the  symp- 
toms are  so  urgent  that  it  is  necessary  to  make  scarification  of  the  membrane 
or  to  do  tracheotomy.  When  the  swelling  is  in  the  glottis  or  the  pharynx 
difficulty  in  swallowing  and  a  sense  of  constriction  are  proportionate  to  the 
amount  of  oedema.  In  a  few  instances  the  swelling  has  come  on  so  abruptly 
and  reached  such  an  extent  that  the  awful  sensation  of  choking  to  death 
develops  within  a  very  short  period.  Only  one  case  has  been  reported  where 
the  oedema  of  the  glottis  was  so  great  that  death  resulted.  (Krieger  :  Med- 
itsinskvie  Obozrenie,  1889,  No.  17). 

In  about  one-third  of  the  cases  gastro-intestinal  symptoms  are  prominent. 
They  are,  first,  a  feeling  of  uneasiness  and  tension,  as  if  something  un digesti- 
ble had  been  swallowed  ;  with  this  there  is  loss  of  appetite  and  sense  of  weight 
in  the  epigastrium,  which  is  soon  followed  by  a  feeling  of  distention  in  the 
stomach,  nausea,  and  constipation.  The  symptoms  grow  more  distressing, 
and  sharp  colicky  pains  often  attend  with  profuse  vomiting,  and  great  thirst 
follows.  The  pain  is  often  so  severe  as  to  demand  the  administration  of  mor- 
phine. The  character  of  the  vomit  depends  at  first  ujDon  the  contents  of  the 
stomach,  but  later  it  is  watery,  contains  a  good  deal  of  stringy  mucus,  and  is 
profuse  in  quantity.  After  the  paroxysm,  which  may  last  from  a  few  minutes 
to  several  hours,  there  is  frequently  diarrhoea  of  a  colliquative  nature  with 
an  apparent  retraction  of  the  abdomen,  and  a  general  feeling  of  languor  and 
prostration.  Often  during  or  following  such  an  attack  the  patient  passes  a 
large  quantity  of  water,  which,  however,  contains  nothing  abnormal  save  an 
increased  quantity  of  earthy  phosphates. 

A  few  authors  have  reported  cases  in  which  the  oedema  seemed  to  mani- 
fest itself  in  the  lungs,  although  this  has  never  been  proven  by  post-mortem 
examination.  If  it  be  granted  that  it  does  occur  in  the  lungs,  the  symptoms 
resulting  will  not  differ  materially  from  those  of  ordinary  pulmonary  oedema 
except  in  the  suddenness  of  its  onset  and  the  urgency  of  the  symptoms  and, 
frequently,  the  abrupt  mode  of  departure. 

The  primary  point  of  manifestation  and  the  area  of  distribution  of  the 
swellings  were  studied  by  me  in  a  series  of  71  cases,  personal  and  taken 
from  the  literature.  In  these  the  swelling  showed  itself  primarilly :  in  the 
face  in  29  cases,  on  the  extremities  in  22,  in  the  larynx  in  5,  on  the  genitals, 
penis,  vulva,  and  scrotum  in  3,  on  the  body  in  6,  on  the  gums  and  palate  in 
1,  in  the  stomach  in  3,  on  the  neck  and  behind  the  ear  in  1  each.  Of  the 
cases  in  which  the  swelling  appeared  primarily  on  the  face,  3  were  restricted 
to  the  forehead,  3  occurred  first  on  the  eyelids,  7  on  the  lips,  while  the  re- 
mainder were  distributed  on  various  parts  of  the  face.  On  the  extremities 
the  hands  are  by  far  most  frequently  affected,  and  the  swelling  here  attains 
sometimes  an  enormous  degree.  The  crest  of  the  ilium,  the  buttocks,  the 
front  of  the  abdomen,  and  over  the  shins,  may  be  the  seat  of  the  swellings. 

Although  it  attacks  some  regions  by  preference,  it  rarely  confines  itself  to 
one  locality  ;  migration  is  one  of  its  marked  characteristics,  and  rarely  is  it 
confined  to  one  locality.  The  occurrence  of  swelling  in  one  spot  seems  to 
predispose  that  place  for  future  attacks.  Parts  of  the  body  which  have  pre- 
viously been  injured,  or  which  have  been  the  seat  of  protracted  pain,  seem 
in  some  instances  to  be  a  favorite  seat  for  the  swellings. 

The  interval  between  attacks  is  a  variable  one :  in  some  cases  a  few  days, 
in  others  as  many  months.  The  general  health  between  the  attacks  is,  as  a 
rule,  good.     In  one  case  recently  under  the  writer's  observation,  there  was 


THE  TROPHO-NEUBOSES.  889 

some  tachycardia,  palpitation,  and  a  pulse  of  very  low  tension  ;  but  the  cause 
of  the  disease  in  this  man  was  undoubtedly  tobacco,  it  being  his  habit  to 
consume  from  thirty  to  fifty  cigars  daily ;  so  the  cardiac  symptoms  were  at- 
tributed to  the  smoking.  For  a  day  or  two  after  an  attack  there  may  be  a 
feeling  of  tiredness  and  languor,  especially  if  the  digestive  mucous  membranes 
have  been  involved,  but  this  soon  passes  away,  and  the  patient  remains  well 
until  the  appearance  of  the  next  attack. 

Diagnosis  and  Prognosis.  The  diagnosis  of  this  disease  is,  as  a  rule,  not  diffi- 
cult, particularly  if  arrived  at  by  a  process  of  exclusion.  The  fact  that  the 
swelling  is  distinctly  circumscribed,  that  it  is  not  tender  to  the  touch,  that  it 
does  not  pit  on  pressure,  that  it  has  none  of  the  characteristics  of  an  inflam- 
matory swelling,  that  it  is  frequently  associated  with  urticaria,  and  the  mode  of 
its  onset  and  disappearance  are  characteristic  and  are  not  easily  mistaken  for 
other  forms  of  oedema.  Kussner  {Berlin.  Min.  Wochenschr.,  1889,  No.  16) 
has  described  angioneurotic  oedema  as  occurring  with  a  rheumatic  attack, 
but  it  is  probable  that  such  attacks  are  but  intercurrent  non-inflammatory 
exudates  into  the  joint,  which  complicate  this  disease,  as  was  mentioned  pre- 
viously. It  may  be  confounded  with  the  blue  oedema  of  hysteria,  as  de- 
scribed by  Sydenham,  or  the  white  oederaatous  swellings  occurring  with  the 
same  disease,  as  described  by  Charcot.  In  hysteria,  however,  and  especially 
if  the  hysterical  attack  is  sufficiently  profound  to  have  oedema  as  one  of  its 
attendants,  there  will  always  be  found  some  of  the  well-known  stigmata  of 
hysteria,  which  will  be  sufficient  to  make  the  diagnosis.  It  may  be  said  with 
truth  that  the  oedema  occurring  with  hysteria  is  an  angioneurotic  oedema,  but 
it  has  a  difierent  symptomatology  and  suggests  different  treatment  than  the 
symptom-complex  which  we  have  described.  Although  almost  all  the  cases  of 
angioneurotic  oedema  are  developed  in  neurotic  subjects,  in  my  experience 
it  is  most  uncommon  to  find  any  evidences  of  hysteria.  Malarial  oedema, 
menstrual  oedema,  and  a  disease  of  the  Antipodes,  known  as  Australian 
blight,  are  in  all  probability  forms  influenced  by  the  etiological  factor  of  the 
disease  in  question.  It  is  barely  possible  to  confound  it  Avith  erythema 
nodosum,  but  the  absence  of  tenderness  and  the  pale  color  will  make  the 
•diagnosis.  The  integrity  of  the  internal  organs  and  the  peripheral  vessels 
will  exclude  the  possibility  of  attributing  the  oedema  to  some  primary  cause. 
The  duration  of  the  disease  varies  from  a  period  sufficient  for  one  attack  to 
a  lifetime.  It  is  probable  that  a  respectable  proportion  of  the  cases  cease 
spontaneously  as  the  patient  grows  older.  In  some  cases,  after  an  absence 
of  several  years,  the  symptoms  manifest  themselves.  In  some  cases  it  continues 
to  recur  with  varying  intervals  during  the  patient's  entire  life,  which  may 
not,  however,  be  perceptibly  shortened  by  the  occurrence  of  these  attacks. 
In  a  general  way  it  may  be  said  that  when  the  disease  does  not  appear  in  the 
mucous  membranes  it  does  not  in  any  way  interfere  with  the  life  of  the 
patient.  When  it  does  affect  the  mucous  membranes,  especially  of  the  larynx 
and  pharynx,  there  is  danger  to  life  from  suffocation.  The  prognosis  as  re- 
g;ards  recovery  is  fairly  good,  particularly  if  there  be  no  hereditary  element 
in  the  etiology.  The  prognosis  is  best  in  those  cases  which  can  be  proven  to 
be  dependent  on  some  toxic  element,  such  as  tobacco,  alcohol,  and  malaria, 
and  in  those  associated  with  some  diathesis,  such  as  the  lithsemic. 

Pathology.  The  nature  of  the  lesion  is  unquestionably  that  of  a  non-in- 
flammatory oedema,  and  clinical  and  experimental  evidences  tend  to  show 
that  the  essential  disease  is  a  vasomotor  neurosis  rather  than  a  tropho-neu- 
rosis.  The  vasomotor  system  frequently  is  called  upon  to  manifest  josychical 
states,  either  by  an  excessive  dilatation  of  the  vessels  or  by  a  contraction, 
causing  blushing  or  pallor.  That  is,  there  is  no  doubt  of  the  occurrence  of 
of  neurotic  ischsemia  and  hypersemia.     There  is  no  dearth  of  clinical  evi- 


890  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

dence  to  prove  that  oedema  may  occur  through  purely  nervous  influence* 
Weir  Mitchell  has  recorded  several  instances  of  the  occurrence  of  oedema 
associated  with  injury  of  a  nerve,  and  it  is  not  uncommon  to  see  a  non-in- 
flammatory swelling  develop  after  stretching  of  a  nerve  for  a  therapeutic 
purpose.  Cases  of  trigeminal  neuralgia  and  of  cranial  neuralgia,  which  are 
accompanied  by  oedematous  swelling,  and  transitory  oedema  associated  with 
some  diseases  of  the  spinal  cord,  such  as  tabes,  although  not  the  rule,  are 
still  not  uncommon.  The  cases  that  develop  oedema  under  hypnotism  would 
seem  to  be  most  convincing  to  prove  that  psychical  and  nervous  influences 
are  sufficient  to  cause  such  swellings.  Many  of  these  cases  have  been  re- 
ported. A  case  related  by  Paschalis  (Gazeta  lekarska,  1890,  No.  30)  shows 
clearly  the  psychical  influence.  A  young  woman  consulted  a  fortune-teller, 
who  prophesied  misfortune  for  her  client  if  she  went  to  a  certain  town.  She 
went,  however,  but  soon  after  her  arrival  had  severe  pain  in  the  arm  and 
forearm,  which  became  oedematous  and  remained  so  until  she  left  the  town. 
Experimentally  it  has  been  proved  that  irritation  of  the  peripheral  end  of 
the  divided  lingual  nerve  will  cause  oedema  of  the  tongue,  and  Horsley  and 
Boyce  have  corroborated  Ranvier's  statement  that  after  ligation  of  the  iliac 
vein  on  one  side,  oedema  does  not  occur  in  the  limb  of  that  side  until  after 
the  sciatic  nerve  has  been  cut.  That  the  transudation  of  living  fluids  through 
living  membranes  is  not  a  mere  physical  phenomenon  has  been  proven  by 
Tigersteclt  and  Santesson  (Mitihei/ung  vomPhysiolog.  Lab.  des  Carol.  Med.- 
Chir.  InstU.  in  Stockholm,  1886). 

The  fact  that  a  neurotic  oedema  can  occur  seems  to  be  beyond  cavil.  The 
seat  of  the  oedema  is  probably  most  often  in  the  connective  tissue  of  the  derma 
beneath  the  papilla  and  in  the  subdermal  tissue ;  very  rarely  the  oedema 
confines  itself  to  the  more  superficial  parts.  The  nerves  affected  are  the 
vasomotor,  and  the  sequence  of  events  is  probably  a  local  inhibition  of  the 
vaso-constrictors  or  a  reflex  stimulation  of  the  vaso-dilators ;  the  result  is  a 
retardation  of  the  current  and  a  resulting  serous  exudation. 

The  disease  in  its  development  has  a  close  relation  to  other  vasomotor 
neuroses,  such  as  morbid  blushing  and  flushing,  and  exophthalmic  goitre,  to 
many  of  the  arthopathies  not  yet  well  understood  and  particularly  to  urti- 
caria, which  is  so  commonly  an  accompaniment  of  the  appearance  of  the 
oedema. 

Treatment.  Unless  the  cause  can  be  discovered,  removed,  or  counteracted, 
therapeutic  measures  are  of  but  little  avail  either  in  mitigating  the  length  or  the 
severity  of  the  attacks.  If  the  cause  can  be  discovered,  its  inhibition  and  plac- 
ing the  patient  on  a  vasomotor  tonic  and  stimulant  will  be  followed  by  relief. 
The  verity  of  this  statement  is  well  shown  by  the  patient  spoken  of  previously 
in  whom  the  disease  was  the  result  of  the  excessive  use  of  tobacco.  As  soon  as- 
the  tobacco  was  interdicted  and  the  patient  placed  on  mineral  acids  and  strych- 
nine he  began  to  recover.  As  a  rule,  the  greatest  success  will  be  obtained  by 
adopting  such  measures  as  give  tone  and  stability  to  the  nervous  system. 
As  an  all-round  vasomotor  and  general  tonic  to  the  nervous  system  strych- 
nine is  the  best.  It  should  be  given  in  large  doses  and  until  its  physological 
effects  are  manifest,  particularly  on  the  spinal  cord.  The  next  most  impor- 
tant drug  in  the  treatment  of  the  disease  is  atropine  ;  it  should  be  given  like- 
wise in  large  doses,  and  its  administration  continued  in  small  doses  during 
the  intervals  between  attacks.  Tonics,  invigorating  baths,  exercise,  massage, 
and  the  prevention  of  cold  and  trauma  are  the  most  important  factors  in 
the  treatment  of  this  disease.  If  there  be  an  excess  of  uric  acid  in  the 
blood,  as  manifested  by  a  disproportionate  relation  to  the  urea  in  the  urine, 
this  condition  demands  regulating.  In  these  cases  the  administration  of 
colchicum  is  often  followed  by  gratifying  results.     The  frequency  of  the 


THE  TROPHO-NEUROSES. 


891 


Fig.  291. 


attacks  will  be  diminished  by  attention  to  the  bowels,  digestion,  and  menstrua- 
tion. For  the  paroxysmal  hsemoglobinuria  and  albuminuria  that  sometimes 
occur,  quietness  and  low  diet  should  be  enjoined.  The  treatment  at  the  time 
of  an  attack  will  depend  somewhat  on  the  part  of  the  body  where  the  dis- 
ease is  manifest.  If  the  dermal  surface  of  the  body  is  the  seat  of  the  swell- 
ing, the  most  satisfactory  treatment  is  to  keep  the  patient  quiet,  in  an  equable 
temperature,  and  apply  dry  heat  to  the 
swelling ;  if  there  is  much  uneasiness  a  mild 
anodyne  may  be  given.  Compression  by 
means  of  a  bandage  or  a  Gamgee  dressing 
is  sometimes  of  benefit.  When  the  disease 
manifests  itself  in  the  mucous  membranes,  the 
treatment  is  entirely  symptomatic.  When 
the  gastro-intestinal  symptoms  are  promi- 
nent, moi"phine  should  be  given.  When  the 
swelling  occurs  in  the  pharynx  or  the  larynx, 
the  physician  should  be  ready  to  operate  at 
any  moment. 

Measures  devoted  to  bettering  the  general 
health  of  the  patient  will  be  followed  by  the 
best  results. 

ACROMEGALY. 

In  1886  P.  Marie,  of  Paris,  described  a 
chronic  disease  characterized  by  great  in- 
crease of  the  extremities  of  the  body,  the 
hands,  the  feet,  and  the  face  and  head,  to 
which  he  gave  the  name  acromegaly.  Since 
that  time  the  disease  has  been  recognized 
the  world  over,  and  upward  of  125  cases 
have  since  been  reported,  in  many  of  which 
carefiil  post-mortem  examinations  have  been 
made.  Although  the  most  striking  changes 
in  acromegaly  are  to  be  seen  in  the  extremi- 
ties, the  disease  is  by  no  means  limited  to 
them;  it  involves  in  its  progress  almost 
every  part  of  the  body.  Like  a  great 
many  other  diseases  that  are  seemingly  of 
recent  date,  acromegaly  has  been  noticed 
and  described  for  many  decades  past.  A 
disease  which  was  probably  acromegaly  was  reported  in  two  cases  by  Fried- 
reich under  the  title  of  hyperostosis  of  the  entire  skeleton ;  another  by 
Fritsche  and  Klebs  under  the  title  of  gigantism  ;  another  by  Lombroso  as 
general  hypertrophy,  macrosmia.  Some  of  the  cases  that  have  been  published 
under  the  heading  of  myxoedema  have  been  cases  of  acromegaly,  particularly 
one  reported  byHenrot  (Notes  de  Clinique  Medicale,  Rheims,  1877.)  Souza- 
Leite  thinks  that  there  can  be  no  question  but  that  a  case  reported  by  Sau- 
cerotte-Xoel  in  1772  was  a  typical  case  of  this  disease. 

The  name  acromegaly  literally  means  large  extremities,  and  many  writers 
believe  that  this  term  is  too  limited  to  embrace  a  disease  in  which  enlarge- 
ment of  the  extremities  is  but  one  of  many  striking  features.  Von  Reck- 
linghausen has  suggested  the  name  pachyacrie,  and  he  has  received  the  sup- 
port of  Mosler,  and  more   recently  Arnold  {Yirclwiv's  Archlv,   vol.  135), 


Case  of  acromegaly.    (Osborne 


892 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


who  says  that  as  the  extremities  are  not  only  enlarged  in  length,  but  from 
the  enormous  growth  of  bone  and  accompanying  changes  in  the  soft  tissue 
the  volume  is  greatly  increased,  the  term  pachyacrie  would  literally  and  ex- 
actly describe  the  condition  of  these  parts. 

Etiology.  The  disease  affects  males  and  females  about  equally,  the  ten- 
dency being  in  favor  of  males.  It  occurs  in  every  race ;  cases  of  it  having 
been  reported  in  the  negro,  the  Indian,  and  the  Mongolian.     Although  it 

Fig.  292. 


Hand  in  acromegaly.    (Osborne.) 


may  develop  at  any  age,  it  is  most  frequently  discovered  between  the  ages  of 
twenty  and  forty  years.  It  is  probable  that  the  disease  begins  to  develop 
most  frequently  shortly  after  the  age  of  puberty,  but  unless  its  course  is  rapid 
it  is  rarely  considered  other  than  excessive  natural  growth  at  first.  It  may 
occur  in  the  first  year  of  life,  Moncorvo  {Rev.  Mensuelle  des  Maladies  des 
I'Enfance,  December,  1892%  of  Rio  Janeiro,  has  recently  reported  such  a 
case,  and  it  may  develop  after  sixty  years.  So  far  three  congenital  cases  have 
been  repoi'ted,  although  Marie  has  stated  that  congenital  and  hereditary 
influences  can  be  eliminated.  The  previous  health  of  the  patient  has  seem- 
ingly no  bearing  on  the  development  of  the  disease.  In  most  of  the  patients 
the  general  health  has  been  good.  In  a  few  a  history  of  rheumatism,  mala- 
ria, or  some  of  the  more  common  acute  diseases  have  been  obtained,  but 
they  have  positively  no  significance.  Among  the  exciting  causes  that  have 
been  mentioned  by  more  than  one  writer  are  mental  worry  and  depression, 
fright,  exposure  to  cold,  injuries,  alcoholism,  rheumatism  and  gout. 

It  occurs  in  connection  with  syringomyelia,  with  locomotor  ataxia,  with 
elephantiasis,  hypertrophic  osteo-arthropathy,  gigantism,  and  some  psycho- 
ses. Various  theories  have  been  suggested  to  explain  the  occurrence  of 
acromegaly,  some  of  which  have  already  been  disproven,  notably  one  by 
Freund,  who  suggested  that  the  disease  was  one  of  development  showing  it- 
self first  about  the  time  of  puberty  and  consisting  of  a  return  to  a  primitive 
type,  with  large  hands  and  feet,  projecting  lower  jaw,  receding  forehead,  etc. 
Klebs  suggested  that  the  thymus  gland,  which  he  had  found  in  some  cases 


THE  TBOPHO-NEUBOSES.  893 

that  had  come  to  autopsy,  and  which  Erb  thought  was  indicated  by  the 
presence  of  retrosternal  dulness,  might  be  a  starting-point  of  a  vascular 
budding  and  proliferation  with  the  formation  of  angioblasts  and  resulting 
angiomatosis,  which  afterward  played  an  important  part  in  the  production  of 
the  characteristic  signs  of  the  disease.  It  is  now  conceded  that  the  theory 
has  no  anatomical  basis,  for  the  comparatively  large  number  of  cases  that 
have  come  to  autopsy  during  the  past  two  or  three  years  do  not  in  any  way 
bear  it  out.  Virchow  suggested  that  in  acromegaly  we  have  described  but 
half  a  disease,  the  latter  and  degenerative  half ;  that  in  the  beginning  these 
cases  are  often  accompanied  by  an  increase  of  muscular  power,  and  that  some 
of  them  are  hereditary.  Von  Recklinghausen  ]Dropagated  a  nervous  theory 
to  explain  the  origin  of  acromegaly  :  the  disease  was  essentially  an  angio- 
neurosis,  the  primary  manifestations  being  in  the  bloodvessels,  especially  the 
veins,  and  the  result  of  defective  innervation.  INIany  of  the  symj)toms  of 
the  disease,  such  as  the  excessive  perspiration,  the  polyuria,  pigmentation  of 
the  skin,  and  disturbances  of  menstruation,  lend  support  to  this  theory.  In 
fact,  it  may  be  said  that  the  supposition  that  the  disease  is  a  tropho-neurosis 
dependent  upon  or  associated  with  disease  of  the  pituitary  gland,  and  less 
frequently  the  thyroid,  is  constantly  being  corroborated  by  autopsies  that 
are  carefiilly  performed,  in  the  greater  number  of  which  some  diseased 
change  has  been  found. 

The  fiinction  of  the  pituitary  gland  is  not  well  known,  but  recent  re- 
searches, particularly  those  of  Andriezen,  Boyce,  and  others,  have  thrown 
much  light  on  this  subject.  The  former  investigator  has  proven  that  the 
subneural  gland  in  larval  amphioxus  is  the  analogue  of  the  pituitary  gland 
in  higher  animals  and  in  man.  He  believes  that  the  ensemble  of  evidence 
proves  that  the  pituitary  gland  is  not  a  simple  structure  having  one  simple 
ftmction,  but  a  complex  organ  composed  of  three  parts :  («)  An  anterior 
secreting  glandular  organ,  (6)  a  water-vascular  tube  lined  with  ciliated  epi- 
thelium and  connecting  the  buccal  cavity  Avith  the  ventricles  and  the  rest  of 
the  neural  cavities,  and  (c)  a  posterior  sensitive  nervous  lobe.  The  last  two 
are  well  developed  and  functionate  in  ancestral  vertebrata,  but  become  oblit- 
erated and  atrophied  in  structure  and  function  in  all  forms  above  larval 
acraniates  and  ammocetes.  In  man  the  posterior  lobe  represents  little 
beyond  a  neuroglia  remnant  of  what  was  once  a  functional  portion  of  nerve- 
tissue  in  ancestral  vertebrata.  The  glandular  secreting  portion  Cthe  ante- 
rior lobe  is  the  type  of  a  secreting  structure  of  epithelial  cells  arranged  in 
lobules  and  acini  with  many  ducts  opening  into  one  principal  duct.  Its 
secretion  is  carried  with  the  water  vascular  stream  through  the  central  nerv- 
ous system,  and  the  action  of  that  secretion  must  be  either  a  trophic  one  on 
the  nervous  tissues  or  it  must  have  a  destructive  effect  to  neutralize  waste 
products  resulting  from  the  activity  of  nerve-tissues. 

The  secretion  of  the  pituitary  is  needed  just  as  much  after  the  closure  of 
the  pituitary  duct  and  the  cessation  of  the  water  vascular  system,  for  the 
oxygen  which  was  then  provided  for  the  nervous  system  by  the  water  vascu- 
lar system  is  now  provided  by  the  blood  vascular.  Hence  the  pituitary  con- 
tinues its  secretion  after  the  duct  is  obliterated  and  the  gland  is  changed  into  a 
ductless  gland,  the  difference  being  that  the  secretion  is  an  internal  one  and 
absorbed  by  the  lymphatics. 

The  pituitary  gland  reaches  its  highest  functional  development  before 
man  is  reached  in  the  scale  of  evolution,  but  there  can  be  no  question 
that  it  plays  an  important  part  in  the  economy  analogous  to  that  of  other 
ductless  glands,  such  as  the  thyroid.  Clinically  and  anatomically  it  has 
been  proven  to  be  diseased  in  a  large  number  of  acromegalics,  and  the  con- 
viction is  growing  that  it  is  the  most  important  etiological  factor. 


894  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Symptoms.  The  symptoms  of  the  disease  come  on  very  gradually,  and  in 
most  cases  it  is  impossible  for  the  patient  to  tell  the  time  when  the  disease 
first  showed  itself.  Very  frequently  it  is  recognized  first  by  the  physician 
who  sees  the  patient  for  some  other  trouble,  or  accidentally.  The  early 
symptoms  are  a  feeling  of  general  weakness,  apathy,  frontal  headache,  which 
may  become  very  severe,  and  some  dragging  pain  and  pareesthesia  in  the 
extremities.  In  women  irregularity  of  menstruation  and  in  men  diminu- 
tion of  sexual  appetite  and  potency  are  early  symptoms.  The  patient  may 
notice  that  his  desire  for  food  and  drink  is  increased  and  that  he  is  gaining 
in  weight.  In  some  cases  vertigo  and  disinclination  to  make  any  great 
mental  or  bodily  exertion  are  early  symptoms.  The  patient  may  notice  that 
psychically  he  is  not  so  so  alert  as  formerly,  and  his  friends  notice  that  he  is 
introspective  and  depressed.  Vasomotor  symptoms,  such  as  excessive  perspira- 
tion, increase  of  urine,  and  pigmentation  of  the  skin,  and  a  tolerance  of  cold 
weather  may  all  be  early  symptoms.  Concomitant  with  these  or  following 
them  the  patient  or  some  one  with  whom  he  comes  in  contact  (his  boot- 
maker, glovemaker,  or  tailor),  notices  that  there  is  an  enlargement  of  the 
fingers  and  the  hands,  and  simultaneously,  or  later,  a  similar  increase  in  the 
feet  and  face,  while  the  stature  is  gradually  becoming  less.     (Fig.  293). 

Fig.  293. 


Hands  and  feet  in  early  stage  of  acromegaly. 

If  one  examines  such  a  patient  he  will  find  that  the  patient  has  a  peculiar 
posture  both  in  walking  and  standing ;  the  neck  is  bent  forward,  while  the 
head  is  tilted  slightly  backward  in  order  to  bring  the  eyes  up  to  a  level ;  the 
shoulders  are  rounded  and  stooping,  while  the  chest  is  prominent ;  the  gait 
is  non-elastic  and  heavy.  The  patient's  posture  is  accentuated  by  the  mark- 
edly prognathous  lower  jaw,  which  is  projecting  and  heavy.  The  lips  are 
large,  particularly  the  lower  one ;  the  mouth  has  lost  its  expression ;  the 
naso-labial  creases  have  become  fissures ;  the  nose  is  enlarged,  proboscis-like, 
frequently  slightly  pigmented,  and  with  wide  nasal  apertures ;  the  eyes  are 
deeply  set  and  overhung  by  thickened  supraorbital  arches  on  which  the 
eyebrows  are  coai-se  and  unkempt ;  the  lower  part  of  the  forehead  is  bulging, 
and  this  gives  a  retreating  appearance  to  the  upper  part ;  the  malar  bones 


THE  TROPHO-NEUROSES. 


895 


and  zygoma  stand  out  prominently ;  the  cheeks  are  flattened  ;  the  ears  are 
enlarged ;  the  hair  is  coai'se  and  dry  ;  the  beard  is  scant ;  and  the  skin  of  the 
face  is  dry  and  frequently  pigmented.  The  expression  of  the  eyes  is  dull, 
unanimated,  a  patient  grieving  sort  of  look.  (Fig.  294.)  The  hands  are 
enlarged,  but  the  proportion  between  the  hands  and  fingers  is  preserved  ;  the 
fingers  are  sausage-shape  and  the  hands  resemble  a  spade.  The  nails  are 
small,  flat,  and  longitudinally  striated.  The  wrists  are  enlarged  and  thick- 
ened, which  gives  the  resemblance  of  the  hands  to  a  battledore.  The  soft 
parts  of  the  hands  are  markedly  increased,  especially  along  the  ulnar  side, 

Fig.   294. 


Case  of  acromegaly,  showing  facial  expression.    (Dercum.) 

and  the  lines  in  the  palms  are  greatly  deej^ened.  All  the  tissues  of  the 
hands  are  excessively  developed,  the  bones,  the  muscles,  the  cellulo-adipose 
tissue,  and  the  skin.  Similar  changes  are  to  be  seen  in  the  feet.  The  large 
toe  may  be  increased  out  of  all  proportion  to  the  rest  of  the  foot,  and  fre- 
quently very  striking  is  a  pad  of  thickened  skin  and  cellulo-adipose  tissue 
along  the  fibular  edge  of  the  foot.  The  foot  has  lost  its  arch  and  its  grace, 
and  the  increase  in  the  os  calcis  makes  it  project  backward  like  a  snowshoe. 
The  spinal  column  shows  a  cervico-dorsal  kyphosis ;  the  thorax  projects 
anteriorly,  and,  with  the  enlarged  sternum,  gives  the  appearance  of  a  hump 
on  the  chest.  The  kyphosis  and  the  enlargement  of  the  thoracic  cage  give 
rise  to  a  deformity  which  has  been  aptly  compared  by  Marie  to  the  figure  of 
Punch.  There  is  frequently  a  slight  degree  of  scoliosis,  and  always,  if  the 
course  of  the  disease  is  sufficiently  long,  a  compensating  lordosis  in  the  lower 
dorsal  and  upper  lumbar  region.     (Fig.  291.) 


896  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

The  mammary  glands  are  flabby,  soft,  and  small ;  the  abdomen  is  volum- 
inous ;  and  the  genital  organs  in  both  men  and  women  are  frequently  the  seat 
of  marked  changes.  In  women  the  labia  majora,  the  nymphse,  and  the  other 
parts  of  the  vulva  are  very  greatly  increased  ;  the  vagina  is  long  and  capa- 
cious and  the  uterus  presents  the  changes  common  to  senile  involution.  In 
man  the  genitals  are  atrophied  or  in  some  cases  hypertrophied.  On  the 
skin  of  the  face  and  back  and  chest  are  frequently  found  small  molluscous 
growths. 

So  much  can  be  determined  by  looking  at  the  patient.  If  the  examination 
be  made  with  some  detail  it  will  be  found  that  none  of  the  special  senses 
with  the  exception  of  sight  are  very  much  disordered.  Smell  and  taste  have 
been  reported  defective  in  but  one  or  two  cases.  In  a  few  cases  the  patient 
complains  of  tinnitus  and  gradually  increasing  deafness,  and  in  these  cases  a 
thickened  and  degenerated  membrana  tympani  has  been  found.  Exophthal- 
mos is  a  common  symptom,  and  is  due  both  to  actual  enlargement  of  the  eye- 
balls and  bony  growth  in  the  orbital  cavities.  Narrowing  of  the  visual  fields 
and  hemianopsia  are  reported  in  a  great  number  of  cases.  Ophthalmoscopi- 
cally  varying  degrees  of  optic  neuritis  and  atrophy  are  found.  Some  optic 
neuritis,  the  result  of  pressure,  may  be  demonstrated  very  early  in  the  course 
of  the  disease,  while  vision  is  still  normal.  Nystagmus  and  paralysis  of  the 
ocular  muscles  are  more  common.  Disturbance  of  sensation  is  rare.  The 
skin  is  hard  and  hypertrophied  over  the  extremities,  while  on  the  body  and 
face,  and  especially  the  arms,  there  is  a  considerable  deposit  of  brownish 
pigment.  The  muscles,  especially  of  the  arms  and  legs,  are  in  the  beginning 
of  good  tone  and  development  depending  upon  the  patient's  occupation. 
With  a  few  exceptions,  they  are  never  greatly  hypertrophied  except  in  the 
hands  and  feet.  Electrical  irritability  of  nerves  and  muscles  may  be  sHghtly 
diminished,  but  is,  as  a  rule,  normal.  After  the  disease  has  lasted  for  a 
variable  time  the  muscles  become  soft  and  flabby,  and,  occasionally,  the 
unfortunate  patient,  unmindful  of  the  weakness  which  goes  hand-in-hand 
with  the  muscular  atrophy,  looks  upon  the  thinning  of  his  legs  and  arms  as 
a  good  omen.  When  the  patient  takes  a  long  inspiration  it  is  noticed  that 
the  expansion  is  almost  wholly  confined  to  the  inferior  portion  of  the  thorax 
and  the  abdomen.  Percussion  of  the  thorax  reveals  nothing  abnormal,  ex- 
cept in  some  cases  a  limited  area  of  retrosternal  dulness,  which  Erb  supposed 
was  due  to  the  presence  of  the  thymus  gland.  This  supposition  has  been 
disproven,  and  the  dulness  may  be  attributed  to  the  increase  in  thickness  of 
the  manubrium. 

The  visceral  organs  are,  as  a  rule,  normal.  The  voice  is  markedly  changed 
in  both  men  and  women.  It  is  low  pitched,  resonant,  very  voluminous, 
and  of  a  peculiarly  disagreeable  intonation.  The  larynx  is  greatly  aug- 
mented in  volume,  and  Marie  explains  the  increased  resonance  by  the  dilata- 
tion of  the  sinuses  of  the  face.  Speech  is  slow,  guttural,  somewhat  embar- 
rassed, and  seems  to  stick  in  the  mouth.  This  is  due  to  the  enlargement  of 
the  tongue,  which  may  go  on  to  an  enormous  degree.  The  tongue  is  deeply 
fissured,  the  alveolar  processes  enlarged,  and  the  palate  thickened. 

The  urine  is  generally  markedly  increased  in  quantity,  occasionally  con- 
tains albumin,  and  less  frequently  sugar  and  pei^tones.  The  appetite  is 
increased,  and  constipation  and  hemorrhoids  are  common  attendants.  Per- 
spiration is  commonly  excessive,  and  often  of  a  most  disagreeable  odor.  Elec- 
trical irritability  of  the  muscles  and  nerves  are  normal,  as  are  the  reflexes, 
except,  of  course,  a  quantitative  diminution  when  the  muscles  are  atrophied. 

Mentally  the  patient  is  oftfen  irritable,  depressed,  forgetful,  and  introspec- 
tive, and  presents  some  impairment  of  the  intellectual  faculties  ;  occasionally 
somnolency  is  very  marked. 


THE  TBOPHO-NEUBOSES.  897 

The  course  of  the  disease  is  a  progressive  one,  and  invariably  ends  in 
death,  either  from  exhaustion,  commonly  the  result  of  intra-cranial  pressure, 
from  suicide,  or  some  intercurrent  disease  which  finds  an  easy  victim  in  the 
acromegalic.  The  duration  of  the  disease  cannot  be  stated  with  accuracy, 
but  is  probably  from  ten  to  twenty  years. 

Differential  Diagnosis.  Acromegaly  must  be  differentiated  from  myxoe- 
dema,  hypertrophic  osteo-arthropathy,  osteitis  deformans,  leontiasis  ossea, 
elephantiasis,  adiposis  dolorosa,  gigantism,  and  local  hypertrophies.  The  first 
two  mentioned  are  of  most  importance,  and  the  j^oints  of  difference  are  con- 
trasted in  the  following  columns  : 

Acromegaly.  Myxmdema. 

1.  Occurs  most  commonly  in  early  adult  life.  1.  A  disease  of  mature  life,  40  to  50. 

2.  In  males  and  females  equally.  2.  Five  times  as  frequent  in  females  as  in  males. 

3.  Enlargement  of  the  bones  characteristic.  3.  No  enlargement  of  the  bones. 

4.  Marked  prognathism  of  jaw  and  flattening  of  4.  Face  full-moon  shape. 

cheeks 

5.  Skin  is  brownish-yellow  ;  hair  coarse  and  un-       5.  Skin  pale,  waxy,  shiny,  and  boggy ;  hair  falls 

wieldy  ;  the  nails  are  short  and  striated.  out ;  nails  not  affected. 

6.  Fingers  are  symmetrical  and  sausage-shaped.        fi.  Fingers  clubbed  at  the  end. 

7.  The  administration  of  thyroid  extract  is  of  the       7.  Thyroid  treatment  of  the  greatest  benefit. 

smallest  benefit. 

Acromegaly.  Hypertrophic  Osteo-arlhropathy. 

1.  Not  associated  with  pulmonary  trouble.  1.  Always  secondary  to  some  pulmonarj^  car- 

diac, or  otitic  disease. 

2.  Enlargement  of  the  hands  and  fingers  uni-       2.  Symmetryof  hands  and  fingers  not  preserved  ; 

versal  and  symmetrical.  joints  and  ends  of  fingers  principally  en- 

larged. 

3.  Nails  too  small  for  fingers.  3.  Nails  too  large  for  fingers,  and  characteristic 

beak-shape. 

4.  Cervico-dorsal  kyphosis.  4.  Dorso-lumbar  kyphosis. 

5.  Increase  of  bony  and  soft  tissue.  5.  Increase  in  bony  tissue  alone,  especially  at 

the  articular  ends  of  long  bones. 

6.  Lower  jaw  markedly  prognathous.  6.  Lower  jaw  not  particularly  prognathous. 

7.  Eye  symptoms  common.  7.  Eye  symptoms  rare. 

8.  Mentally  depressed  and  introspective.  8.  Mentally  hopeful. 

Arthritis  deformans,  leontiasis,  and  elephantiasis  will  rarely  be  confounded 
with  acromegaly  if  the  latter  is  carefully  studied.  In  leontiasis  ossium  there 
is  a  growth  of  true  bony  structure  in  the  shape  of  tumors  of  the  cranium 
and  face,  and  generally  an  absence  of  hypertrophy  of  the  extremities.  In 
arthritis  deformans  the  changes  are  principally  in  the  joints  of  the  extremi- 
ties, the  face  is  rarely  affected.  Elephantiasis  consists  of  cystic  and  tubular 
enlargement  of  the  lymphatics,  first  of  the  cutaneous  structure,  then  of  the 
more  deeply-seated  tissues,  attended  by  thickening  and  induration  of  the 
skin  and  connective  tissue,  and  dilatation  and  multiplication  of  the  blood- 
vessels, with  wasting  of  the  muscles  and  absence  of  changes  in  bony  struc- 
tures. In  osteitis  deformans  the  increase  in  bone  tissue  is  most  marked  in 
the  cranial  bones.  The  bones  of  the  face  are  but  slightly  affected.  The 
long  bones  are  principally  involved,  and  often  show  great  curvature  and  de- 
formity. The  hands  are  not  commonly  enlarged,  and  the  lower  part  of  the 
face  is  pointed.  The  differential  diagnosis  of  gigantism,  adiposis  dolorosa, 
and  erythromelalgia  will  readily  suggest  itself  It  should  be  kept  in  mind 
that  acromegaly  is  frequently  seen  in  giants,  such  cases  having  been  reported 
by  Dana,  Bramwell,  and  Taruffi. 

Pathology.  The  most  constant  organ  to  show  disease  in  acromegaly  is  the 
pituitary  gland.  In  a  large  proportion  of  the  autopsies  that  have  been  made 
this  organ  has  been  found  to  be  the  seat  of  tumor,  cyst,  hypertrophy,  or  in  some 
way  diseased.  Very  much  less  frequently  the  thyroid  gland  is  diseased ;  cystic, 
enlarged,  or  atrophied.  Very  rarely  is  the  thymus  found  diseased.  The  char- 
acteristic pathological  changes  are  to  be  seen  in  the  bones,  particularly  in  the 
extremities  of  the  long  bones.  The  growth  of  the  bones  is  a  true  hypertrophy, 
the  increase  taking  place  from  the  periosteum.     The  long  bones  may  appar- 

57 


898  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ently  lengthen  from  a  laying  on  of  bony  structure  at  their  extremities,  while 
the  shaft  is  not  at  all  afFected.  The  bones  of  the  cranium  are  thickened, 
and  new  bone  develops  in  the  diploe  and  in  the  outer  and  inner  jDlates.  The 
frontal  and  sphenoidal  sinuses  are  greatly  dilated,  the  sella  turcica  is  gener- 
ally deepened  and  enlarged.  All  the  bones  entering  into  the  formation  of 
the  parts  already  described  as  enlarged,  show  the  hypertrophy.  The  blood- 
vessels are  frequently  increased  in  calibre,  and  their  walls  thinned,  and  this 
is  especially  noticeable  in  the  veins.  An  increase  of  neuroglia  cells  of  the 
brain  and  hypertrophy  and  sclerosis  of  the  sympathetic  ganglia  are  occasion- 
ally found.  The  skin  is  hypertrophied,  particularly  over  those  parts  where 
the  enlargement  has  been  the  greatest,  the  cellulo-adipose  tissue  is  increased, 
and  the  muscles  are  generally  atroj^hied. 

The  bodies  of  the  vertebrae  are  generally  enlarged,  especially  in  the  ante- 
rior portion,  and  the  intervetebral  cartilages  are  thickened.  The  sternum, 
the  costal  cartilages,  the  clavicle,  the  scapulae,  and  pelvis  all  show  varying 
degrees  of  hypertrophy.  The  visceral  organs  are,  as  a  rule,  normal,  or  show 
only  the  lesions  of  intercurrent  diseases. 

Treatment.  The  treatment  is  entirely  symptomatic ;  measures  devoted  to 
keeping  up  the  general  strength  of  the  patient  should  be  taken.  The  head- 
ache and  pains  are  best  combated  by  the  use  of  antipyrin,  phenacetin,  and 
arsenic.  The  thyroid  extract  has  been  used  empirically.  In  a  case  now 
under  my  observation  the  patient  has  been  taking  it  for  upward  of  a  year 
without  the  slightest  degree  of  benefit  except  that  it  has  exercised  a  cosmetic 
action  on  the  skin,  which  has  become  softer  and  more  pliable.  The  patient 
has  also  lost  flesh.  It  may  be  remarked  in  this  connection  that  the  thyroid 
extract  seems  to  have  a  particular  power  to  reduce  obesity,  and  by  so  doing 
it  may  at  first  seem  to  exercise  a  beneficent  action  on  the  disease,  but  even 
this  is  temporary  and  fleeting. 


ADIPOSIS   DOLOROSA. 

Under  the  name  adiposis  dolorosa,  Dercum,  of  Philadelphia,  has  described 
a  peculiar  dystrophy  occurring  in  adult  persons  characterized  by  the  deposi- 
tion and  formation  of  fat  in  various  parts  of  the  body,  first  in  the  form  of 
bunches  or  nodules,  later  uncircumscribed,  and  attended  with  pain  and  fre- 
quently diminished  cutaneous  sensibility  and  excessive  muscular  weakness. 
No  other  cases  than  those  cited  by  the  first  writer  have  yet  been  jDut  on 
record,  but  cases  have  been  observed  by  other  clinicians.  Dr.  F.  P.  Henry 
having  described  a  case  under  one  title  of  myxoedematoid  distrophy.  Dr. 
Frederick  Peterson  and  Dr.  B.  C.  Loveland  have  put  at  my  disposal  the 
notes  of  six  cases  which  they  have  had  opportunity  to  carefully  study.  With 
the  exception  of  one  case  seen  by  Peterson,  all  the  patients  have  been  in  women 
from  forty  to  sixty  years  old.  Another  suggestive  factor  in  their  histories  is 
that  in  none  of  them,  except  in  one  case  observed  by  the  writer,  can  a  spe- 
cific or  alcoholic  history  be  ruled  out.  In  the  family  history  a  neurojoathic 
predisposition  is  evident  in  all  the  cases.  Further  than  this  nothing  can  be 
said  of  the  etiology. 

The  patient  first  notices  an  enlargement  of  some  part  of  the  body,  the 
ankles  or  legs,  the  arms  or  shoulders,  or  the  trunk.  This  enlargement  is  apt 
to  show  itself  in  the  shape  of  nodules  or  a  more  or  less  limited  enlargement ; 
these  may  for  some  time  limit  themselves  to  the  original  areas,  but  it  gener- 
ally increases  gradually  in  size,  and  eventually  the  deposit  makes  its  appear- 
ance elseAvhere  and  may  become  very  extensive.  Regions  of  the  body  may 
exist  which  remain  ^permanently  uninvolved.     The  onset  of  these  swellings 


THE  TROPHO-NEUBOSES.  899 

is  coincident  with  such  nervous  symptoms  as  parsesthesise,  sense  of  coldness 
in  the  part  affected,  dull,  aching  pain,  and  as  the  fatty  accumulation  increases 
and  becomes  more  universally  distributed  there  is  a  considerable  loss  of  mus- 
cular power  and  lessened  cutaneous  sensibility,  Avhich  may  go  on  to  complete 
ansesthesia,  especially  in  parts  where  the  subcutaneous  accumulation  is  greatest. 
The  pain  in  these  cases  is  a  very  variable  quantity  ;  in  some  cases  it  has  been 
paroxysmal,  of  a  burning,  scalding  character,  wlaile  in  others  it  is  present 
only  when  the  parts  are  subjected  to  pressure.  The  appearance  of  the  en- 
largements is  in  no  way  characteristic.  If  it  shows  itself  first  about  the 
ankles  the  parts  will  appear  puffy,  but  pressure  shows  that  it  is  not  in  the 
least  oedematous ;  the  skin  is  white,  soft,  flexible,  not  thickened,  and  except 
that  it  is  very  dry,  feels  quite  normal.  When  the  bunches  of  fat  develop 
first  on  the  upper  extremities  or  body  they  are  more  or  less  well  defined,  and 
as  they  continue  to  increase  in  size  they  form  huge  pendulous  masses.  (See 
Fig.  295.)     To  the  touch  they  are  somewhat  elastic,  comparatively  firm,  yet 

Fig.  295. 


Adiposis  Dolorosa.    (Dercum.) 


withal  have  a  pultaceous  feeling,  which  Dercum  says  resembles  the  feel  of  a 
large  varicocele,  except  that  it  is  more  resistant.  These  swellings  may  reach 
an  enormous  size,  so  that  combined  with  the  muscular  weakness  and  pain, 
which  movement  frequently  causes,  they  serve  to  make  locomotion  very  diffi- 
cult and  eventually  impossible.  The  fatty  accumulations  have  not  been 
noticed  in  the  hands,  face,  or  feet,  and  frequently  the  contrast  between  the 
feet  Avhich  preserve  their  normal  outline  and  contour  and  the  legs,  when  the 
latter  are  involved,  is  most  strikiug. 

Symptoms  that  were  present  in  some  of  the  cases  observed,  but  not  in  all, 
were  headache,  occasional  attacks  of  herpes  zoster,  attacks  of  hsematemesis 
and  epistaxis,  early  appearance  of  the  menopause,  and  in  one  case  the  recur- 
rence of  the  uterine  flow  many  years  after  cessation  of  menstruation. 

Trophic  symptoms,  such  as  pigmentation  of  some  parts  of  the  skin,  atrojshy, 
and  reaction  of  degeneration  in  the  thenar  and  hypothenar  muscles,  and 
absence  of  perspiration,  occurred  in  two  cases.  A  lessening  of  the  patellar 
and  triceps  reflex  has  been  observed,  but  this  Avas  probably  due  to  mechanical 
interference.  In  four  cases  there  was  progressive  mental  weakness,  and  in 
one  of  these  cases  complete  dementia  resulted.  Two  cases  have  come  to 
autopsy,  but  the  nervous  system  was  not  investigated  microscopically  in  either 
one.  In  both  cases  the  most  remarkable  deviation  from  normal,  aside  from 
the  fatty  accumulations,  was  a  change  in  the  thyroid  gland  ;  in  one  case  it 
was  enlarged,  in  the  other  diminished  in  size,  but  in  both  cases  it  was  infil- 


900  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

trated  by  calcareous  matter.  Otherwise  the  autopsies  showed  nothing  but 
the  lesions  of  the  disease  from  which  the  patient  died,  commonly  bronchitis, 
pulmonary  oedema,  and  degenerate  heart. 

Dercum  examined  microscopically  portions  of  the  fatty  accumulations 
■which  he  obtained  in  two  of  his  cases  by  means  of  a  Duchenne  trocar.  The 
examination  revealed  connective  tissue  and  fat  cells  present  in  varying  de- 
grees. The  former  was  decidedly  embryonal  in  type,  the  cells  being  large 
and  fusiform,  and  their  nuclei  correspondingly  large  and  prominent.  The 
fat  cells  for  the  most  part  were  associated  with  these  connective-tissue  cells, 
and  occasionally  individual  fat  cells  were  seen  in  which  fatty  metamorphosis 
had  not  been  complete.  In  the  more  recent  cases  the  embryonal  connective- 
tissue  cells  w^ere  considerable,  while  in  the  older  areas  a  fully  formed  adult 
fatty  tissue  seemed  to  be  present. 

What  the  nature  of  the  disease  is  it  is  impossible  to  say.  Dercum  origin- 
ally described  his  first  case  by  the  title  "  A  Subcutaneous  Connective-tissue 
Dystrophy  of  the  Arms  and  Back  associated  with  Symptoms  resembling 
Myxoedema."  The  fact  that  the  thyroid  gland  has  been  found  diseased  in 
the  two  cases  in  which  a  post-mortem  has  been  made  is  important  in  view  of 
what  we  know  is  the  dependence  of  myxoedema  upon  disease  of  this  organ. 
Dercum,  however,  is  of  the  opinion  that  as  these  cases  lack  the  peculiar 
physiognomy,  the  spade-like  hands,  the  infiltrated  skin,  the  peculiar  slow- 
ing of  speech,  and  a  host  of  other  symptoms  found  in  true  myxoedema, 
that  we  are  not  dealing  with  aberrant  forms  of  this  disease.  In  his  opinion 
we  have  to  do  with  a  connective-tissue  dystrophy,  a  fatty  metamorphosis  of 
various  stages  of  completeness,  occurring  in  separate  regions,  or  at  best 
unevenly  distributed,  and  associated  with  symptoms  suggestive  of  a  fugitive 
and  irregular  irritation  of  nerve-trunks — possibly  a  neuritis.  That  this,  how- 
ever, does  not  embrace  the  whole  truth  is  evidenced  by  such  symptoms  as 
the  diminished  sweating,  the  headache,  and  contraction  of  the  visual  fields. 
To  Peterson  it  seems  that  the  pathological  condition  underlying  this  disease 
is  a  rudimentary  polyneuritis,  with  a  hyperplasia  of  connective  tissue  and  a 
fatty  infiltration  of  connective-tissue  cells,  and  with  this  view  the  writer  is 
in  fullest  accord.  The  fact  that  syphilis  or  alcoholism  is  a  prominent  factor 
in  all  of  the  patients'  previous  histories  would  lend  color  to  this  view,  and  it 
is  quite  probable  that  microscopical  examination  of  the  nerves  in  future 
cases  will  show  the  presence  of  some  change  in  their  perij^heral  nerves. 

The  disease  has  to  be  diflferentiated  from  myxoedema,  acromegaly,  general 
obesity,  and  elephantiasis ;  but  in  view  of  the  fact  that  it  is  because  this  dis- 
ease does  not  tally  with  the  clinical  picture  of  any  of  these  diseases  that 
led  to  its  being  set  apart  for  separate  description  the  diagnosis  Avill  not  be 
difiicult.  It  is  diagnosed  from  lipomatosis  perimuscularis  circumscripta  by 
the  fact  that  the  latter  is  painless. 

The  disease  does  not  tend  to  spontaneous  cessation  or  to  recovery.  All  of 
the  cases  have  been  of  a  ^progressive  nature.  The  indications  for  treatment 
are  to  improve  the  nutrition  by  means  of  change  of  climate,  water  therapy, 
electricity,  measures  that  contribute  to  excessive  oxidation,  the  administra- 
tion of  strychnine  and  massage.  In  the  light  of  what  has  been  said  in  a  pre- 
vious connection  of  the  efiicacy  of  thyroid  therapy  to  reduce  simple  obesity, 
and  of  its  really  marvellous  properties  in  many  cases  of  myxoedema,  this  is 
a  form  of  treatment  that  should  be  given  a  thorough  trial. 

'SCLERODERMA. 

Scleroderma  is  a  disease  resulting  in  a  diflflise  or  circumscribed  induration 
and  atrophy  of  the  skin  and  subcutaneous  tissue.     It  has  been  variously  de- 


THE  TBOPHO-NEUBOSES.  901 

scribed  as  "  hide-bouucl "  disease,  scleroma  adultorum,  sclerosis,  cliorionitis, 
elephantiasis  sclerosis,  etc.  Clinically,  two  forms  of  the  disease  are  distin- 
guished:  (1)  Diffuse  symmetrical  scleroderma,  and  (2)  circumscribed  sclero- 
derma, more  commonly  known  as  morphoea  or  Addison's  keloid.  Formerly, 
morphoea  was  considered  a  disease  apart  from  scleroderma,  but  at  the  present 
time  almost  all  writers  on  the  subject  are  in  accord  that  it  is  a  circumscribed 
variety  of  scleroderma.     There  are  others,  however,  who  deny  this. 

The  most  characteristic  change  in  scleroderma  is  first  an  infiltration  giving 
rise  to  a  hard  swelling  in  the  beginning,  which  is  frequently  preceded  by 
vasomotor  disturbances,  and  later  the  absorption  of  the  infiltrated  tissue  and 
the  occurrence  of  a  scar-like  atrophy.  That  the  disease  is  a  very  rare  one  is 
shown  by  the  statement  of  Croker,  who  says  that  in  his  wide  experience 
with  skin  disease  he  has  treated  but  five  cases. 

Etiology.  Nothing  positively  is  known  of  its  actual  causation.  The  theory 
that  it  is  a  vasomotor  neurosis  receives  most  support.  The  etiological  factors 
of  importance  seem  to  be  sex  and  previous  infectious  disease.  About  three- 
fourths  of  all  the  patients  are  females.  It  may  occur  at  any  age,  from  one 
year  to  seventy,  but  the  majority  of  patients  are  in  the  second,  the  fourth, 
and  the  sixth  decennium.  It  occurs  after  infectious  diseases,  such  as  ery- 
sipelas, scarlatina,  pneumonia,  malaria,  tuberculosis,  and  rheumatism.  The 
time  elapsing  between  the  activity  of  any  of  these  diseases  and  the  manifes- 
tations of  scleroderma  is  a  variable  one,  but  usually  it  is  not  so  long  but  that  a 
relationship  can  be  traced.  Other  factors  that  seem  to  have  a  causal  rela- 
tionship are  first  of  all  exposure  to  cold  and  extreme  temperatures,  trauma, 
anomalies  of  constitution,  such  as  anaemia  and  scrofulosis.  Psychical  influ- 
ences, grief,  anxiety,  and  worry  are  often  present.  An  infectious  origin,  as 
was  suggested  by  Hoppe-Seyler,  cannot  be  conceded.  It  occurs  almost  always 
in  neuropathic  individuals  and  occasionally  in  those  who  are  suffering  from 
some  nervous  disease,  such  as  syringomyelia,  chronic  myelitis,  Raynaud's 
disease,  and  disease  of  the  brain. 

Symptoms.  The  disease  is  frequently  first  noticed  after  exposure  to  cold 
and  wet  or  fatiguing  and  exhausting  influences.  Pain  in  the  joints  and  ex- 
tremities may  precede  for  some  time  the  feeling  of  stiffness  in  the  skin.  This 
feeling  of  stiflfhess  is  most  commonly  felt  at  the  back  of  the  neck,  the  shoulders 
and  arms,  the  face  and  scalp.  The  lower  extremities  are  affected  very  rarely. 
The  onset  of  the  stiffness  is  insidious  and  unattended  with  constitutional 
manifestations.  Its  progress  may  be  either  slow  or  rapid.  When  sclero- 
dermatous induration  has  reached  its  height  the  skin  of  the  affected  region 
is  somewhat  increased  in  volume  and  of  leather-like  thickness,  and  as  it  in- 
volves the  skin  over  the  joints  these  become  fixed  as  the  skin  becomes  rigid. 
The  line  of  demarcation  between  the  healthy  and  the  involved  skin  is  not  a 
closely  defined  one  either  to  the  eye  or  to  the  touch,  for  the  one  merges  grad- 
ually into  the  other.  Attempts  to  pinch  up  the  skin  or  to  produce  pressure  on 
pitting  are  not  successful,  but  when  the  finger  is  quickly  and  firmly  drawn 
across  the  surface  a  whitish  line  with  a  pink  border,  which  disappears  slowly, 
is  left  behind.  When  the  skin  of  the  face  is  affected  all  trace  of  expression 
is  obliterated  and  the  regular  features  take  upon  them  the  white,  set  straight- 
ness  of  a  death  mask.  The  mouth  can  scarcely  be  opened,  the  ala?  of  the 
nose  are  bound,  and  the  eyes  nearly  closed  or  drawn  wide  open.  When  the 
skin  over  the  chest  is  involved,  the  latter  is  flattened,  the  breasts  compressed 
so  as  to  be  quite  effaced,  and  respiration  is  often  seriously  impeded.  In- 
volvement of  the  skin  of  other  parts  of  the  body  produces  more  or  less  fixa- 
tion depending  upon  the  parts  affected.  The  head  may  be  drawn  up  and 
almost  immovable  from  affection  of  the  skin  at  the  back  of  the  neck,  the 
upper  extremities  may  be  fixed  and  incapable  of  flexion  or  extension,  and 


902  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  process  may  become  so  extensive  that  the  patient  is  in  a  state  of  more  or 
less  complete  rigidity. 

The  aj)pearance  of  the  skin  differs  in  different  patients  and  in  different 
stages  of  the  disease.  It  may  be  so  white  that  it  resembles  marble,  or 
it  may  be  mottled,  pigmented,  striated,  and  the  natural  lines  obliterated. 
The  presence  of  subcutaneous  nodules  similar  to  those  sometimes  found 
in  rheumatism  and  in  chorea  occasionally  pushes  the  skin  up  and  gives 
it  an  uneven  appearance,  particularly  over  the  bones.  Parsesthesia,  pru- 
ritus, hyperesthesia  in  the  parts  affected  are  not  infrequent,  although,  as  a 
rule,  there  is  no  defect  of  sensibility.  The  secretions  of  the  skin  are  not 
notabl}^  diminished.  In  rare  instances  the  more  exposed  mucous  membranes, 
such  as  those  of  the  vagina,  the  mouth,  pharynx,  etc.,  are  affected. 

After  the  disease  is  fully  developed  recovery  may  take  place  without  leaving 
any  trace,  although,  as  a  rule,  it  may  be  said  that  it  shows  no  tendency  to  spon- 
taneous cure ;  or  atrophy  of  the  parts  may  progress.  Although  this  atrophy 
is  symmetrical  it  often  causes  deformities.  An  extremity  may  be  reduced 
almost  to  skeleton  size,  the  joints  fixed,  and  even  wasting  of  the  bones  may 
occur.  To  the  deformity  occurring  in  the  hand  due  to  flexion  and  extension 
of  the  phalanges  and  fingers.  Ball  has  given  the  name  sclerodactylie.  The  lips 
may  become  as  thin  as  ribbon  and  unyielding,  the  teeth  fall  from  atrophy  of 
the  gums,  and  the  eyes  may  be  uncovered  from  contraction  of  the  orbicularis. 

The  course  of  the  disease  may  extend  over  several  years.  As  has  been 
said,  during  the  stage  of  hypertrophy  recovery  may  occur,  but  after  the 
atrophic  state  is  fully  developed  recovery  never  results.  Although  the  dis- 
ease does  not  itself  cause  death,  it  predisj)oses  to  acute  disease,  such  as  rheu- 
matism and  acute  inflammations  of  the  respiratory  tract,  and  these,  because 
of  the  emaciation  and  depression  of  vitality  of  the  patient,  are  very  apt  to 
lead  to  a  fatal  termination.  When  Raynaud's  phenomenon  complicates  this 
disease,  which  it  does  not  infrequently,  the  prognosis  is  bad. 

At  the  present  day  there  is  little  doubt  that  morphcea  (f^opiprj^  form  or  blotch) 
is  a  circumscribed  variety  of  scleroderma.  It  presents  itself  in  the  form  of 
patches,  bauds,  or  streaks.  These  patches  vary  in  size  from  the  end  of  the 
finger  to  the  palm  of  the  hand.  They  present  themselves  gradually  without 
attracting  the  patient's  attention,  and  as  they  often  develop  on  parts  of  the 
body  that  are  not  easily  seen,  such  as  the  back  of  the  neck,  the  patch  fre- 
quently obtains  its  full  development  before  the  patient  is  cognizant  of  its 
presence.  In  color  they  are  dead- white  or  yellowish,  bordered  by  a  pinkish 
zone,  due  to  minute  dilated  bloodvessels,  which  may  be  made  out  by  careflil 
scrutiny.  The  patches  are  usually  limited  to  one  side  of  the  body  and  often 
confined  to  the  distribution  of  one  or  more  nerves,  as  in  herpes  zoster,  and 
on  account  of  this  parallelism  Hutchinson  has  suggested  the  name  of  her- 
petiform  morphoea. 

They  are  especially  apt  to  occur  on  the  breasts  and  on  the  face  over  the 
distribution  of  the  fifth  nerve,  particularly  its  supraorbital  branch  (Fig.  296). 
Unlike  the  diffuse  form,  it  is  more  common  on  the  lower  than  the  upper  ex- 
tremities. On  the  lower  extremities  the  surface  to  which  the  terminal  twigs  of 
the  short  saphenous  nerve  are  distributed  is  a  favorite  seat  of  morphoea.  The 
affected  skin  feels  like  parchment  or  leather  depending  upon  the  amount  of 
infiltration,  but  it  is  not  so  hide-bound  as  in  symmetrical  scleroderma.  The 
subjective  sensations  complained  of  do  not  differ  materially  except  in  inten- 
sity from  those  of  the  more  diffuse  form.  When  this  form  of  scleroderma 
occurs  in  bands  it  is  usually  single  and  raised  up  into  a  sort  of  a  ridge,  or  if 
adherent  to  the  adjacent  tissues  it  is  sunk  into  a  sulcus.  It  may  stretch  itself 
the  whole  length  of  an  extremity  or  it  may  extend  across  the  forehead  or  nose, 
and,  from  a  superficial  examination,  it  is  easily  mistaken  for  a  scar.     The 


THE  TROPHO-lS'EUROSES.  903 

course  of  this  form  of  the  disease  is  usually  slow,  but  iu  some  cases  a  patch 
may  be  evolved  in  a  few  days.  As  iu  the  difllise  form,  it  may  disappear  and 
the  skin  assume  its  natural  appearance,  or  it  may  go  on  to  contracture. 

In  morphoea  the  potency  of  neurotic  influences  in  causing  the  disease  are 
more  apparent  than  in  the  diffuse  form,  but  aside  from  this  the  etiology  is 
not  materially  different.  In  some  cases  pressure  or  local  irritation,  as  from 
a  garter,  seems  to  determine  the  location  of  the  affection. 


Fig. 

296. 

wt 

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m 

T*^H 

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m 

^ 

Morphcea.    Traumatic  origin.    (Cantrell.) 

Pathology.  Anatomically  the  disease  is  characterized  by  a  proliferation 
of  connective  tissue  and  by  vascular  changes  which  eventuate  in  a  fibrous 
peri-,  meso-,  and  endarteritis.  The  changes  in  the  bloodvessels  precede  those 
in  the  skin  and  are  causative  of  the  latter.  That  this  disorder  of  the  blood- 
vessels is  probably  a  vasomotor  one,  and  that  the  central  nervous  system  as 
well  as  the  sympathetic  is  involved  is  shown  by  its  association  with  diseases 
of  these  parts,  by  the  distribution  of  the  circumscribed  form,  and,  particu- 
larly, by  treatment  which  is  most  successful  when  the  measures  are  directed 
to  the  vasomotor  system.  The  thickening  of  the  nerve-sheaths  and  fatty 
degeneration  of  nerves  found  in  parts  affected  with  scleroderma  are  secondary 
to  the  vascular  changes.  The  result  of  thickening  of  the  vessels  is  to  inter- 
rupt the  circulation,  and  this  causes  the  swelling  and  hyperplasia  of  the  first 
stage  of  the  disease.  If  this  impairment  of  circulation  continues  long  enough 
it  leads  to  depravity  of  nutrition  and  atrophic  changes.  In  the  circum- 
scribed form  the  changes  in  the  bloodvessels  are  less  severe  and  is  greatest  at 
the  centre  of  the  patch,  while  at  the  periphery  or  border  of  the  patch  there 
is  a  dilatation  of  the  capillaries,  and  to  this  can  be  attributed  the  pinkish 
zone  often  seen  at  the  border  of  the  blotch.  The  morbid  anatomy  of  the 
sclerodermatous  process  shows  that  the  epidermis  is  of  normal  thickness  ;  the 
striatum  corneum  is  seen  to  be  composed  of  a  few  layers  of  flattened  cells  ; 
the  papillfe  and  appendages  of  the  skin  are  normal,  but  their  connective 


904  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

tissue  envelope  shows  extensive  small  cell  infiltration ;  a  similar  condition 
is  to  be  seen  in  the  subpapillary  bloodvessels.  The  upper  and  lower  layers 
of  the  corium  show  a  considerable  connective  tissue,  the  individual  fibrillge 
of  which  are  distinctly  divided  into  sections. 

The  diagnosis  of  scleroderma,  either  of  the  circumscribed  form  or  the  sym- 
metrical, offers  no  difficulties  if  the  disease  is  fully  developed.  The  striking 
swelling  and  hardness  of  the  skin,  its  hide-bound  immovability,  the  peculiar 
color  of  the  diseased  areas  in  the  first  as  well  as  in  the  last  stage,  and  the 
fixation  of  parts  aflfected,  are  pathognomonic.  The  condition  from  which 
the  circumscribed  form  of  morphoea  is  most  difficult  to  diflTerentiate  is  hemi- 
atrophia  facialis.  Both  diseases  are  tropho-neuroses  and  often  affect  similar 
areas,  and  undoubtedly  many  of  the  cases  reported  under  the  former  heading 
are  quite  as  properly  described  under  the  latter.  The  two  diseases  are,  how- 
ever, distinct.  In  the  former  all  the  tissues  are  affected  primarily ;  in  the 
latter  atrophy  of  the  deeper  tissue  is  secondary  to  pressure.  In  the  former 
it  is  very  probable  that  the  pathological  cause  of  the  disease  is  defect  of  de- 
velopment or  disease  of  the  fifth  nerve. 

Treatment  of  these  cases  is  not  considered  so  hopeless  now  as  formerly. 
The  object  of  treatment  should  be  to  invigorate  the  patient,  to  pay  especial 
attention  to  the  vascular  system,  and  to  obviate  factors  that  are  known  to 
aggravate  the  disease.  Careful  attention  to  diet,  exercise,  and  hygiene, 
combined  with  the  administration  of  iodides  and  arsenic  and  cod-Hver  oil, 
will  best  meet  the  first  indication.  Electricity  by  means  of  the  constant 
current,  salt-water  baths,  followed  by  an  application  of  a  2  per  cent,  salicylic 
vaseline,  wall  meet  the  second,  and  a  salubrious  and  equable  climate  for  the 
diffuse  form,  and  a  careful  avoidance  of  exposure  and  chilling  in  the  circum- 
scribed, will  best  obviate  the  causes  that  aggravate  the  disease. 

Lustgarten  has  referred  to  one  case  of  general  sclerodenna  under  his  ob- 
servation which  was  cured  by  the  use  of  the  thyroid  extract.  Sachs  has  also 
seen  a  case  of  the  cliffiise  form  of  a  severe  type  and  of  many  years'  duration 
in  which  the  thyroid  extract  has  done  so  much  good  that  the  patient  is  able 
to  do  her  housework,  sew,  etc.  Much  has  been  claimed  for  massage  in  the 
treatment  of  the  generalized  form,  and  undoubtedly  in  some  cases  it  does 
good,  particularly  if  combined  with  hydrotherapy  in  the  most  approved 
forms,  but  great  care  is  necessary  not  to  allow  the  massage  to  act  as  an  irri- 
tant ;  if  it  does  it  becomes  an  agent  for  harm,  instead  of  good. 

PROGRESSIVE  FACIAL  HEMIATROPHY. 

As  was  stated  above,  the  disease  that  so  closely  resembles  morphoea  of  the 
face  that  many  physicians,  particularly  dermatologists,  believe  them  to  be 
the  same  disease,  is  hemiatrophia  facialis.  Since  this  disease  was  first  de- 
scribed by  Parry,  in  1825,  it  has  been  known  by  such  names  as  facial  tropho- 
neurosis, prosopodysmorphie,  neurotic  atrophy  of  the  face,  aplasie  lamineuse 
progressive,  and  atrophic  du  tissu  conjonctif.  The  name,  progressive  facial 
hemiatrophy,  carries  a  clear  conception  of  the  disease  from  a  chnical  stand- 
point. The  disease  is,  as  its  name  implies,  a  progressive  wasting  of  one  side  of 
the  face,  in  which  all  the  structures  participate  in  a  varying  degree  ;  the  mus- 
cles least,  and  the  skin,  cellulo-adipose  tissue,  and  bone  most  of  all.  Although 
the  disease  has  been  extensively  written  on  during  the  past  half  century, 
since  Romberg,  in  1846,  gave  an  explicit  account  of  its  symptomatology,  the 
number  of  cases  reported  is  "still  very  few  and  the  disease  correspondingly 
rare.  In  an  extensive  search  of  the  literature  I  have  found  records  of  but 
126  cases. 


THE  TROPHO-NEUBOSES.  905 

Etiology,  The  disease  occurs  in  neuropathic  individuals  by  preference, 
and  more  frequently  in  females  than  in  males.  Youth  is  the  favorite  period 
for  its  development,  although  cases  have  been  reported  in  young  children 
and  after  sixty  (Borgherini).  Direct  heredity  has  been  determined  in  two 
cases.  In  Seeligmuller's  case  the  mother  of  a  nine-year-old  child  with  hemi- 
atrophy was  similarly  affected.  Local  trauma,  such  as  a  squeeze  of  the  face 
and  head  between  two  doors  (Skyrme),  a  blow  on  the  side  of  the  face  (From- 
hold-Treu,  Maragliano,  Schuchardt),  has  been  attributed  in  a  number  of 
instances.  Exposure  to  cold  and  irritation  of  the  side  of  the  face- — such,  for 
instance,  as  an  abscess  behind  the  ear  (Preobrashenski) — has  been  thought 
to  have  some  etiological  influence.  In  one  instance  the  disease  developed 
immediately  after  incision  and  probing  of  a  phlegmonous  dacrocystitis 
(Borgherini),  and  in  another  after  an  inflammation  of  the  submaxillary 
gland,  which  had  been  associated  with  angina  (Baerwald).  In  a  few  cases 
one  of  the  infectious  diseases — influenza,  erysij)elas,  scarlatina,  and  typhoid 
— has  preceded  the  onset  of  symptoms.  It  occurs  frequently  in  people  who 
have  some  degenerative  nervous  disease,  such  as  hysteria  (Parry,  Noth- 
nagel),  epilepsy  (Meyer,  Brunner),  tabes  (Jolly),  insanity  (Mendel),  mul- 
tiple sclerosis  (Jolly),  and  syringomyelia  (Schlesinger,  Dejerine,  and  Mi- 
raillia).  It  has  occui'red  in  connection  with  multiple  exostosis  of  the  head 
and  face  (Karewski),  with  localized  and  diffuse  scleroderma  in  other  parts 
of  the  body  (Nixon,  Muratow,  Rosenthal,  ISTewmark),  with  pityriasis  rubra 
(Graebe\  and  with  Addison's  disease  (Schulz).  It  may  occur  Avith  disease 
of  the  fifth  nerve. 

Symptoms.  After  any  of  the  above  etiological  factors,  or  without  any 
apparent  cause,  the  patient  notices  one  or  more  whitish  spots  on  the  side  of 
the  face,  generally  on  the  lower  jaw  or  near  the  orbit,  which  gradually  be- 
come larger,  or,  if  more  than  one,  they  coalesce  and  become  yellow  or  yel- 
lowish-white in  color.  The  skin  over  these  patches  or  areas  sinks  and  forms 
pits  or  trough-like  depressions,  due  to  the  disappearance  of  the  subcutaneous 
fat.  The  skin  may  become  pigmented,  not  only  in  the  areas  where  the 
atrophy  is  marked,  but  on  other  parts  of  the  face.  This  pigmentation  is  in 
small  spots  or  patches,  and  varies  in  color  from  a  grayish-yellow  to  brown  or 
blue.  The  atrophy  involves  the  skin,  both  in  its  dermal  and  epidermal 
layers,  its  appendages,  the  cellulo-adipose  tissue,  and  bone,  and  the  muscles  to 
a  very  slight  degree.  The  hair  of  the  beard,  of  the  head,  and  the  eyelashes 
may  lose  its  color  and  fall  out  in  patches,  or  the  areas  of  alopecia  may  be 
quite  symmetrical.  The  sebaceous  glands  are  atrophied  and  their  secretion 
diminished  and  eventually  checked.  The  secretion  of  perspiration  is  normal, 
frequently  increased.  After  a  variable  time  the  entire  half  of  the  face  be- 
comes involved,  and  a  deep  fissure  like  a  sabre-cut  in  the  centre  of  the  forehead 
and  chin  separates  it  from  the  healthy  side.  This  fissure  or  depression  has  been 
considered  one  of  the  landmarks  of  the  disease,  but  Borgherini  has  recently 
reported  a  case  where  the  disease  involved  both  sides  of  the  face,  and  there 
was  no  difference  between  the  two  sides.  When  the  disease  is  well  devel- 
oped, shedding  of  the  epidermis  and  preservation  of  the  contractility  of  the 
muscular  fibres  of  the  skin  give  the  latter  a  roughened,  puckered  appear- 
ance. The  atrophy  may  involve  the  tongue,  the  hard  and  soft  palate,  the 
gums,  and  the  uvula.  In  the  face  it  may  become  so  extensive  that  the  dis- 
eased side  looks  like  an  appendage  to  the  normal  side. 

As  a  rule,  there  are  no  marked  disturbances  of  sensibility.  A  slight  degree  of 
hypersesthesia  has  been  reported  by  Tanturri  and  by  Vulpian,  but  excessive 
sensibility  is  more  common.  Neuralgic  pains  preceding  the  appearance  of 
the  disease  and  during  its  early  course  are  by  no  means  uncommon,  although 
formerly  so  considered.      Itching  of   the  skin  is  sometimes  a  distressing 


906 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


symptom,  and  occurs  when  the  disease  is  associated  with  patches  of  sclero- 
derma in  other  parts  of  the  body.  The  tension  of  the  atrophying  skin  may 
give  a  sensation  as  if  a  rubber  mask  was  stretched  across  the  face.  An  un- 
common symptom  that  has  been  observed  by  Axmann  and  Heuter  preceding 
the  development  of  the  disease,  and  by  Sachs,  Muratow,  and  Fromhold-Treu 
dui'ing  the  disease,  is  a  spasm  of  the  buccinator  and  masseter,  rarely  of  the 
temporal  muscles.  (Fig.  297.)  These  twitchings  may  be  clonic  alone,  or  clonic 
followed  by  a  tonic  condition,  which  lasts  for  a  few  minutes,  and  during 
which  time  the  patient  cannot  separate  the  jaws.  Sometimes  it  extends  to 
the  tongue  and  interferes  with  its  functions.  When  these  twitchings  occur 
they  are  generally  the  cause  of  a  good  deal  of  pain,  and  are  made  worse  by 
exposure  and  by  excitement.  As  the  disease  progresses,  disappearance  of 
the  fat  in  which  the  eyeball  is  imbedded  gives  the  patient  a  painful  appear- 
ance, due  to  enopthalmos.  The  special  senses  show  deviation  from  the  normal 
only  in  rare  instances,  taste  and  heai'ing  being  impaired  somewhat  more  fre- 
quently than  sight.  Occasionally  a  unilateral  myosis  or  pin-point  pupil 
shows  the  influence  of  the  sympathetic,  and  is  present  with  other  symptoms 
referable  to  that  part  of  the  nervous  system,  such  as  difference  in  surface 


Fig.  297. 


Fig.  298. 


Hemiatrophia  facialis.    (Sachs.) 


Facial  hemiatrophy  in  an  infant  under  the  care  of 
Dr.  Dercum.    (Jefferson  Medical  College  Hospital.) 


temperature  of  the  two  sides  of  the  face  (Sachs,  Seeligmuller),  pallor  or  flush- 
ing of  the  face,  hemihyperidrosis,  or  absence  of  perspiration  on  one  side  of 
the  face,  and  contraction  of  the  nostril.  With  the  exception  of  those  cases 
in  which  the  sympathetic  seems  to  be  involved  the  bloodvessels  retain  their 
normal  tone  and  calibre.  In  the  advanced  stages  of  the  disease  the  stretched 
skin  presses  upon  the  vessels  and  interferes  with  their  response  to  vasomotor 
influences,  and  the  result  is  a  continual  pallor,  inability  to  blush,  and  loss  of 
vascular  response  to  electrical  stimulation.  Extremely  rare  symptoms  are 
neuroparalytic  ophthalmia  and  difficulty  in  swallowing.  Marie  and  Marinesco 
have  described  a  case  of  hemiatrophy  of  the  face  and  upper  limb,  with  facial 
j)aralysis  of  the  same  side,  which  apparently  does  not  entirely  correspond 
with  the  description  given  above,  insomuch  as  the  skin  was  not  changed  in 
thickness,  consistency,  or  color.  They  regard  the  phenomena  which  their 
patient  presented  as  due  to  changes  in  the  domain  of  the  great  sympathetic. 
The  course  of  the  disease  is  generally  rapid  in  the  beginning  up  to  a  cer- 
tain stage ;  then  its  progress  may  apparently  cease  for  a  long  time,  to  be  fol- 
lowed sooner  or  later  by  a  period  of  exacerbation.    The  prognosis  as  regards 


THE  TROPHO-NEUBOSES.  907 

recovery  is  unfavorable ;  the  first  case  of  such  a  desirable  termination  is  not  yet 
on  record.  It  must  be  said,  however,  that  the  disease  does  not  tend  to  shorten 
life,  and  so  far  cases  have  not  come  to  autopsy  except  in  two  instances.  The 
findings  in  both  these  cases  are  most  suggestive  to  a  proper  interpretation  of 
the  pathology  of  the  disease.  The  case  of  Avhich  Mendel  was  fortunate 
enough  to  obtain  an  autopsy  had  been  under  observation  by  Romberg, 
Remak,  and  Virchow,  and  is  well  known  in  the  literature,  and  an  analysis 
of  the  symptoms  of  this  case  had  been  used  to  fortify  the  theory  that  the  dis- 
ease was  a  neurotrophic  one.  The  patient  had  during  twenty-five  years 
presented  the  symptoms  of  typical  facial  hemiatrophy  complicated  by  atrophy 
of  the  left  upper  extremity.  Erysipelas  during  a  confinement  had  immedi- 
ately preceded  the  development  of  the  disease  originally.  A  minute  exam- 
ination of  the  entire  nervous  system  revealed  a  proliferating  interstitial  neu- 
ritis of  the  left  fifth  nerve,  most  marked  in  its  second  branch.  The  seventh 
nerve  was  entirely  normal,  while  the  left  musculo-spiral  had  undergone 
changes  similar  to  those  in  the  left  fifth  nerve.  Centrally,  an  atrophy  of  the 
descending  root  of  the  fifth  nerve  and  a  partial  atrophy  of  the  substantia 
ferruginea  was  all  that  was  of  importance.  In  Homen's  case  a  tumor  of  the 
dura  mater,  which  pressed  U]30n  the  Gasserian  ganglion  and  the  branches  of 
the  trigeminal  nerve  caused  a  hemiatrophy  of  the  face  and  tongue,  accom- 
panied by  anaesthesia  of  the  region  afiected  and  paralysis  of  the  oculo-motor 
nerve.  On  autopsy  it  was  found  that  the  tumor  caused  a  degeneration  of 
the  nerve,  especially  of  its  sensory  portion,  the  part  corresponding  to  the 
posterior-root  nerves  and  in  part  of  the  third  nerve,  and  microscopical  exam- 
ination revealed  the  phenomena  of  degeneration  in  all  the  branches  of  the 
fifth  nerve  and  some  of  the  seventh,  third,  fourth,  and  sixth  nerves.  These 
two  cases  are  not  sufficient  to  warrant  us  in  saying  that  the  pathology  of  the 
disease  is  lesion  of  the  fifth  nerve,  but  in  view  of  the  fact  that  the  only  cases 
in  which  autopsies  have  been  made  have  shown  lesion  of  this  nerve,  and  more- 
over, when  they  corroborate  the  most  plausible  theory  that  has  been  pro- 
pounded, they  are  very  suggestive. 

Experimental  evidence  to  prove  that  hemiatrophy  may  result  after  injury 
to  the  fifth  nerve  is  not  wanting.  Girard  has  seen  hemiatrophia  facialis, 
atrophy  of  the  muscles  of  mastication,  thinning  of  the  hair,  atrophy  of  the 
bones  and  face,  and  partial  atrophy  of  the  tongue  follow  section  of  the  pos- 
terior root  of  the  trigeminus  at  the  base  of  the  skull.  He  concludes,  as  most 
investigators  before  him  have  concluded,  that  the  trophic  fibres  of  the  tri- 
geminus are  in  the  posterior  root.  He  believes,  further,  that  the  seventh 
nerve  plays  no  role  in  the  development  of  hemiatrophy.  Schiff*,  however, 
has  proven  that  experimental  atrophy  involves  not  alone  the  muscles  of 
mastication,  but  also  the  other  face  muscles.  These  facts,  taken  together 
with  distribution  of  the  atrophy  and  the  various  arguments  that  can  be  ad- 
duced to  show  that  the  disease  is  neurotic,  go  far  to  corroborate  the  view 
that  the  affection  is  a  tropho-neurosis  dependent  upon  lesion  of  the  fifth 
nerve.  There  is  much  clinical  evidence  to  suggest  that  the  disease  can  be 
due  to  other  causes,  particularly  affection  of  the  cervical  sympathetic. 
Seeligmuller  has  described  a  case  in  which  the  wasting  followed  injury  to 
the  cervical  sympathetic  of  the  same  side,  and  Popoff*  thinks  his  case  can  be 
explained  in  no  other  way.  But  the  theory  suggested,  a  compression  of  the 
arteries  going  to  the  bones  by  the  cutaneous  and  subcutaneous  wasting,  to 
explain  the  mechanism  of  these  cases,  is  not  in  accord  with  the  teachings  of 
physiology.  The  vasomotor  symptoms  that  sometimes  occur  with  the  dis- 
ease can  be  explained  by  affection  of  the  fibres  of  the  sympathetic  that  run 
in  the  fifth  nerve. 

The  disease  can  only  be  confounded  with  congenital  asymmetry,  morphoea, 


908  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  possibly  facial  paralysis.  In  congenital  asymmetry  there  are  other 
conspicuous  somatic  and  mental  defects  which  will  quickly  make  the  diag- 
nosis. Its  relationship  to  morphoea  has  already  been  spoken  of.  Only  the 
most  careless  observer  could  mistake  it  for  an  ancient  case  of  facial  paralysis. 

Treatment.  As  the  disease  is  incurable,  preventive  treatment,  if  possible, 
in  the  shape  of  removing  the  cause,  is  of  greatest  importance.  Basing  his 
suggestion  on  the  fact  that  section  or  excision  of  the  fifth  nerve  for  the  relief 
of  neuralgia  is  not  followed  by  any  atrophic  change,  and  upon  the  hypothesis 
that  hemifacial  atrophy  depends,  not  so  much  upon  a  failure  of  trophic 
nerve  stimulus  as  upon  a  perversion  of  that  stimulus,  Dercum  has  suggested 
early  resection  of  the  branches  of  the  trifacial.  There  are  no  records  to  show 
that  this  plan  has  ever  been  tried.  The  use  of  galvanic  electricity  helps  to 
stay  the  progress  of  the  disease  in  some  instances. 

To  overcome  the  cosmetic  defect  when  the  disease  has  reached  a  standstill 
the  patient  may  have  a  plate  constructed  by  a  dentist  which  can  be  attached 
to  the  teeth  of  the  upper  jaw  on  the  affected  side  and  Avith  a  slightly  convex 
surface  against  the  mucous  membrane  of  the  cheek.  This  can  be  worn  with 
comfort,  and  detracts  remarkably  from  the  unsightliness  of  the  deformity. 


FACIAL  HBMIHYPERTROPHY 

Scattered  throughout  medical  literature  are  a  number  of  cases  reported  in 
which  the  only  departure  from  normal  is  the  enlargement  of  one-half  of  the 
body  or  a  segment  of  one-half.  These  cases  are  in  some  instances  associated 
with  other  diseases,  but,  as  a  rule,  the  hypertrophy  is  the  only  pathological 
condition.  The  parts  of  the  body  that  are  most  frequently  the  seat  of  uni- 
lateral hypertrophy  are  the  extremities,  the  cephalic,  and  digital. 

Unilateral  hypertrophy  limited  to  the  head  and  face  occurs  less  frequently 
than  hypertrophy  of  one-half  of  the  body.  It  is  very  much  rarer  than  its 
analogue  and  opposite,  progressive  facial  hemiatrophy.  The  majority  of 
cases  on  record  are  of  congenital  origin,  although  fases  have  been  reported 
by  Schieck,  Berger,  Dana,  and  Montgomery  and  Thomson  in  which  the  over- 
growth began  during  the  first  years  of  life,  always  before  puberty.  In  some 
of  these  cases  irritation  of  the  fifth  nerve  would  seem  to  be  the  initial  pro- 
cess in  the  disease.  In  Berger's  case  the  overgrowth  followed  an  inveterate 
neuralgia  of  this  nerve.  In  Montgomery's  case  it  was  thought  possible  to 
attribute  the  onset  of  the  growth  to  an  irritation  of  the  branches  of  the 
fifth  by  an  abscess  of  the  cheek,  which  was  present  shortly  before  the  pro- 
gressive unilateral  enlargement  of  the  face  was  first  noticed.  In  Dana's 
case  the  disease  was  associated  with  gigantism.  Of  15  cases  selected  from 
the  literature,  9  were  males  and  6  were  females.  Both  sides  of  the  face  are 
involved  with  equal  frequency,  the  proportion  being  slightly  in  favor  of 
the  right  side.  The  enlargement  may  involve  the  entire  side  of  the  face 
and  head,  or  it  may  be  manifest  principalh^  in  the  eyebrow,  the  zygoma, 
the  cheek,  or  the  angle  of  the  jaw ;  generally,  however,  it  confines  itself 
very  closely  to  the  distribution  of  the  fifth  nerve  or  one  of  its  branches. 
If  the  condition  is  not  congenital,  the  first  signs  of  the  disease  Avill  pass  un- 
noticed, as  a  slight  degree  of  facial  asymmetry  is  not  uncommon  in  indi- 
viduals who  are  considered  normal.  Ordinarily  the  enlargement  begins  first 
in  the  alveolar  eminence  of  the  superior  maxillary,  in  the  supra-orbital 
arch  or  in  the  malar  process.  It  involves  the  skin  and  subcutaneous  struc- 
ture as  well  as  the  bone,  and,  although  limited  to  the  side  of  the  face,  it  may 
involve  the  ear,  the  temple,  lips,  lids,  buccal  cavity,  the  mucous  membrane 
of  the  mouth  and  cheek,  the  teeth,  gums,  tongue  and  tonsils.     When  the 


THE  TBOPHO-NEUBOSES. 


909 


hypertrophy  is  fully  developed  the  patient  presents  a  striking  appearance, 
and  at  first  glance  the  condition  may  be  taken  for  hemiatrophia  facialis  on 
account  of  the  disproportion  between  the  two  sides.  The  expression  of  the 
face  is  changed,  the  mouth  is  distorted,  the  fissures  of  the  face  are  deepened 
on  the  affected  side.  The  skin,  although  sometimes  unaflTected,  generally 
participates  in  the  thickening,  the  color  may  be  normal,  although  in  some 
cases  it  is  pigmented  ;  very  rarely  does  it  betray  any  evidences  of  hypersemia. 
In  one  case  reported  the  skin  was  rough,  coarse,  thickened,^  and  in  some 
places  even  tumefied,  and  somewhat  darker  than  on  the  opposite  side.  The 
hair  occasionally  participates  in  the  evidences  of  overnutrition,  and  the  lanugo 
as  well  as  the  bristling  hairs  become  coarser  on  one  side  of  the  head  and 
face  than  on  the  other.    The  surface  temperature  is  equal  on  both  sides ; 


Fig.  299. 


Hemihypertrophy  efface.    (Montgomery.) 

this  in  contrast  to  cases  of  hemihyper- 
trophy of  the  body,  in  which  consid- 
erable deviation  of  temperature  of  the 
sides  has  been  noticed. 

Occasionally  glandular  secretion,  per- 
spiration, and  saliva,  are  increased  ;  this 
has  been  observed  most  frequently  in 
congenital  cases.  There  are  no  dis- 
turbances of  sensibility  except  in  those 
cases  in  which  the  skin  is  very  much 
thickened ;  tactile  sense  may  be  some- 
what blunted  (Lewin).  In  a  case 
reported  by  Friedreich  there  was  dimi- 
nution of  the  sense  of  taste  and  sight, 
but  whether  or  not  there  were  ophthal- 
moscopic findings  to  explain  the  disturbance  of  vision  is  not  stated.  In 
cases  where  the  eyes  have  been  examined  carefully  no  defects  have  been 
found.  In  a  few  cases  that  have  come  to  autopsy  an  examination  of  the 
affected  tissues  hat  been  made,  but  no  investigation  of  the  nervous  system. 
The  morbid  phenomena  in  the  bones  is  essentially  an  hyperostosis  with 
enlargement  of  the  foramina  and  broadening  and  widening  of  the  natural 
fissures  and  crevices.  In  some  cases  this  hyperostosis  is  uniformly  distrib- 
uted ;  in  other  cases  it  has  a  tendency  to  develop  in  masses  which  may  cause 
pressure  on  important  structures,  and  so  produce  symptoms.     In  Thomson's 


Facial  hemihypertrophy  in  a  giant.    (Dana.; 


910  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

case  pressure  on  the  brain  caused  epilepsy  and  consecutive  mental  deteriora- 
tion. The  muscular  tissue,  instead  of  being  enlarged,  is  atroj)hied  and  the 
thickness  of  the  soft  parts  is  due  to  an  increase  of  cellulo-adipose  tissue. 
The  skin  is  sometimes  involved,  but  the  epithelium  is  normal. 

In  instances  where  portions  of  the  tissue  has  been  excised  for  microscopical 
examination  during  life,  the  bloodvessels  have  shown  round-cell  infiltration. 
The  pathology-  of  the  disease  is  based  on  theory.  It  is  supposed  that  we 
have  to  deal  with  a  neurotic  hypertrophy,  a  hypertrophy  that  is  secondary 
to  irritation  of  certain  trophic  fibres  contained  in  the  fifth  nerve  which  causes 
an  exaltation  of  fimction  and  results  in  an  overgrowth  due  to  an  excessive 
proliferation  of  the  vulgar  cells  of  the  parts.  The  exact  limitation  of  the 
h\^Dertrophy  to  the  distribution  of  the  fifth  nerve  or  one  of  its  branches,  and 
the  remarkable  contrast  between  it  and  hemiatrophia  facialis,  in  Avhich  the 
fifth  nerve  is  diseased,  speak  in  support  of  this  supposition.  It  cannot  well 
be  explained  on  vascular  grounds  alone.  Although  in  many  cases  hypersemia 
is  found,  it  is  probably  secondary  to  the  hypertrophv,  instead  of  productive 
of  it. 

The  course  of  the  disease  is  as  a  rule  a  progressive  one,  but  after  adult  age 
is  reached  its  progress  is  very  slow.  In  one  case  only  did  it  tend  to  shorten 
life  by  causing  pressure  on  the  brain.  Xo  form  of  treatment  has  been  sug- 
gested that  is  worthy  of  serious  consideration. 


HEMIHYPERTROPHY  AND  LOCAL  HYPERTROPHIES. 

Hypertrophy  of  one  extremity  or  of  one  side  of  the  body  is  very  rare. 
Hypertrophy  of  the  fingers  and  toes  is  more  common.  The  former  is  fre- 
quently, but  not  always,  congenital ;  the  latter  may  occur  with  diseases  in 
which  enlargement  of  the  body  is  the  most  j)rominent  symptom,  such  as 
acromegaly  and  gigantism. 

Richardiere,  who  has  described  two  cases  of  congenital  hyj)ertrophy  of  the 
hand,  considers  that  there  are  two  forms  of  such  hypertrophy.  A  true  hyper- 
trophy, in  which  all  the  parts  participate,  the  soft  parts,  the  tendons  and 
bones  are  augmented  in  volume.  In  the  variety  which  he  terms  false  hyper- 
trophy, there  is  an  abnormal  development  of  cellular  tissue  and  subcutaneous 
fat.  The  discrepancy  in  size  between  the  two  sides  of  the  body  or  between 
two  extremities  may  be  very  distinct  at  birth,  and  the  relative  proportion  be- 
tween the  enlarged  and  the  normal  size  is  preserved  during  the  years  that 
the  child  continues  to  grow.  This  is  well  seen  in  a  case  reported  by  Moebius 
about  ten  years  ago.  In  referring  again  to  the  case  in  a  recent  communica- 
tion, he  says  the  diflTerence  in  the  two  sides  has  remained  practically  the  same 
during  the  past  eleven  years.  The  hypertrophy  of  one-half  of  the  body 
may  be  so  great  at  birth  as  to  constitute  almost  a  monstrosity.  This  was  so 
in  a  case  reported  by  Demme,  in  which,  in  addition  to  the  enlargement  of 
one-half  of  the  body,  the  tongue  was  increased  to  more  than  twice  its  natural 
size,  and  was  never  withdrawn  into  the  mouth ;  eventually  it  suffocated  the 
little  patient.  The  hypertrophied  extremity  may  be  increased  in  length  as 
well  as  in  breadth  and  volume.  The  structural  participation  differs  in  dif- 
ferent cases.  In  some  instances  the  muscles  of  the  limb  are  h^^pertrophied, 
and  there  is  a  corresponding  increase  in  strength.  This  was  so  in  a  patient 
reported  by  Osier,  In  most  cases,  however,  the  muscles  are  very  deficient, 
and  the  result  is  more  or  less  disability  of  the  member  and  possibly  some  de- 
formity. The  cellulo-adipose  tissue  shows  the  greatest  change.  The  bones 
are  not  involved  in  the  majoi'ity  of  cases ;  they  may  be  involved  in  one  part 
of  the  body,  but  not  in  another,  although  the  latter  may  be  greatly  increased 


THE  TROPHO-NEUBOSES. 


911 


in  size.  This  was  so  in  Demme's  case,  in  which  the  left  half  of  the  body 
was  involved,  but  the  bony  increase  was  confined  to  the  skull.  In  cases 
where  the  mviscles  do  not  seem  to  be  especially  involved,  microscopical  ex- 
amination of  them  shows  increased  diameter  of  the  muscular  fibres,  absence 
of  cross  striping,  granular  degeneration,  decrease  of  inter-fibral  tissue,  in- 
crease in  nuclei  of  the  sarcolemma  and  development  of  embryonic  cells  in  the 
connective  tissue  between  the  muscle  bundles.  Neither  the  nerve  endings  nor 
the  peripheral  nerves  seem  to  be  affected.  In  one  case  it  was  thought  that 
there  was  an  increase  in  ganglionic  cells  of  the  anterior  cornua  of  the  affected 
side,  and  one  hemisphere  of  the  brain  was  larger  than  the  other.     A  remark- 

FlG.  301. 


Hemihypertrophy.    (Moebius.) 


able  fact  that  has  been  observed  in'  several  cases  is  a  unilateral  increase  of 
surface  temperature.  This  has  been  noted  by  Trelat  and  Monod,  by  Oilier 
and  by  Redard.  The  last  mentioned  author  thinks  that  if  all  cases  are  ex- 
amined carefully  in  reference  to  this  point  a  diffei'ence  in  the  two  sides  will 
be  found.  Careful  observation  by  other  clinicians  discredits  this  statement. 
Sensibility  of  the  enlarged  extremities  is  as  a  rule  undisturbed,  likewise  the 
vascular  supply  as  manifest  by  the  pulse  of  the  part  and  by  the  color.  Very 
rarely  there  is  pigmentation  of  the  skin  or  evidences  of  continued  hyper- 
semia.  Hyperidrosis  has  been  observed  in  some  cases,  but  it  is  not  the  rule. 
In  some  instances  the  superficial  glands  are  enlarged  and  spots  like  cysts 
appear  beneath  the  skin,  but  there  is  nothing  to  suggest  elephantiasis. 


912  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Crossed  lateral  hypertrophy  has  been  reported  only  in  a  few  instances.  In 
Friedreich's  case  the  left  side  of  the  face  and  left  arm  and  the  right  lower 
extremity  were  enlarged,  and  in  this  case  the  vascular  symptoms  wei'e  marked. 

Local  hypertrophy,  unless  compensatory,  is  also  a  rare  condition.  It  is 
most  often  seen  affecting  an  appendage  of  the  body,  such  as  the  jDenis,  the 
breasts,  the  external  ear,  etc.,  or  the  carj)al  or  pedal  digits.  Compensatory 
hypertrophy  is  not  uncommonly  seen  in  one  testicle  or  one  kidney  after  the 
removal  of  its  fellow.  The  lymphatic  glands  also  exhibit  the  phenomena  of 
compensatory  hypertrophy.  Local  hypertrophy  may  be  congenital  or  it 
may  develop  at  any  time  up  to  the  age  of  maturity.  It  is  seen  almost  en- 
tirely in  those  who  are  neurotic  through  inheritance,  or  in  those  who  are  suf- 
fering from  some  affection  of  the  nervous  system.  In  the  case  reported  by 
Springer  the  two  large  toes  developed  an  enormous  symmetrical  enlargement 
while  the  patient  was  suffering  from  myelitis.  In  Kanthack's  case  of  acro- 
megaly the  second  toe  was  hypertrophied  out  of  all  proj)ortion  to  the  enlarged 
foot.  Hysteria  in  some  of  its  manifestations  is  at  the  bottom  of  many  cases, 
especially  where  the  breasts  are  involved.  Hypertrophy  of  the  nails,  onycho- 
gryphosis,  is  associated  with  neuritis,  neuralgia,  myelitis,  injuries  to  nerves, 
and  in  some  cases  of  muscular  atrophy.  Enlargement  of  an  ear  is  generally 
seen  with  some  manifestations  of  disordered  sympathetic  on  the  same  side. 
Hypertrophy  of  the  cephalic  extremity  developing  late  in  life  has  been 
noticed  by  Starr.  Although  the  hypertrophy  seen  in  cretins  is  neurotic,  we 
do  not  discuss  it  here.  It  is  treated  under  cretinism.  Hypertrophy  of 
adipose  tissue  shows  itself  either  in  the  shape  of  obesity,  circumscribed  or 
diffuse,  or  adiposis  dolorosa,  and  it  is  with  these  that  such  cases  as  the  one 
reported  by  Mitchell  (American  Journal  of  the  Medical  Sciences,  1885,  p.  162) 
is  to  be  classified.  Hypertrophy  of  individual  muscles  or  groups  of  muscles 
are  almost  without  exception  traceable  to  overuse  or  overstimulation. 

The  only  suggestion  that  has  been  made  in  the  way  of  treatment  for  any 
of  these  cases  is  pressure  on  the  vascular  supply  when  they  develop  pre- 
natally,  or  injection  of  an  astringent  into  the  parts,  such  as  iodine  when  they 
are  congenital.  There  is  no  record  that  any  such  measures  have  ever  been 
of  any  service. 


CHAPTER  XXXI. 

TROPHIC  DISEASES  ASSOCIATED  WITH  PATHOLOG- 
ICAL CHANGES  m  THE  THYROID  GLAND. 

By  CHAKLES  W.  BURR,  M.D. 

MYXGEDEMA. 

Definition.  A  constitutional  disease  dependent  upon  atrophy  of  the  thy- 
roid gland  and  characterized  by  a  myxoedematous  condition  of  the  subdernial 
tissues  and  progressive  mental  failure. 

History.  The  first  description  of  the  disease  is  given  in  a  paper  by  Sir 
William  Gull,  "Upon  a  Cretinoid  State  Supervening  in  Adult  Women," 
published  in  1873.  Four  years  later  Ord  published  an  article  describing  the 
condition  both  clinically  and  pathologically,  and  proposed  the  name  myxoe- 
dema  (mucous  oedema).  The  most  exhaustive  study  of  the  subject  is  the 
report  of  the  committee  appointed  by  the  Clinical  Society  of  London,  pub- 
lished in  1888. 

Etiology.  Climate  seems  to  exert  no  influence,  at  least,  as  the  disease 
becomes  better  known  more  cases  and  in  more  scattered  regions  are  being 
reported.  It  is  much  more  frequent  in  women  than  in  men,  probably  in  the 
proportion  of  ten  to  one.  It  may  be  transmitted  through  the  mother,  and 
several  persons  in  one  generation  may  be  attacked.  It  is  to  a  large  degree 
a  disease  of  middle  life.  It  has  occurred  after  acute  articular  rheumatism, 
erysipelas,  and  persistent  hemorrhages.  Hochler,  Pospieloff,  and  others  have 
seen  it  in  syphilitics,  and  in  the  case  of  the  first-named  cure  followed  specific 
treatment. 

The  direct  and  immediate  cause  is  atrophy  of  the  thyroid  gland.  As  to 
the  causes  of  the  atrophy,  we  are  still  largely  in  the  dark.  It  is  by  no  means 
impossible  that  in  some  cases  the  thyroiditis  secondary  to  the  acute  infectious 
fevers  may  pass  on  to  the  condition  of  sclerosis,  and  thus  be  a  cause.  The 
disease  has  been  produced  artificially  by  removal  of  the  gland  both  in  ani- 
mals and  man.     We  will  speak  more  fully  of  this  under  the  pathology. 

Symptoms.  The  onset  is  ordinarily  slow,  and  the  whole  course  of  the  dis- 
ease occupies  from  ten  to  fifteen  years.  There  are  a  few  cases,  however,  like 
the  following,  described  by  Osier,  to  which,  as  he  says,  the  term  acute  myxoe- 
dema  might  be  applied:  "A  young  man,  aged  twenty  years,  presented  a 
gradual  enlargement  of  the  face,  particularly  of  the  lips,  cheeks,  and  nose, 
without  actual  oedema.  The  backs  of  the  hands  were  also  swollen,  but  did 
not  pit.  The  condition  came  on  with  enlargement  of  the  thyroid,  and,  after 
persisting  for  between  three  and  four  months,  is  now  subsiding." 

The  symptoms  are  referable  to  the  skin,  the  mental  functions,  and  the 
thyroid  gland. 

The  coarse,  broadened,  moon-shaped  face  is  characteristic.  The  nose  is 
wide  and  thick,  and  the  mouth  larger  than  normal.     The  lips  are  thickened. 

58 


914 


NERVOUS  DISEASES  AND  THEIB  TREATMENT. 


The  eyelids  are  swollen  sometimes  so  greatly  that  they  cannot  be  opened. 
The  complexion  is  yellowish  white,  with  oftentimes  a  recldish  patch  on  either 
cheek.  The  expression  is  immobile  and  stupid.  Like  the  face,  the  bulk  of 
the  whole  body  is  increased. 

The  yellow-white  skin,  on  superficial  examination,  looks  oedematous,  but 
it  does  not  pit  on  pressure.  On  the  contrary,  it  is  firm  and  elastic.  This 
false  oedema  is  less  marked  on  the  trunk  than  on  the  extremities  and  face, 
and  is  not  influenced  by  gravitation.  Perspiration  and  the  sebaceous  secre- 
tions are  scanty  or  absent.    The  skin  is  dry  but  not  tense,  and  scaly  particles 

Fig.  303. 


Fig.  302. 


Photograph  taken  when  the  dis- 
ease was  commencing.  (Hun,  Amer- 
ican Journ.  of  the  Medical  Sciences, 
July,  1888.) 


Photograph  of  same  case  taken  when  disease  was  fully 
developed. 


of  epithelium  brush  off.  The  hair  is  dry  and  brittle,  the  eyebrows  and  lashes 
fall  out,  and  baldness  comes  on.  The  hands  and  feet  are  swollen,  and  the 
fingers  move  with  difficulty.  The  nails  are  brittle,  striated,  and  either  atro- 
phied or  thickened.  In  the  supra-clavicular  and  axillary  regions  local 
swellings  occur  resembling  false  lipomata.  The  mucous  membranes  are 
swollen  and  dry.  Toward  the  end  there  may  occur  a  secondary  nephritis 
which  complicates  the  picture  of  the  disease. 

The  mental  changes  were  noted  by  Gull.  In  his  first  paper  he  says :  "  The 
mind,  which  previously  had  been  active  and  inquisitive,  assumed  a  gentle, 
placid  indifference  corresponding  to  the  muscular  languor,  yet  the  intellect 
was  unimpaired."  Slowness  in  mental  processes,  in  apprehension,  thought, 
and  action,  is  almost  constant,  being  absent  in  only  three  of  the  cases  studied 
by  the  committee.  Nevertheless  patients  are  liable  to  outbursts  of  fretful- 
ness  and  ill  humor.  Absolute  insanity,  acute  or  chronic  mania,  dementia  or 
melancholia  with  delusions  or  hallucinations  occur  in  about  one-half  of  the 
cases.  Delirium  of  suspicion '  and  exaltation  is  not  infrequent.  Shame  on 
account  of  the  appearance  may  precipitate  mental  trouble.  Thus  Wilks 
records  a  case  in  which  a  young  woman  living  in  a  country  town  was  so  dis- 


TB  OPHIC  DISEASES.  915 

tressed  by  the  village  boys  shouting  after  her,  "pig-faced  woman,"  that  she 
refused  to  go  out  at  all,  began  to  find  insult  when  none  was  intended,  and 
finally  became  so  threatening  and  violent  that  she  had  to  be  placed  in  an 
asylum.  The  peculiar  slowness  and  deliberation  in  all  movements  are  also 
due  to  the  mental  condition,  and  not  to  anj^  paralytic  weakness.  Memory  is 
impaired.  Speech  is  slow  and  difficult.  Out  of  the  one  hundred  and  nine 
cases  analyzed  by  the  committee  of  the  Clinical  Society,  the  thyroid  was  found 
atrophied  in  twenty-two  cases,  not  altered  in  size  in  twenty-three,  and  with  a 
history  of  previous  enlargement  in  three.  In  life  it  is  frequently  diflftcult, 
especially  if  the  neck  be  thickened,  as  happens  so  often,  to  tell  anything  about 
the  presence  of  atrophy,  so  that  such  figures  as  the  above  have  only  a  rela- 
tive value.  Ord  reports  one  case  and  Sollier  two  in  which  exophthalmic 
goitre  preceded  the  myxoedema. 

To  the  above  main  symptoms  are  added  always  secondary  ones.  The 
bodily  temperature  is  below  the  normal — 97°  to  97.5°.  The  only  objective 
sensory  symptom  is  delay  in  recognizing  sensory  stimuli,  but  various  pares- 
thesias, feeling  of  coldness,  pricking,  and  numbness  are  common.  Ringing 
in  the  ears,  vertigo,  and  dull  headache  are  frequent.  Albuminuria  and  rarely 
glycosuria  may  be  present.  The  urine  is  apt  to  be  large  in  amount  and  of 
low  specific  gravity,  and  a  few  casts  may  be  found.  Palsies,  contracture,  and 
tremor  are  very  rare.  The  knee-jerk  is  present,  but  decreased.  The  heart, 
lungs,  and  abdominal  organs  usually  functionate  normally.  Sleep  is  usually 
good ;  indeed,  there  may  be  excessive  somnolence ;  but,  occasionally,  one  or 
the  other  form  of  night  horror  is  complained  of.  Smell,  taste,  and  hearing 
are  deficient.  Anaemia  is  common.  Krapelin  found  in  three  cases  abnormal 
size  of  the  red  corpuscles,  a  high  specific  gravity  of  the  blood,  and  a  lowered 
amount  of  fibrin.  Remissions  are  not  infrequent,  the  patients  being  always 
better  in  summer.  Death  may  result  from  the  disease  itself,  or,  as  is  more 
frequent,  from  pulmonary  phthisis,  or  renal  or  cerebral  complications. 

Differential  Diagnosis.  The  most  important  point  is  to  differentiate  the 
mucous  oedema  from  the  common  oedema  due  to  Bright's  disease,  a  matter 
the  more  important  since  casts,  few  in  number,  it  is  true,  may  be  present  in  the 
urine  in  the  first  condition.  The  paper  of  M.  Allen  Starr  is  the  best  upon 
the  subject.  Mucous  oedema  is  uninfluenced  by  gravitation  ;  the  upj)er  eyelid 
is  affected  as  much,  or  it  may  be  more  than  the  lower.  It  is  more  intense 
over  the  masseter  muscles  and  in  the  supra-clavicular  spaces  than  elsewhere. 
The  genitals  are  not  especially  affected  as  in  nephritis.  There  is  no  pitting 
on  pressure,  and,  indeed,  the  fluid  below  the  skin  cannot  be  displaced.  In 
chronic  nephritis  the  skin  may  be  the  same  dirty,  yellowish-white,  the  mental 
and  gastric  symptoms  may  be  similar,  but  in  nej)hritis  we  do  not  have  the 
reddish  patches  upon  the  cheeks,  the  dry  scaly  skin,  and  the  total  absence  of 
perspiration. 

Obesity,  scleroderma,  Arabian  elephantiasis,  and  acromegaly,  though  some 
of  them,  at  any  rate,  will  probably  be  proven  to  stand  in  close  relation  to 
affections  of  the  thyroid,  can  scarcely  be  mistaken  for  myxoedema,  and  need 
only  be  mentioned.     (See  also  page  897.) 

There  is  a  condition  described  by  Dercum  under  the  name  of  adiposis 
dolorosa,  characterized  by  great  and  widespread  hyperplasia  of  the  subcuta- 
neous fat,  with  local  dejoosits  in  certain  parts  of  the  body,  accompanied  by 
pain,  muscular  degeneration,  and  diminished  perspiration,  which,  while  not 
bearing  any  great  resemblance  to  myxoedema,  should  be  mentioned  here, 
since  in  two  of  the  three  cases  reported  (one  by  Henry)  the  thyroids  were 
indurated  and  calcareous.     (See  page  898.) 

Prognosis.  The  prognosis  formerly  Avas  absolutely  bad.  Under  new 
methods  of  treatment  the  disease  certainly  can  be  immensely  ameliorated — 


916  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

indeed,  the  symptoms  caused  to  disappear.  Whether,  however,  cases  will 
remain  cured  over  a  series  of  years  is  yet  to  be  determined. 

Morbid  Anatomy  and  Pathology.  Let  us  first  consider  the  effects  of  sur- 
gical removal  of  the  thyroid  producing  operative  myxoedema  (cachexia  strumi- 
priva).  Reverdin  pointed  out  that  in  certain  cases  in  which  removal  was  done 
for  goitre  the  patient  became  cretinous.  Horsley  proved  that  complete  re- 
moval of  the  gland  in  monkeys  was  succeeded  by  a  myxoedematous  condition. 
Kocher,  of  Bonn,  showed  that  the  same  condition  followed  in  a  small  pro- 
portion of  cases  in  man.  Complete  removal  is  necessary,  since  if  but  a  small 
portion  be  left  it  seems  to  functionate  well.  In  certain  cases  supernumerary 
glands  take  the  place  of  the  main  one.  The  condition  usually  begins  to 
develop  about  four  months  after  operation.  There  is  mental  and  physical 
lassitude,  slowly  oncoming  changes  in  the  skin,  etc.,  till  finally  all  the  symp- 
toms appear.  The  extent  of  symptoms  varies  inversely  with  the  age  of  the 
patient.  Thus,  if  the  operation  be  done  in  early  childhood  myxoedematous 
cretinism  results,  while  in  adult  life  we  have  only  the  symptoms  of  myx- 
oedema. 

In  cases  of  the  natural  disease  that  have  come  to  post-mortem  the  thyroid 
gland  has  always  been  atrophied,  sometimes  more  in  one  lobe  than  the  other. 
Macroscopically,  the  organ  is  bluish-white,  hard  and  firm.  Microscopically, 
there  is  in  the  early  stage  an  infiltration  of  the  walls  of  the  vesicles  by  em- 
bryonic tissue  and  a  proliferation  of  epithelium.  There  are  at  the  end  stages 
the  evidences  of  a  chronic  thyroiditis.  Secondary  changes  in  other  organs 
are  frequent.  The  subcutaneous  fat  is  u.sually  abundant,  though  there  may 
be  emaciation.  There  is  an  increase  of  connective  tissue,  not  in  the  skin 
only,  but  throughout  the  entire  body.  The  tubes  of  the  sweat  and  sebaceous 
glands  are  blocked  by  swollen  epithelium.  Perineuritis  is  sometimes  present 
in  the  skin.  Ord  found  on  chemical  examination  a  large  excess  of  mucin 
in  the  skin,  and  other  observers  have  found  it  even  in  the  blood.  In  Griind- 
ler's  case  of  operative  myxoedema,  on  the  contrary,  and  in  several  spontane- 
ous cases  no  such  excess  was  found.  The  amount  present  probably  depends 
upon  the  stage  at  which  death  occurs.  The  cerebral  hypophysis  is  not  infre- 
quently enlarged,  but  may  be  normal  in  size.  In  this  connection  it  is  of 
interest  to  note  that  in  the  experiments  of  Hofmeister  on  rabbits,  enlargement 
of  the  hypophysis  appeared.  Save  for  fibrous  changes  in  the  cervical  sym- 
pathetic, no  serious  changes  have  been  found  in  the  nervous  system. 

While  it  must  be  accepted  as  proven  that  the  thyroid  gland  is  the  seat  of  the 
essential  lesion  in  myxoedema,  yet  that  is  only  one  step  in  the  pathology.  When 
we  attempt  to  go  further  to  find  what  it  is  that  influences  the  entire  organism 
so  markedly  we  are  beset  with  difficulties  owing  to  our  small  knowledge  of 
the  functions  of  the  gland.  According  to  Horsley,  it  is  a  blood-forming 
organ.  Experimentally  he  showed  that  during  the  anemia  resulting  from 
its  removal  the  blood  of  the  thyroid  vein  contains  7  per  cent,  more  corpuscles 
than  the  corresponding  artery.  He  also  found  that  mucin  Avas  increased 
in  the  skin,  the  salivary  glands  and  the  blood,  and  hence  holds  that  the 
gland  regulates  the  formation  of  it.  We  do  not  know,  however,  whether 
mucin  is  itself  a  poison  or  whether  it  is  merely  an  evidence  of  degeneration. 
According  to  Schiff",  the  normal  thyroid  secretes  a  substance  which  influences 
the  nutrition  of  the  nervous  system.  The  absence  of  this  substance  pro- 
duces the  trophic  changes  found  in  myxoedema.  That  the  blood  is  toxic  is 
proven  by  the  fact  that,  though  harmless  in  healthy  animals,  it  hastens  the 
cachexia  in  those  in  which  the  thyroid  has  been  removed,  as  has  been  shown 
in  the  experiments  of  Rogdwitsch,  Fano,  and  others.  Putnam  thinks  that 
certain  of  the  phenomena  of  the  disease,  for  example,  the  localized  swellings 
in  the  neck  and  the  changes  in  the  ovaries  of  rabbits  can  be  less  easily 


TR  OPHIC  DISEASES.  917 

explained  as  results  of  irritation  and  degeneration  than  as  evidences  of  a  sort 
of  variation  in  structure,  analogous,  j^erliaps,  to  that  which  follows  castration. 
Treatment.  Schiff  found  that  if  a  thyroid  gland  was  imj^lanted  in  the 
peritoneum  of  rabbits  thyroidectomy  was  harmless.  Murray,  in  1891,  intro- 
duced treatment  by  hypodermatic  injections  of  thyroid  juice  in  women,  with 
good  results.  Since  then  many  brilliant  results  have  been  obtained  by  the 
use  of  the  gland  in  many  ways.  The  fresh  sheep's  thyroid,  finely  minced, 
may  be  eaten  raw  or  slightly  warmed,  a  half  or  quarter  of  a  gland  being  a 
dose.  For  hypodermatic  vise  the  following  solution  is  recommeded  by  Murray  : 
One  drachm  each  of  expressed  juice,  glycerin,  and  one-half  of  one  per  cent, 
watery  solution  of  carbolic  acid.  The  dose  is  from  five  to  fifteen  minims, 
injection  two  or  three  times  weekly.  The  dried  extract  in  doses  of  five 
grains  by  the  mouth  seems  to  answer  every  purpose.  The  ansemia  is  not 
relieved  by  treatment,  indeed,  it  may  become  more  aggravated.  Gray  sums 
up  the  effect  of  thyroid  treatment  as  follows  :  Elevation  of  temperature, 
increased  appetite,  with  more  complete  absorption  of  nitrogenous  foods; 
loss  of  weight,  with  nitrogen  excreted  in  excess  of  that  taken  in  the  food  ; 
growth  of  skeleton  in  the  very  young  ;  marked  improvement  in  body  nutri- 
tion generally ;  increased  activity  of  mucous  membranes,  skin,  and  kidneys. 
Removal  to  a  warm  climate  is  sometimes  necessary  on  account  of  the  ex- 
treme suffering  produced  by  cold.  Warm  or  Turkish  baths  are  useful. 
Pilocarpine  hypodermatically  employed  often  does  good. 


CRETINISM. 

The  etymology  of  the  word  is  undetermined.  It  has  been  variously  claimed 
to  be  derived  from  the  Latin,  creta,  chalk,  in  allusion  to  the  chalky  color  of 
the  skin  ;  from  christianus,  because  cretins  are  good-natured,  and  from  cre- 
tina,  stupid.     Cretins  are  sometimes  improperly  called  Capots  or  Cagots. 

Etiology.  The  disease  is  found  in  all  countries.  It  is  both  endemic  and 
sporadic,  and  we  will  concern  ourselves  principally  with  the  latter  type.  In 
the  countries  in  which  it  is  endemic  it  is  not  found  over  large  areas  of  terri- 
tory, but  here  and  there  in  limited  tracts.  It  is  especially  frequent  in  moun- 
tainous regions.  The  Alps,  the  Pyrenees,  the  Vosges,  and  the  Jura  are  favorite 
seats.  In  North  America  the  endemic  form  is  confined  to  certain  parts  of 
Vermont,  Massachusetts,  and  California.  Drinking  glacier  water  and  water 
rich  in  lime  salts  is  an  alleged  cause.  It  is  very  doubtful,  since  in  certain 
countries  in  which  there  are  large  deposits  of  limestone  cretins  are  rare,  and 
in  others  in  which  the  water  is  perfectly  soft  they  are  common.  Altitude, 
atmospheric  moisture,  and  all  climatic  and  geologic  factors  have  been  thought 
to  be  causative.  Heredity  is  important.  Judson  Bury  lays  great  stress  on 
interbreeding.  The  disease  may  begin  in  early  uterine  life,  in  which  case  the 
sufferer  rarely  survives  birth,  or  late  in  uterine  life,  or  after  birth.  The  fre- 
quency of  the  sporadic  form  increases  with  the  knowledge  of  the  disease ; 
from  Philadelphia  alone,  for  instance,  cases  have  been  reported  by  Dercum, 
Mills,  Sinkler,  and  Lloyd. 

Symptoms.  In  the  sporadic  type  the  symptoms  usually  begin  about  the 
fifth  year.  They  are  characterized  by  mental  degeneration  and  j^hysical 
retardation.  Growth  is  stunted,  the  stature  rarely  reaching  beyond  five  feet. 
The  different  parts  of  the  body  develop  disproportionately,  causing  deformi- 
ties. The  limbs  are  crooked,  the  ends  of  the  long  bones  enlarged,  the  trunk 
too  long,  and  the  chest  large  and  flattened.  There  is  lumbar  lordosis,  throw- 
ing the  abdomen  far  forward.  The  head  is  brachy cephalic,  the  vertex  and 
occiput  flattened.     The  hands  are  large,  flat,  spade-like,  the  gait  awkward, 


918  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

bear-like.     The  liair  is  a  dirty  brown,  coarse,  rough,  and  thick.     The  body 
hair  does  not  grow  at  all  or  is  scanty.     The  face  is  large  and  square,  the  uose- 

FiG.   304. 


A  cretin,  aged  about  thirty-five  years.    (Philadelphia  Hospital.) 
Fig.  305. 


Cretin  ;  same  case  as  shown  in  Fig.  304. 


TROPHIC  DISEASES. 


919 


Fig.  3C6. 


bridge  much  flattened  and  wide,  keeping  the  eyes  far  apart,  and  the  nostrils 
dilated.  The  eyelids  are  swollen,  and  sometimes  cannot  be  opened.  The 
tongue  is  large  and  flabby,  protrudes  between  the  enormously  thickened  lips. 
The  thick,  viscid  saliva  dribbles  constantly.  The  milk  teeth  decay  early, 
and  the  permanent  set  may  never  appear.  The  skin  is  a  dirty  yellowish- 
brown,  coarse  and  wTinkled,  or,  if  myxoedema  be  present,  it  is  pale.  Sub- 
cutaneous fat  is  abundant,  and  there  are  apt  to  be  local  deposits,  especially 
in  the  supraclavicular  fossae.  The  ears  are  malformed  and  stick  out  from 
the  side  of  the  head.  The  muscles  are  soft.  The  neck  is  bull-like,  and 
goitre  may  or  may  not  be  present.  The  eyesight  is  usually  good,  though 
there  may  be  strabismus.  The  other  special  senses  and  common  sensation 
are  poorly  developed.  Puberty  is  delayed,  sometimes  till  the  twenty-fifth 
year,  and  menstruation  either  is  scanty  or  soon  ceases.  Kespiration  and 
pulse  are  slow,  and  the  temperature  subnormal.  The  circulation  is  poor,  the 
extremities  cold  and  blue.  Eed  patches  occur  on  the  cheeks.  The  urine  is 
thick,  bad  smelling,  and  quickly  becomes  ammoniacal.  Speech  is  thick,  the 
voice  rough.  Sleep  is  heavy.  They  are  liable  to  curious  attacks,  in  which 
they  will  sit  for  hours,  the  eyes  open  and  fixed,  the  body  motionless,  scarcely 
breathing,  and  showing  almost  no  signs  of 
life.  It  would  almost  seem,  as  Mafiei  says, 
"  that  the  soul  had  entirely  left  the  body." 
The  amount  of  mental  deterioration  varies 
much.  Sometimes  it  is  possible  to  educate 
them  to  fulfil  many  of  the  ordinary  duties 
of  life.  One,  for  instance,  who  had  but 
little  schooling,  keeps  a  news-stand,  sup- 
ports himself,  and  knows  well  the  value 
of  money.  From  this  there  are  all  grades 
down  to  absolute  vacuity,  in  which  the 
patient,  though  not  paralyzed,  cannot  walk, 
nor  talk,  nor  understand,  nor  even  feed 
himself,  being  merely  vegetative.  Though 
ordinarily  quiet,  gentle,  even  affectionate, 
they  sometimes  are  irritable  and  easily  an- 
gered. All  movements,  all  actions,  mental 
or  physical,  are  slow,  not  only  in  the  initia- 
tion, but  throughout  the  act.  Many  are  deaf 
and  dumb.  According  to  the  report  of  the 
Sardinian  Commission,  only  one-third  have 
normal  hearing.  The  disease  usually  pro- 
gresses for  twelve  or  fourteen  years,  and 
then  remains  stationary. 

Morbid  Anatomy.  Cretinism,  whether 
sporadic  or  endemic  is  closely  alhed  to  if 
not  identical  with  myxoedema.  We  will 
here,  therefore,  consider  only  the  lesions 
found  and  refer  the  reader  for  the  study  of 
the  pathology  to  myxcedema. 

Autopsies  have  been  few.  The  first  sporadic  case  was  reported  by  Curling. 
The  most  important  lesions  are  those  of  the  thyroid  gland  and  the  osseous 
system.  In  cases  beginning  early  in  uterine  life  the  thyroid  is  alwaj^s  absent. 
In  those  commencing  later  it  usually  atrophies  slowly  ;  sometimes,  however, 
it  increases  in  size  and  may  develop  into  a  large  goitre.  But  little  is 
known  of  the  microscopic  structure  of  the  gland.  Virchow's  description  of 
the  skull  of  an  endemic  cretin  has  become  classic.     The  spheno-basilar  bone 


A  case  of  sporadic  cretinism.   (Dercum.) 


920  JSEBVOVS  DISEASES  AND  THEIR  TREATMENT. 

was  prematurely  ossified,  preventing  antero-posterior  growth,  of  the  skull. 
This  would  cause,  in  order  to  compensate,  expansion  of  the  cranial  vault, 
and  hence  widely  open  fontanelles.  The  condition  has  not,  however,  proven 
constant.  Lombroso  reports  a  case  in  which  the  basilar  process  and  the 
occipital  condyles  were  absent.  The  boues  of  the  skull  may  be  greatly 
thickened.  All  the  long  bones  (developing  in  cartilage),  except  the  clavicle, 
are  shortened.  The  brain  may  present  various  convolutional  anomalies,  but 
none  are  constant.  In  Barlow's  case  the  most  interesting  abnormabty  was 
abnormal  fissuration  in  the  temporo-sphenoidal  lobe.  The  cerebellum  was 
more  covered  by  the  cerebrum  than  normal.  Many  cases  of  so-called  foetal 
rickets  are,  according  to  Barlow  and  Bury,  really  cases  of  foetal  cretinism. 
Post-mortem  there  is  much  subcutaneous  fat.  The  limbs  are  dwarfed.  The 
long  bones  are  firm,  smooth,  and  unduly  compact.  In  the  skull  the  mem- 
brane-formed bones  are  well  developed,  those  formed  in  cartilage  are  stunted. 
Microscopically  the  bone  condition  is  the  reverse  of  that  found  in  rickets. 
The  thyroid  is  not  atrophied  in  all  cases.  Eberth  has  found  similar  condi- 
tions in  malformed  calves. 

Treatment.  The  thyroid  treatment  should  be  used  in  the  same  way  as  in 
myxoedema,  and  it  is  probable  that  in  every  institution  for  the  feeble-minded 
and  in  every  insane  asylum  there  are  few  or  more  cases  that  could  be  greatly 
benefited. 

EXOPHTHALMIC    GOITRE. 

Syno^s^yms  :  Graves's  Disease ;  Basedow's  Disease ;  Struma  Exophthal- 
mica  ;  Cardio-thyroid  Exophthalmus. 

History.  The  Italian  Flajani  was  probably  the  first  to  describe  the  con- 
dition (in  1802).  The  English  physician  Parry  speaks  of  the  most  im- 
portant symptoms  in  his  work  published  in  1825,  but  it  was  not  until  Graves's 
description  of  the  disease,  in  1835,  that  the  interrelation  of  the  three  great 
symptoms  was  recognized.  Basedow  discovered  the  disease,  independently 
of  Graves,  in  Germany  in  1840. 

Etiology.  No  specific  cause  is  known.  Direct  inheritance  plays  a  very 
subordinate  part.  Occasionally,  however,  several  persons  in  one  generation 
are  affected,  as  in  the  family  reported  by  Oesterreicher,  in  which  eight  out  of 
ten  children  sufiered.  Indirect  inheritance  through  insane,  epileptic,  or 
neurotic  parents  is  frequent.  It  is  far  more  frequent  in  women  than  in  men. 
Of  thirty  cases  only  one  Avas  a  man.  In  Eshner's  table  forty-two  are  males 
and  one  hundred  and  eighty-five  females,  a  proportion  of  about  one  to  four. 
E.OSS  says  it  afiects  females  twice  as  often  as  males.  It  may  occur  at  any 
period  of  Hfe,  except  early  infancy  and  extreme  old  age.  The  thirtieth  year 
is  the  time  of  greatest  frequency.  Hawkes  reports  a  case  in  a  gii'l  of  six 
years,  and  Gowers  has  seen  it  appear  as  late  as  fifty-three.  The  causes  of 
cystic  goitre  are  without  causative  influence.  There  is  no  evidence  that  pre- 
ceding organic  heart  disease  predisposes  to  the  aflfection.  All  factoid  which 
tend  to  reduce  strength,  exposure,  anemia,  chronic  discharges,  abortion  are, 
of  course,  in  a  way  causes.  The  most  frequent  and  most  important  imme- 
diate cause  is  emotion — a  sudden  moral  shock  or  prolonged  grief.  Thus  a 
man  when  told  of  his  brother's  sudden  death  began  immediately  to  complain 
of  palpitation  and  soon  presented  the  tjq^ical  symptoms. 

Symptoms.  Rarely  the  onset  is  rapid,  almost  sudden,  and  the  course 
very  acute.  Such  usually  die,,  though  sometimes  recovery  takes  place  or  the 
condition  becomes  chronic.  Osier  quotes  a  case  of  J.  H.  Lloyd's.  A  woman, 
aged  thirty -nine  years,  who  had  been  considered  perfectly  healthy,  but  whose 
friends  had  noticed  for  some  time  that  her  eyes  looked  rather  prominent,  was 


TROPHIC  DISEASES.  921 

suddenly  seized  with  intense  vomiting  and  diarrhoea,  rapid  action  of  the  heart, 
and  great  throbbing  of  the  arteries.  The  eyes  were  prominent  and  staring, 
the  thyroid  much  enlarged  and  soft.  The  patient  died  on  the  third  day. 
Another  case,  scarcely  comj^arable  to  the  foregoing,  but  of  interest  as  show- 
ing all  the  objective  signs  without  any  subjective  symptoms  until  they  sud- 
denly developed  after  a  slight  shock,  was  that  of  a  woman  who  came  to  the 
hospital  solely  on  account  of  the  disfigurement  produced  by  exophthalmos, 
and  who  began  to  complain  bitterly  of  ^palpitation  and  tremor  immediately 
after  being  exhibited  in  clinic.  Most  frequently  the  development  of  the  dis- 
ease extends  over  many  months.  Of  the  three  cardinal  symptoms,  cardiac 
overaction,  exophthalmos,  and  goitre,  the  first  named  usually  appears  earliest. 
The  course  of  events  is  about  as  follows :  At  the  beginning  the  patient  com- 
plains of  attacks  of  palpitation  and  cardiac  distress  after  exertion  or  emo- 
tion, with  some  dyspnoea.     Examination  may  reveal  nothing  but  a  rapid 

Fig.  307. 


Exophthalmic  goitre. 

pulse.  As  time  passes  the  attacks  become  more  frequent,  are  more  severe, 
and  last  longer  until  finally  the  pulse-rate  becomes  persistently  high,  often 
100  or  120  per  minute,  rarely  200.  There  is  increased  force  of  the  heart's 
action  as  well  as  increased  frequency.  The  impulse  is  strong  and  widely 
diflfiised,  the  entire  chest  sometimes  throbbing.  Early  the  apex  beat  is  in 
the  normal  position,  but  later  it  is  displaced  downward,  and  to  the  left,  and 
the  signs  of  dilatation  appear.  Hypertrophy  is  rarer.  The  heart  sounds 
are  loud.  Graves  in  one  case  heard  them  four  feet  distant  from  the  body. 
Systolic  murmurs  heard  plainest  at  the  base,  but  sometimes  audible  at  the 
apex  and  transmitted  to  the  axilla,  are  common.  They  are  not  always  func- 
tional. It  is  probable  that  not  infrequently  in  the  fully  developed  disease 
there  is  a  true  mitral  regurgitation  ;  the  mitral  orifice  having  been  mechani- 
cally dilated  by  the  dilating  ventricle,  an  apical  thrill  may  be  felt.  The 
carotids  and  even  the  abdominal  aorta  are  dilated  and  pulsate  strongly. 
Venous  and  capillary  pulse  sometimes  is  present.  Systolic  murmurs  are 
heard  in  the  larger  arteries.     There  is  greater  or  less  dyspnoea. 


922  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Enlargement  of  the  thyroid  and  exophthalmos  usually  appear  together, 
or  at  about  the  same  time,  and  after  the  cardiac  symptoms.  The  enlarge- 
ment is  slow  and  painless  and  affects  the  whole  organ,  one  lobe  much 
more  than  the  other,  or  very  rarely  the  isthmus  only.  At  first  the  swell- 
ing is  soft,  but  its  density  depends  much  upon  the  strength  of  the  cardiac 
action.  Is  never  so  great  as  that  which  is  seen  in  common  cystic  bron- 
chocele,  and  varies  from  time  to  time.  The  arteries,  and,  indeed,  the  whole 
gland  pulsate  strongly.  A  thrill  is  felt  on  jDalpation,  and  on  auscultation 
there  is  heard  a  distinct,  sometimes,  loud  systolic  murmur.  According  to 
Guttman  there  is  a  bruit  in  the  goitre  synchronous  with  the  pulse,  even 
though  the  heart  sounds  are  normal.  It  is  j)robably  due  to  aneurismal  dila- 
tation of  the  arteries.  A  venous  hum  in  the  neck  is  frequent.  The  superfi- 
cial veins  may  be  much  dilated.  Striking,  as  the  thyroid  symptoms  often 
are,  there  are  not  a  few  cases  in  which  at  no  time  in  the  course  of  the  dis- 
ease is  there  any  recognizable  involvement  of  the  gland. 

Exophthalmos  rarely  is  the  first  symptom.  It  may  be  very  slight,  caus- 
ing only  a  staring  appearance,  or  so  great,  as  is  alleged  in  one  case,  as  to  dis- 
locate the  ball  completely  from  the  orbit.  Frequently  it  is  sufficient  to  allow 
the  scleral  coat  to  be  seen  above  and  below  the  cornea,  and  sometimes  the 
insertions  of  the  recti  muscles  are  exposed.  The  amount  of  exophthalmos  varies 
from  time  to  time.  Usually  vision  is  unaffected,  but  occasionally  the  antero- 
posterior diameter  of  the  globe  is  increased,  producing  myopia.  The  pupils 
are  normal.  Ophthalmoscoi^ic  examination  is  usually  negative  except  that 
arterial  and  venous  pulse  is  sometimes  present.  Qildema  of  the  disk,  and 
rarely  atrophy,  due  most  probably  to  the  mechanical  stretching  of  the  nerve, 
are  met  with.  When  the  exophthalmos  is  great  the  lids  are  prevented 
mechanically  from  closing,  and  the  dry  conjunctivae  become  inflamed.  Opac- 
ity of  the  cornea,  and  even  ulceration  and  destruction  of  it,  may  ensue. 
Sometimes  there  is  oedema  of  the  lids,  even  though  the  exophthalmos  is 
slight.  The  so-called  von  Graefe's  sign  is  very  important.  In  health,  on 
looking  downward,  the  upper  lid  follows  the  ball ;  ordinarily  in  this  affec- 
tion, the  lid  either  does  not  move  at  all,  or  descends  haltingly,  not  acting  in 
unison  with  the  ball.  Other  movements  of  the  eyehds,  as  in  winking  or  in 
going  to  sleep,  or  in  voluntarily  closing  the  eyes,  are  not  interfered  with. 
The  symptom  is  not  to  be  mistaken  for  the  inability  to  close  the  eye  because 
of  the  extreme  exophthalmos.  Stelwag's  sign,  the  widening  of  the  jDalpebral 
fissure,  on  account  of  the  retraction  of  the  upper  lid,  is  really  only  one  of 
the  factors  of  von  Graefe's  sign.  Retraction  of  the  lower  lid  is  spoken  of 
by  Hill,  Griffith,  and  others.  Joffroy  found  in  three  cases  a  condition 
which  bears  much  analogy  to  von  Graefe's  sign.  If  the  patient,  looking  at 
the  ground  was  told  to  look  at  the  ceiling,  as  the  eyeballs  rolled  up  the 
frontal  muscle  did  not  contract  as  in  health.  Voluntary  contraction  of  the 
muscle  was  perfect. 

The  general  condition  of  the  patient  is  much  affected.  She  is  apt  to  be 
irritable  or  depressed,  hysterical,  and  neurasthenic.  Anaemia  and  ema- 
ciation are  frequent.  There  is  apt  to  be  moderate  or  even  quite  high 
fever,  but  the  temperature  may  be  normal  throughout.  Subjective  sense 
of  heat,  hot  flashes,  profuse  perspiration,  sometimes  very  acid  and  rarely 
local,  are  often  complained  of.  The  "  tache  cerebrale"  sometimes  can  be 
obtained. 

Tremor  is  almost  a  constant  symptom.  It  may  be  fine  and  slight,  or 
coarse  ;  indeed,  choreiform.  The  hands  are  often  alone  affected,  but  it  may  be 
more  extensive,  involving  in  one  case,  for  example,  the  tongue.  While  it  is 
present  during  rest  it  may  be  increased  by  voluntary  muscular  effort  or 
emotion. 


TROPHIC  DISEASES.  923 

Cardiac  overaction,  exophthalmos,  and  goitre,  together  with  tremor,  con- 
stitute the  essence  of  the  disease ;  but  there  are  always  present,  to  a  greater 
or  less  degree,  other  symptoms  which  may  have  their  origin,  so  varied  are 
they,  in  almost  every  organ.  One  of  the  most  important  complications  is  in- 
sanity. The  type  found  varies  much,  ranging  from  the  simple  depression 
and  irritability  spoken  of  above  to  extreme  melancholia  or  acute  mania.  As 
a  rule,  the  mental  symptoms  are  periodic,  or  Graves'  disease  may  recur,  with 
attacks  of  periodic  mania.  In  general  paralysis  there  may  be  exophthalmos 
only,  or  the  entire  triad  of  symptoms.  The  coexistence  of  mental  disturb- 
ance is  far  too  frequent  to  be  merely  coincidental,  and  as  Spitzka  well  says, 
"  It  is  an  interesting  problem  for  the  future  to  solve  why  enlargement  of  the 
thyroid  should  in  two  disorders,  such  as  exophthalmos  and  cretinism,  be 
associated  with  mental  disorder." 

Owing  probably  to  the  dilatation  of  the  small  bloodvessels  and  the  excessive 
perspiration,  there  is  a  marked  diminution  of  the  electrical  resistance  of  the 
skin,  which,  while  normally  amounting  to  from  4000  to  6000  ohms,  may  be 
reduced  to  3000  ohms.  Local  redness  of  the  skin,  and  even  a  general  ery- 
thema is  not  very  uncommon,  and  vitiligo  sometimes  occurs.  Urticaria 
may  be  troublesome.  In  one  case  the  j^atient  was  awakened  several  times 
to  find  painful  wheals  scattered  over  legs,  arms,  and  trunk.  They  would 
last  a  day  or  two,  and  then  pass  quickly  away.  Bronzing  similar  to  that  of 
Addison's  disease,  but  almost  never  affecting  the  mucous  membranes,  has 
l»een  occasionally  observed.  In  a  case  of  my  own  it  seemed  to  deepen  or 
grow  less  from  week  to  week.  There  is  sometimes  marked  oedema.  Gow- 
ers  speaks  of  a  case  in  which  myxoedematous  swelling  of  the  eyelid  and 
pigmentation  of  the  skin  followed  permanent  recovery. 

Polyuria  is  common.  Glycosuria  is  not  very  frequent.  Transient  albu- 
minuria is  probably  present  at  some  period  in  every  case. 

The  alimentary  tract  offers  many  interesting  symptoms.  There  may  be 
simple  anorexia  or  nausea  at  the  sight  of  food  and  vomiting,  or,  on  the  con- 
trary, the  appetite  may  be  ravenous.  Sometimes  there  are  attacks  of  acute 
severe  diarrhoea,  in  which  many  large,  painless,  watery  stools,  with  undigested 
food,  are  passed  daily.  The  attack  may  be  so  sudden  and  severe  as  to  re- 
semble sporadic  cholera.  The  condition  has  been  regarded  as  an  intestinal 
sweating.  The  biliary  secretion  may  be  increased  and  an  icterus  of  several 
months'  duration  develop. 

Menstruation  is  either  very  irregular  or  suppressed,  and  its  absence  may 
coincide  with  a  severe  and  persistent  leucorrhoea.  It  is  stated  that  among 
men  there  may  be  at  the  beginning  a  marked  increase  of  sexual  desire,  fol- 
lowed later  by  impotence. 

There  are  many  complications  referable  to  the  nervous  system.  Various 
palsies  of  the  cranial  nerves,  especially  the  motor  nerves  of  the  eye,  the  third, 
fourth,  and  sixth  are  met  with.  Ballet  speaks  of  a  case  in  which  complete 
external  ophthalmoplegia  was  associated  with  double  facial  palsy,  and  Gowers 
quotes  from  Bristow  one  in  Avhich  it  was  associated  with  right  hemiansesthe- 
sia,  including  the  special  senses,  epileptic  fits,  palsy,  with  rigidity  of  the  right 
side,  hemorrhages  from  the  ears,  and  persistent  pyrexia.  Post-mortem  ex- 
amination revealed  nothing. 

Paraplegia,  either  spastic  or  flaccid,  chronic  muscular  atrophy,  paralysis  of 
the  sphincters,  even  locomotor  ataxia,  and  acute  myelitis  are  occasional  com- 
plications. 

At  times  there  are  marked  local  trophic  changes,  the  hair  may  be  lost 
from  the  brows  and  lids,  the  mamm?e  atrophy,  the  skin  even  becomes  gangren- 
ous in  places. 

Epilepsy,  neuralgia  and  migraine  are  occasional  complications. 


924  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Course  and  Prognosis,  Fortunately  no  one  patient  suffers  from  the  entire 
long  catalogue  of  symptoms.  Cardiac  excitement  is  probably  never  absent, 
though  its  intensity  may  vary  greatly.  The  disease  is  in  most  cases  essen- 
tially chronic,  and  the  exact  date  of  onset  is  hard  to  determine,  since  the 
affection  may  exist  for  a  greater  or  less  time  without  the  knowledge  of  the 
patient.  Throwing  out  the  very  acute  cases  mentioned  above,  death  is  rare 
within  six  months,  and  the  disease  may  last  five  or  even  ten  years.  Re- 
covery results  in  about  25  per  cent,  of  the  cases,  according  to  Gowers,  and 
it  is  probable  that  this  estimate  is  far  within  the  truth  if  ill-developed  cases 
be  included.  Remissions  are  not  infrequent,  and  complete  intermissions 
occur  sometimes.  The  symptoms  may  disappear  independently  of  each 
other.  Thus,  not  infrequently,  while  the  heart  continues  much  affected,  ex- 
ophthalmos and  goitre  may,  under  treatment,  become  much  less  marked. 

The  prognosis  in  any  given  case  is  difficult.  While  in  general  it  is  true 
that  the  more  severe  the  s5"mptoms  the  worse  the  outlook,  it  is  also  true 
that  the  worst  symptom  may  subside  and  the  subordinate  ones  persist.  Cases 
seen  early,  and  which  have  developed  rather  rapidly,  are  more  favorable 
than  those  in  which  the  onset  was  very  slow  and  unnoticed.  Pregnancy, 
curiously,  sometimes  exerts  a  beneficial  influence.  The  disease  is  more  fatal 
in  men  than  in  women. 

Death  usually  results  from  the  heart.  Palpitation  and  dyspnoea  increase, 
oedema  and  diarrhoea  set  in,  and  great  general  exhaustion  ends  the  scene. 
Tuberculosis  is  sometimes  the  immediate  cause,  or  vascular  cerebral  trouble. 

Diagnosis.  In  well-developed  cases  there  is  no  difficulty  in  making  a  diag- 
nosis. If  the  onset  be  very  acute  mistakes  can  easily  be  made.  Thus,  if  the 
fever  take  a  typhoid  course,  as  happens  sometimes,  and  the  legitimate  symp- 
toms are  slight,  the  affection  may  for  a  time  be  mistaken  for  typhoid  fever. 
Again,  if  the  symptoms  be  largely  thoracic,  and  raj)id  emaciation  and  profuse 
sweating  be  present,  acute  phthisis  may  be  thought  of  The  difficulty  is 
further  increased  here  by  the  fact  that  in  the  latter  disease  there  may  be  at 
first  no  stethoscopic  signs.  When  hysteria  is  added  to  chlorosis,  the  palpita- 
tion, the  hffimic  murmur,  the  digestive  troubles,  the  nervousness,  all  combine 
to  give  a  picture  much  resembling  beginning  Graves's  disease. 

The  cases  in  which  the  symptoms  are  almost  purely  cardiac  in  the  early 
stages  are  often  difficult  to  diagnose.  Either  organic  heart  disease  is  feared, 
or  the  trouble  is  made  light  of  as  being  merely  nervous.  Every  case  of  per- 
sistently rapid  heart  without  definite  cause  should  be  carefully  examined  for 
ocular  and  thyroid  symptoms. 

Ordinary  cystic  goitre  is  usually  easily  differentiated.  There  are  neither 
heart  nor  eye  symptoms,  the  enlargement  is  greater,  and  endemic  influences 
may  be  present.  Occasionally,  however,  the  goitre,  from  pressure  on  the  sym- 
pathetic and  vagus,  may  cause  rapid  pulse,  one-sided  exophthalmos,  and  spas- 
modic mydriasis.  Carotid  aneurism  needs  only  to  be  remembered  to  avoid 
error. 

The  morbid  anatomy  of  Graves's  disease  is  chaotic,  its  patholgy  unknown. 
Post-mortem,  various  changes  in  many  organs  have  been  found,  changes  so 
numerous  as  not  to  give  light,  but  rather  to  confuse. 

The  heart  is  dilated  and  the  walls  may  be  thickened  and  degenerated. 
Slight  valvular  endocarditis  is  common ;  when  severe  it  is  probably  not  due 
to  the  cause  of  Graves's  disease,  but  coincident  with  it.  Examination  of 
the  cardiac  ganglion  has  been  negative.  There  is  dilatation  and  thickening 
of  the  walls,  and  even  atheroma  of  the  arteries  to  a  greater  or  less  degree 
throughout  the  body. 

The  thyroid  may  be  simply  hypertrophied.  Sometimes  there  are  marked 
colloid  changes  throvighout  the  organ  or  in  small  areas,  forming  cysts  sur- 


TROPHIC  DISEASES.  925 

rounded  by  fibrous  envelojjes.  In  still  other  cases  there  is  great  proliferation 
of  the  connective  tissue  comprising  the  vesicles  and  producing  a  true  sclerosis. 
The  bloodvessels  are  dilated  and  thickened.  Mobius,  Spencer,  and  others 
have  found  a  persistent  thymus  the  seat  of  changes  similar  to  those  found 
in  the  thyroid.  The  orbit  is  often  normal.  Occasionally  the  orbital  fat  is 
increased  in  quantity.  There  are  often  evidences  of  an  active  congestion  of 
the  retro-bulbar  vessels  probably  quite  sufficient  to  have  exerted  some  in- 
fluence in  the  causation  of  exophthalmos.  The  ocular  muscles  are  often  the 
seat  of  fatty  degeneration,  and  in  not  a  few  instances  Miiller's  muscle  has 
been  absent.  Elongation  of  the  optic  nerve  is,  of  course,  present  when  there 
is  exophthalmos. 

No  imjDortant  lesions  in  the  abdominal  viscera  have  been  noted  except  that 
in  three  cases  Savage  found  disease  of  the  supra-renal  cajisules.  In  one  these 
organs  were  small,  diffluent,  and  broke  easily.  Savage  and  Howse  have 
seen  enlargement  of  Peyer's  patches.  Nephritis,  probably  secondary  to 
heart  disease,  occurs  sometimes.  There  may  be  a  chronic  enteritis  following 
prolonged  diarrhoea. 

In  earlier  days  Recklinghausen  and  others  found  lesions  in  the  sympathetic, 
but  recent  observations  with  more  imjDroved  methods  have  not  verified  them. 
Increase  of  the  connective  tissue  in  the  cervical  ganglion,  atrophy  of  the 
nerve  cells  and  the  like  have  certainly  been  found,  but  these  lesions  are  not 
constant ;  in  the  examination  of  Dejerine  and  others  they  were  absent,  and 
when  present  may  be  secondary. 

In  the  spinal  cord  there  has  been  found  an  overgrowth  of  the  neurogliar 
tissue  and  dilated  and  thickened  vessels.  In  some  cases  at  least  those  were 
simply  the  changes  incident  to  age.  Drummond  rejjorts  poliomyelitis. 
Usually  the  medulla  is  normal,  though  sometimes  it  shows  the  evidences  of 
congestion,  and  even  recent  hemorrhages.  Mendel  reports  one  case  in  which 
the  solitary  bundles  were  unequally  developed,  and  one  restiform  body  was 
atrophied.  Marie  and  Marinesco  had  a  case  associated  with  tabes  in  which 
there  was  atrophy  of  the  solitary  bundle  and  of  the  ascending  root  of  the 
tri-facial.  On  the  other  hand,  Oppenheim  reports  the  same  lesion  in  a  tabetic 
who  suffered  from  tachycardia. 

Certainly  many  of  the  lesions  described  have  no  causal  relation  to  the 
disease,  and  no  theory  has  yet  been  evolved  which  satisfactorily  explains  all 
the  major  symptoms.  Theories  there  have  been  in  plenty.  The  opinion  of 
Stokes  and  Graves,  that  the  disease  is  one  of  the  heart  itself,  has  long  since 
fallen  into  oblivion.  The  view  that  the  symptoms  are  caused  by  pressure 
upon  the  vessels  and  nerves  of  the  neck  needs  only  to  be  mentioned  to  be 
dismissed.  Disease  of  the  cervical  sympathetic,  a  view  which  has  had  much 
vogue,  will  explain  some  but  not  all  the  symptoms.  Rather,  we  are  driven 
to  the  central  nervous  system  for  the  seat  of  disease,  and  it  will  probably  be 
proven  to  be  in  the  medulla.  Filehne,  and  after  him  Durdufi,  divided  the 
anterior  part  of  the  restiform  bodies  and  obtained  exophthalmos,  in  some 
cases  enlargement  of  the  thjToid  also,  and  in  one  the  three  major  symptoms. 
The  absence  of  any  very  gross  lesions  in  the  cases  examined,  and  the  proba- 
bility that  the  congestions  and  hemorrhages  sometimes  present  are  merely 
terminal  conditions,  together  with  the  fact  that  cases  of  long-standing  may 
be  recovered  from,  which  is  against  organic  disease,  make  it  conceivable 
that  the  cause  may  be  some  poison  acting  upon  the  medulla  without  causing 
a  lesion  gross  enough  to  be  recognizable  by  our  present  methods  of  examina- 
tion. The  view  that  some  poison  is  the  primary  cause  seems  to  be  the  most 
widely-accepted  doctrine  at  the  present  time.  Mobius  held  that  the  enlarged 
thyroid  produced  a  toxic  blood  state.  Johnston  believes  that  there  is  a 
"  hyperthyroidation "  of  the  organism,  while  others,  Joffi'oy  among  them. 


926  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

claim  that  there  is  an  alteration  of  the  secretion.  Durdnfi  has  found  in  the 
normal  thyroid  a  substance  analogous  to  cocaine,  and  the  latter  may  cause 
increased  pulse-rate,  exophthalmos,  and  trembling,  and  certainly  does  cause 
retraction  of  the  lid  and  a  condition  similar  to  von  Graefe's  sign.  Boinet 
and  Gilbert  have  found  certain  jDtomaines  in  the  urine  which,  however,  do 
not  produce  the  disease  when  injected.  In  conclusion,  we  may  say  tentatively 
that  the  evidence  is  quite  strong  that  the  cause  of  the  disease  is  a  poison 
originating  in  the  thyroid  and  acting  mainly  upon  certain  structures  in  the 
medulla. 

Treatment.  Rest  is  all  important.  In  a  severe  case  the  patient  should  be 
kept  absolutely  in  bed.  Many  drugs  have  been  used.  All  seem  to  do  good 
sometimes.  No  one  can  be  depended  upon  before  trial  in  any  given  case. 
Digitalis  and  strophanthus  sometimes  give  excellent  results,  sometimes  are 
useless,  sometimes  do  harm.  Belladonna,  recommended  strongly  by  Gowers, 
probably  is  the  most  useflil  of  all  drugs.  It  should  be  given  in  ascending 
doses  until  the  jDatient  can  bear  no  more.  The  sheep's  thyroid  gland  and  its 
extract  are  useless.  General  hydrotherapy  is  to  be  recommended.  An  ice- 
bag  over  the  heart,  or  friction  with  ice,  at  first  only  for  a  few  minvites,  and 
increasing  the  time  each  day,  will  often  reduce  the  pulse  very  much  and  give 
the  patient  lasting  relief.  The  galvanic  current  applied  to  the  region  of  the 
cervical  sympathetic  seems  sometimes  to  exert  a  quieting  influence  on  the 
heart's  action.  Either  the  galvanic  or  the  faradic  current  may  be  passed 
with  good  effect  through  the  thyroid,  or  applied  at  the  back  of  the  neck  and 
over  the  heart.  The  thyroid  has  been  excised  frequently,  sometimes  with 
good  result,  often  with  none.  If  anaemia  be  present  iron  must,  of  course,  be 
given.  The  diet  should  be  carefully  regulated.  Jaboulay  has  recently  intro- 
duced a  new  operation,  exothyroipexia,  in  cases  in  which  the  enlargement  of 
the  thyroid  is  vascular.  An  incision  is  made  in  the  median  line,  the  gland 
detached  from  the  trachea  and  exposed  in  the  wound,  covered  by  an  anti- 
septic dressing.  It  rapidly  decreases  to  the  normal  volume,  and  the  wound 
is  closed.  The  result  is  claimed  to  be  excellent.  There  are  certain  cases 
associated  with  nasal  hypertrophy  which  have,  it  is  alleged,  been  cured  by^ 
cauterizing  the  nasal  mucous  membrane. 


CHAPTER    XXXII. 

SYMPTOMATIC  DISORDERS. 

By  JAMES  C.  WILSON,  M.D. 

HEADACHE. 

Definition.  Headache  is  a  term  used  to  designate  difFuse  pain  referred  to 
various  regions  of  the  head.     It  may  be  paroxysmal  or  continuous. 

Synonyms.     Cephalalgia ;  Cephaljea. 

Of  these  terms,  the  former  was  applied  by  the  ancients  to  slight,  limited, 
or  transitory  headaches ;  the  latter  to  severe,  deep-seated,  and  chronic  pains 
in  the  head. 

Headache  is  a  symptomatic  neurosis,  and  cannot  be  regarded  as  in  itself 
constituting  a  definite  disease.  The  propriety  of  the  separate  consideration 
of  headache  in  a  systematic  treatise  like  the  present  may  justly  be  called 
into  question.  Headache  is,  however,  in  many  cases  a  symptom  of  such  im- 
portance and  prominence  that  it  overshadows  all  others  and  lends  to  the 
clinical  picture  its  most  characteristic  feature,  sometimes  at  first  sight  its 
only  obvious  feature.  Headache  is,  moreover,  a  symptom  frequently  signifi- 
cant when  other  morbid  phenomena  are  obscure ;  it  thus  acquires  in  doubt- 
ful cases  diagnostic  value,  often  of  a  high  degree.  Again,  it  is  a  symptom 
of  many  diverse  conditions,  and  therefore  of  far-reaching  and  manifold  im- 
portance. For  these  reasons  it  seems  proper,  even  though  involving  repeti- 
tion, to  consider  it  separately  and  at  some  length. 

Etiology.  Headache  is  a  very  common  nervous  symptom.  It  occurs  in 
varying  degrees  of  intensity  as  a  manifestation  of  the  most  diverse  morbid 
states.  It  arises  at  all  pei'iods  of  life,  but  is  most  common  between  the  ages 
of  puberty  and  middle  life — that  is,  between  the  fifteenth  and  forty-fifth 
years.  Early  childhood  and  advanced  life  enjoy  a  comparative  exemption, 
which  is  to  be  ascribed  partly  to  the  fact  that  these  periods  are  relatively 
free  from  many  of  the  underlying  pathological  conditions  and  partly  to  the 
fact  that  at  the  extremes  of  life  the  cerebral  cortex  is  less  active  function- 
ally ;  that  is  to  say,  less  irritable. 

The  headaches  of  childhood  are  not  only  much  less  frequent  than  those  of 
adult  life,  but  they  are  also  more  limited  in  variety,  and  as  a  rule  less  severe. 

The  influence  of  sex  is  notable.  Women  suffer  more  than  men  in  the  ratio 
of  three  to  one. 

It  would  appear  that  headache  is  more  common  in  city  life  than  among 
country  folk,  among  the  well-to-do  than  the  poor,  in  the  spring  and  autumn 
and  in  temperate  climates.  Highly  educated  j)ersons  and  those  whose  time 
is  devoted  to  letters  and  learning  suffer  more  than  others  to  an  extent  which 
cannot  be  fully  explained  by  their  sedentary  habits. 

Headache  occurs  as  a  symptom  more  or  less  prominent  under  the  follow- 


928  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ing  conditions,  which,  taken  together,  may  be  regarded  as  forming  the  basis 
of  an  etiological  classification  : 

1.  Traumatism  involving  the  head. 

It  is  to  be  noted  that  headache  is  a  constant  symptom  after  recovery  of 
consciousness  in  cerebral  concussion  and  pressure,  but  that  it  occurs  infre- 
quently as  a  direct  symptom  after  surgical  operations  affecting  the  cerebral 
cortex  or  after  laceration  of  brain  substance  if  pressure  have  been  removed, 

2.  Circulatory  disturbances,  as : 

(a)  Passive  congestion,  such  as  is  produced  by  posture,  tight  clothing 
about  the  neck,  or  the  pressure  of  tumors  upon  the  veins  of  the  neck. 

(h)  Active  hypersemia,  such  as  results  from  excessive  or  prolonged  phys- 
ical or  intellectual  strain,  or  attends  the  initial  stage  of  acute  meningitis,  or 
the  action  of  certain  drugs,  as  alcohol,  amyl-nitrite,  nitroglycerin.  The  ves- 
sels of  the  pia  are  dilated,  there  is  increased  tension,  and  pressure  upon  re- 
lated sensitive  nerve  filaments. 

(c)  Anaemia,  either  that  following  loss  of  blood  or  the  ordinary  forms  of 
anaemia,  and  especially  chlorosis.  To  temporary  brain-ansemia  is  due  the 
headache  which  occurs  in  chlorotic  subjects  upon  effort,  as  ascending  a  flight 
of  stairs.  Local  anaemia  may  accompany  brain  exhaustion  from  prolonged 
mental  effort,  and  may  be  invoked  to  explain  the  headache  which  frequently 
arises  under  these  circumstances. 

3.  Inflammation.  Headache  is  a  very  prominent  symptom  in  meningitis, 
whether  due  to  local  cause,  secondary  infection,  or  the  primary  infection  of 
cerebro-spinal  fever. 

4.  Toxaemia.  The  offending  substance  or  substances  in  the  blood  may  be 
the  result  of 

(a)  Infection,  as  in  the  acute  specific  fevers  and  malaria. 

(h)  Incomplete  or  perverted  physiologico-chemical  processes,  or  defective 
elimination  of  waste.  This  variety  of  headache  occurs  in  uraemia,  diabetes, 
gastro-hepatic  derangements,  gout,  rheumatism,  and  lithaemia. 

(c)  The  action  of  drugs  and  poisons. 

a..  Acute :  quinine,  opium,  narcotics  generally,  the  nitrites,  alcohol,  ether, 
carbon  dioxide. 

/?.  Chronic :  lead,  tobacco,  alcohol,  opium,  chloral. 

5.  Changes  in  the  arteries.  Endarteritis,  arterio-sclerosis  ;  hence  in  syph- 
ilis, degenerative  nephritis,  chronic  alcoholism,  lead  poisoning. 

6.  Organic  disease  of  the  brain,  such  as  abscess,  tumor,  aneurism  (not 
miliary),  especially  when  pressure  is  directly  exerted  upon  the  brain-mem- 
branes. 

7.  Caries  of  the  cranial  bones. 

8.  Neuropathic  conditions,  neurasthenia,  hysteria,  epilepsy. 

9.  Reflex  irritation ;  ocular,  nasal,  pharyngeal,  auditory,  gastric,  and  irri- 
tation from  the  reproductive  tract. 

The  etiology  of  a  large  proportion  of  headaches  is  not  simple,  but,  as  will 
be  shown  later,  complex,  two  or  more  of  the  foregoing  factors  often  being 
concerned  in  its  causation. 

Pathological  Considerations.  It  is  customary  to  speak  of  headaches  due 
to  lesions  of  the  skull  or  to  intra-cranial  disease  as  organic ;  of  those  due 
to  other  causes  as  functional.  The  latter  group  includes  by  far  the  greater 
number  of  headaches  encountered  in  general  practice. 

We  know  practically  nothing  of  the  actual  mechanism  by  which  the  pain 
of  headache  is  produced.  Our  knowledge  is  summed  up  in  the  statement 
that  it  is  the  result  of  the  irritation  of  sensory  nerve  fibres,  caused  by  de- 
rangements of  pressure  or  tension,  inflammatory  processes,  toxic  states  of  the 
blood,  and  reflex  disturbance.     We  know,  however,  that  the  membranes. 


SYMPTOMATIC  DISOBBEBS.  929 

and  not  the  brain  substance,  are  chiefly  concerned  in  the  production  of  head- 
ache. The  substance  of  the  brain  in  man  and  the  lower  animals  does  not 
respond  to  direct  irritation  by  pain,  and  lesions  of  the  brain  tissue,  not  di- 
rectly or  indirectly  involving  the  membranes,  may  exist  without  causing 
headache,  such  disturbances  of  sensibility  as  they  produce  being  referred  to 
distant  parts  of  the  body.  The  membranes  of  the  brain,  and  especially  the 
dura,  on  the  other  hand,  are  supplied  with  nerves  of  sensation,  and  are 
dii'ectly  or  indirectly  implicated  in  the  morbid  conditions  Avhich  give  rise  to 
headache.  The  sensory  nerve  supply  of  the  dura  in  the  anterior  three-fourths 
of  its  extent,  that  of  the  falx,  and  probably  that  of  the  tentorium  are  derived 
from  the  trigeminus,  while  the  dura  mater  of  the  posterior  fossa  of  the  skull 
is  supplied  with  sensory  fibres  from  the  vagus. 

In  by  far  the  greater  number  of  headaches  the  diffuse  pain  appears  to  be 
deep-seated  and  intra-cranial.  In  a  small  proportion  of  cases  it  is  referred 
to  the  scalp.  It  is  to  be  noted  in  this  connection  that  the  trigeminus  is  the 
nerve  of  sensation  to  the  scalp  as  far  back  as  the  vertex,  while  the  posterior 
branches  of  the  upper  four  cervical  nerves  supply  the  muscles  and  the  skin 
of  the  back  of  the  neck  and  the  occiput,  and  that  this  group  of  nerves  is  in 
close  central  relation  with  the  trigeminus  on  the  one  hand,  while,  on  the 
other,  the  peripheral  distribution  of  these  branches  in  the  scalp  overlaps  that 
of  the  trigeminus. 

In  certain  rare  cases  superficial  headaches  have  been  due  to  myalgia  of  the 
occipito-frontal,  temporal  or  sterno-mastoid  muscles,  the  afiected  muscle,  at 
its  origin,  insertion  or  elsewhere,  being  the  seat  of  j)oints  of  tenderness  (Hirt). 

It  may  be  assumed  that  functional  headaches  can  occur  either  in  conse- 
quence of  the  action  of  adequate  irritants  directly  upon  the  normal  end- 
organs  of  sensory  nerves,  or  from  the  abnormal  reaction  of  diseased  or  under- 
nourished nerve  fibres  to  slight  pathological  changes  in  the  blood.  Due 
consideration  of  this  postulate  sheds  light  upon  some  varieties  of  troublesome 
headache,  and  is  not  without  bearing  upon  treatment.  It  may  be  added  that 
no  anatomical  changes  in  the  nerve  filaments  of  the  dura  have  been  de- 
scribed and  that  the  processes  afiecting  the  nerves  in  the  functional  forms  of 
headache  are  merely  nutritional  and  mostly  transitory,  albeit  they  frequently 
show  a  tendency  to  recur. 

Clinical  Considerations.  Headaches  are  usually  bilateral ;  they  may  be 
grouped  according  to  the  region  to  which  the  pain  is  referred,  as  frontal, 
occipital,  parietal  and  temporal,  vertical  and  difilise.  Frontal  headache  is 
most  common.  Next  in  order  of  frequency  are  the  diffuse  forms  ;  then  come 
the  vertical,  occipital  and  temporal.  But  headache  sometimes  changes  from 
one  part  of  the  head  to  another,  and  by  no  means  is  constantly  confined  to 
regions  limited  by  anatomical  boundaries.  Again,  headache  may  be  grouped 
according  to  the  character  of  the  pain,  as 

(a)  Pulsating  or  throbbing :  This  form  of  pain  is  characteristic  of  the 
headaches  due  to  circulatory  disturbances.     It  is  often  difflise. 

(6)  Dull,  heavy  :  This  is  the  character  of  the  pain  in  headaches  due  to  tox- 
aemia, which  are  frequently  frontal,  though  sometimes  occipital. 

(e)  Binding  or  constrictive :  Patients  sometimes  describe  the  sensation  as 
that  of  a  tight  iron  band  around  the  head.  This  is  the  headache  of  neuro- 
pathic conditions,  such  as  hysteria  and  neurasthenia.  Its  focus  of  intensity 
is  often  referred  to  the  parietal  and  temporal  regions. 

(d)  Burning  or  sore :  These  are  adjectives  frequently  used  to  qualify  the 
headaches  of  anaemia,  rheumatism  and  gouty  states. 

(e)  Boring  or  sharp  :  These  headaches  are  often  localized  as  "  clavus — the 
sensation  as  if  a  nail  were  being  driven  into  the  head,"  and  are  symptomatic 
of  hysteria. 

59 


930  NERVOUS  DISEASES  AND  THE  IB  TREATMENT. 

The  course  and  duration  of  headache  depend  upon  the  underlying  condi- 
tions. It  may  be  transient,  lasting  a  few  hours ;  or  it  may  f)ersist  with  ex- 
acerbations and  remissions  and  rare  intermissions  for  days  or  months. 

Again  there  may  be  slight  continuous  pain  with  exacerbations  of  varying 
intensity.  This  occurs  in  certain  forms  of  reflex  headache,  notably  those 
which  arise  from  defects  of  accommodation.  In  point  of  fact,  persistent 
headaches  are  often  reflex.  Persistence  is  also  a  characteristic  of  organic 
headaches,  such  as  arise  in  cerebral  tumor  or  abscess,  or  pachymeningitis. 
The  headaches  caused  by  over-indulgence  in  tobacco,  those  of  chronic  alco- 
holism, of  uraemia,  of  syphilis,  of  the  toxsemia  and  malnutrition  of  chronic 
dyspepsia,  and  those  which  occur  after  sunstroke,  are  likewise  persistent, 
though  usually  showing  brief  and  irregular  periods  of  remission. 

As  pointed  out  in  sj^eaking  of  the  etiology,  headache  is  a  very  constant 
symptom  of  injuries  to  the  head,  after  the  recovery  of  consciousness.  The 
headache  which  follows  concussion  or  laceration  of  the  brain  tissue  is  usually 
severe  and  often  continues  for  a  long  period.  It  is  not  infrequently  circum- 
scribed and  may  be  limited  to  a  region  corresponding  to  the  site  of  the 
injury,  or  upon  the  opposite  side  of  the  head.  When  thus  restricted  it  is 
often  associated  with  local  tenderness  on  light  percussion.  On  the  other 
hand,  the  headache  following  injury  is  often  diffuse.  In  either  case  it  is  apt 
to  be  associated  with  vertigo,  lassitude  and  indisposition  to  mental  effort.  As 
the  case  progresses  toward  ultimate  recovery,  head  pain  is  in  many  cases 
readily  excited  by  any  of  the  numerous  causes  of  symptomatic  headache. 

Congestive  headache  may  be  produced  by  mechanical  interference  Avith 
the  return  of  the  blood  from  the  head.  The  headache  caused  by  improper 
clothing  is  usually  slight  and  quickly  disappears  upon  the  removal  of  the 
cause.  That  due  to  venous  obstruction  from  the  pressure  of  tumors  is  not 
usually  severe,  as  the  obstruction  comes  about  gradually.  The  cerebral  con- 
gestion caused  by  violent  paroxysmal  or  frequently  repeated  cough  not  rarely 
gives  rise  to  headache  of  great  intensity. 

Active  cerebral  hypersemia  may  follow  excessive  and  prolonged  mental 
effort ;  or  it  attends  the  initial  stage  of  acute  meningitis,  and  results  from  the 
action  of  certain  vaso-dilator  drugs,  among  the  more  common  of  which  are 
alcohol  and  the  nitrites.  The  headache  attending  cerebral  congestion, 
whether  it  be  passive  or  active,  is  commonly  frontal  or  diffuse,  and,  especially 
in  active  hypersemia,  is  pulsating  or  throbbing. 

Headache  occurs  in  the  anaemia  due  to  blood-loss,  especially  if  the  amount 
has  been  considerable.  It  occurs  also  in  the  various  forms  of  anaemia  due  to 
other  causes  and  especially  in  chlorosis.  Anaemic  headache  is  often  severe. 
It  is  usually  frontal  or  diffl;se,  is  frequently  accompanied  by  a  distressing 
sensation  of  pressure,  and  is  often  associated  with  vertigo,  and  in  rare  in- 
stances with  tinnitus  aurium.  In  some  cases  the  patient  perceives  and  is 
greatly  annoyed  by  the  systolic  murmurs  which  develop  in  well-marked 
anaemia  and  chlorosis.  The  headaches  of  anaemia  are  usually  intensified  by 
temporary  effort. 

Headache  is  a  prominent  and  distressing  symptom  in  all  forms  of  cerebral 
meningitis,  whether  they  be  acute  or  chronic.  It  may  for  a  time  be  localized 
in  cases  where  the  infection  reaches  the  meninges  from  the  middle  ear  or  by 
way  of  the  nasal  passages  and  frontal  sinuses,  or  when  it  occurs  in  conse- 
quence of  disease  or  injury  of  the  cranial  bone.  It  soon,  however,  becomes 
difflise,  and  is  associated  with  rigidity  of  the  neck,  vomiting,  often  explosive 
in  character  and  unaccompanied  by  nausea ;  with  hyperaesthesia,  delirium, 
irregular  fever,  unequal  pupils,  and  intolerance  to  light.  The  headache  is 
usually  continuous,  with  exacerbations  of  great  severity.  As  the  disease 
progresses  to  the  stage  of  depression  and  paralysis,  signs  of  compression  of 


SYMPTOMATIC  BISOBDEBS.  931 

the  brain  develop,  headache  passes  into  stupor,  which  deepens  to  coma. 
Optic  neuritis  is  a  later  manifestation.  Exceptionally  headache  is  not  a 
prominent  symptom  of  cerebral  meningitis,  and  it  may  be  absent  in  the  early 
stages  of  the  lepto-meningitis  of  slow  development. 

Sudden  intense  headache  is  among  the  earlier  symptoms  of  epidemic  cere- 
bro-spinal  fever,  in  which  disease  painful  rigidity  of  the  back  of  the  neck 
and  cerebral  vomiting  occur  as  early  associated  symptoms.  The  headache 
in  this  disease  is  due  in  part  to  toxgemia  and  in  part  to  meningeal  inflam- 
mation. 

Among  the  early  symptoms  of  tubercular  meningitis  is  intense  headache, 
paroxysmal  in  character,  with  darting  pains  in  the  head,  vertigo,  vomiting 
without  nausea,  constipation,  and  great  mental  irritability.  As  the  disease 
develops  the  headache  becomes  persistent,  and  is  accompanied  by  irregular 
fever,  ocular  symptoms  and  other  signs  of  meningitis. 

The  headache  of  pachymeningitis  is  at  first  usually  local.  It  is  accom- 
panied by  fever,  delirium,  and  sometimes  by  convulsions. 

Severe  frontal  headache,  usually  unilateral,  is  a  distressing  symptom  of 
acute  congestion  or  catarrhal  inflammation  of  the  frontal  sinuses. 

Poisons  circulating  in  the  blood  are  among  the  most  common  cause  of 
symptomatic  headache.  The  morbid  condition  of  the  blood  may  be  transient 
or  persistent. 

A  large  proportion  of  toxsemic  headaches  are  due  to  infection.  Chemical 
poisons  are  elaborated  during  the  growth  and  multiplication  of  pathogenic 
germs  which  have  found  access  to  the  body  under  favorable  conditions,  or, 
as  in  the  case  of  the  exanthemata,  by  the  development  of  other  infecting 
principles  of  the  nature  of  which  we  are  as  yet  ignorant. 

The  headache  caused  by  these  poisons  is  very  commonly  frontal ;  it  may, 
however,  be  occipital  or  general,  but  is  very  rarely  one-sided.  It  is  often  at 
first  neuralgic  or  superficial,  but  soon  becomes  dull,  deep-seated  and  severe. 

Headache  is  an  almost  constant  symptom  of  the  period  of  invasion  of  the 
acute  febrile  diseases.  In  typhus  it  is  early  and  severe,  and  is  associated  with 
pain  in  the  back  and  limbs.  In  the  course  of  several  days  it  gives  place  to 
stupor. 

Headache  is  also  a  constant  symptom  in  enteric  fever  during  the  period  of 
prodromes  and  the  stage  of  invasion.  It  is  associated  with  languor  and  be- 
comes aggravated  toward  night.  The  headache  of  enteric  fever  subsides 
spontaneously  during  the  second  week  of  the  disease,  and  is  followed  by  deli- 
rium, usually  of  the  wandering  form. 

The  onset  of  relapsing  fever  is  marked  by  sudden  severe  headache,  with 
chill,  pain  in  the  back  and  legs,  and  wakefulness.  The  headache  persists 
until  the  relapse,  when  it  suddenly  diminishes,  or  ceases  altogether. 

The  headache  of  influenza  is  diffuse,  with  foci  of  intensity  in  the  region 
of  the  frontal  sinuses  and  behind  the  eyeballs.  It  is  attended  with  great 
restlessness  and  malaise,  mental  and  physical  depression,  irregular  fever, 
neuralgic  and  myalgic  pains,  and  in  many  instances  with  profuse  sweating. 
Headache  constitutes  one  of  the  most  troublesome  and  persistent  sequels  of 
influenza. 

Allusion  has  already  been  made  to  the  headache  of  cerebro-spinal  fever. 
The  intense  headache  that  marks  the  period  of  invasion  of  smallpox  is  often 
accompanied  by  excruciating  back  and  joint  pains  ;  these  symptoms  usually 
undergoing  together  a  remarkable  remission  upon  the  appearance  of  the 
rash. 

Headache  occurs  in  some  cases  of  early  syphilis  as  one  of  the  manifesta- 
tions of  the  general  infection,  independent  of  coarse  nerve  lesions.  The 
headaches  of  late  syphilis  are  usually  symptomatic  of  gummata,  meningitis  or 


932  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

arterial  changes.  Headache  is  also  a  symptom  in  many  cases  of  hereditary 
syphilis. 

Certain  protozoa,  as  the  blood  parasites  of  malaria,  are  capable  of  pro- 
ducing toxic  conditions  of  the  blood  of  which  one  of  the  manifestations  is 
headache. 

The  headache  of  ordinary  intermittent  fever  is  a  conspicuous  symptom  of 
the  hot  stage  of  the  paroxysm.  Headache  is  also  a  very  prominent  symp- 
tom in  remittent  fever  ;  while  periodical  headache  attends  chronic  intermit- 
tents  of  blurred  type,  of  which  it  is  often  the  only  sharply  defined  charac- 
teristic. 

A  second  group  of  toxic  substances  of  great  importance  in  the  causation 
of  symptomatic  headache  consists  of  principles  developed  within  the  body  in 
the  course  of  irregular  or  imperfect  tissue  metabolism  or  accumulated  by 
reason  of  delayed  or  arrested  excretion.  The  headaches  due  to  this  group  of 
causes  usually  refuse  to  yield  to  symptomatic  treatment.  Here  especially 
must  the  treatment  be  directed  to  the  cause. 

Many  intractable  headaches  are  due  to  chronic  ursemia.  Headache  aris- 
ing in  this  condition  is  often  intense ;  it  is  apt  to  be  frontal  or  temporal,  and 
is  continuous,  with  irregular  exacerbations  of  great  intensity. 

Headache  of  the  same  general  character  occurs  in  diabetes,  in  gout  and 
in  lithsemic  states.  To  this  class  also  must  be  referred  the  headaches  of 
chronic  lead  poisoning ;  and  those  of  gastro-hepatic  derangements  and  con- 
stipation. These  headaches  are  due  to  a  condition  of  toxaemia  that  is  com- 
plex. They  have  this  in  common — that  they  are  all  intensified  by  alcoholic 
beverages  and  mostly  relieved,  for  a  time,  by  free  purgation. 

Certain  drugs  cause  headache  as  a  manifestation  of  their  medicinal  or 
toxic  action.  This  eflfect  may  arise  from  overdose  or  in  consequence  of  idio- 
syncrasy. The  full,  tense  headache,  with  tinnitus  aurium  as  a  frequent 
accompaniment,  which  follows  large  doses  of  quinine  or  the  salicylates,  is 
well  known.  So  also  is  the  headache  of  opium,  with  floating  sensations  and 
nausea,  and  vomiting  increased  in  the  upright  posture.  The  tense  vertig- 
inous headache  which  rapidly  follows  the  administration  of  full  doses  of  amyl 
nitrite  or  nitroglycerin  is  due  in  part  to  the  direct  action  of  the  drugs  upon 
the  nervous  system,  and  in  part  to  the  over-distention  of  the  bloodvessels. 

Headache  is  a  significant  symptom  in  the  chronic  intoxication  of  lead, 
tobacco,  alcohol,  opium,  and  chloral.  In  the  case  of  lead  and  of  alcohol 
vascular  changes  doubtless  play  a  secondary  part  in  the  production  of  head- 
pain.  The  headaches  of  those  addicted  to  opium  and  chloral  are  largely  to 
be  attrbuted  to  the  depression  arising  from  temporary  withdrawal  of  the 
accustomed  stimulant.  They  are,  as  a  rule,  increased  during  periods  of  absti- 
nence and  relieved  by  the  administration  of  the  habitual  dose,  though  in  the 
case  of  chloral,  binding  head  pains  sometimes  occur,  not  in  the  intervals  be- 
tween the  doses,  but  rather  shortly  after  the  usual  dose. 

Excesses  in  alcohol — the  acute  alcoholism  of  debauch — are  apt  to  be 
followed  by  transitory  headache  of  intense  character,  not  unlike  that  of 
migraine. 

Headache  is  attributed  to  changes  in  the  walls  of  the  minute  arteries. 
The  headache  of  late  syphilis,  of  the  various  forms  of  degenerative  nephri- 
tis, of  chronic  alcoholism  and  of  lead  poisoning,  have  been  regarded  as 
symptomatic  of  the  endarteritis  and  artero-sclerosis  which  occur  in  these 
conditions.  It  is  probable  these  head  pains  are  in  part,  at  least,  due  to  per- 
sistent changes  in  the  blood. 

Headache  plays  an  important  role  in  the  symptomatology  of  the  coarser 
intra-cranial  lesions,  abscess,  tumor,  pachymeningitis  interna  hemorrhagica, 
and  aneurism. 


SYMPTOMATIC  DISOEBEBS.  933 

In  acute  abscess  headache  is  usually  very  severe  and  persistent.  It  is  asso- 
ciated with  vertigo,  and  more  or  less  pronounced  mental  dulness  and  irrita- 
bility. Vomiting  is  a  common,  but  not  by  any  means  a  constant  symptom. 
Chronic  abscess,  which  is  often  latent,  may  present  no  other  symptoms  than 
headache,  vertigo,  mental  dulness,  irritability,  and  physical  depression.  The 
headache  is,  as  a  rule,  most  intense  in  the  region  of  the  lesion.  Hence, 
in  abscess  due  to  ear  disease,  the  pain  is  especially  referred  to  the  parietal  or 
occipital  region  of  the  affected  side  ;  in  abscess  arising  from  disease  of  the  nasal 
cavities  or  ethmoid  bone  the  pain  is  referred  to  the  brow ;  while  in  abscess 
from  traumatism  involving  the  bones  of  the  skull,  the  focus  of  pain  is  located 
in  the  region  of  the  injury,  which  is  in  the  majority  of  the  cases  frontal  or 
temporal. 

Headache  is  present  in  by  far  the  greater  number  of  cases  of  cerebral  or 
cerebellar  tumor.  This  symptom  occurs  with  about  equal  frequency  in 
adults  and  children.  Its  frequency  and  intensity  vary  according  to  the  site 
of  the  new  growth,  the  rapidity  of  its  development,  and,  to  some  extent, 
according  to  its  character.  Thus,  headache  is  more  persistent  and  severe  in 
cerebellar  than  in  cerebral  tumors  ;  in  those  of  the  cerebral  hemispheres  than 
in  those  of  the  base,  and  in  those  that  directly  involve  the  meninges,  the 
pain  being  caused  by  intra-cranial  pressure  and  irritation  of  the  terminal 
filaments  of  the  trigeminus ;  headache  is  a  more  prominent  symptom  in 
tumors  of  rapid  than  in  those  of  slow  growth,  irrespective  of  the  nature  of 
the  pathological  process. 

In  the  earliest  periods  of  life  the  sutures  readily  yield  to  intra-cranial 
pressure,  and  the  symptoms  of  new  growths  within  the  skull  are  correspond- 
ingly modified. 

Aside  from  the  matter  of  rapidity  of  growth  and  the  yielding  of  the 
cranial  bones  in  the  very  young,  the  character  of  the  new  growth  exerts  little 
influence  in  causing  headache.  To  this  general  observation  the  exception 
must  be  made  that  gliomata  are  more  frequently  painless  than  any  other 
form  of  coarse  intra-cranial  disease. 

The  headache  of  brain  tumor  is  almost  always  a  distressing  symptom.  It 
is  sometimes  dull  and  boring  ;  sometimes  lancinating ;  usually  intense,  often 
agonizing.  While  commonly  continuous,  with  exacerbations,  it  not  infre- 
quently recurs  with  a  regular  quotidian  or  tertian  periodicity  suggestive  of 
malaria.  It  is  often  worse  at  night — ^a  peculiarity  which  is  of  diagnostic 
value.  In  some  instances  the  focus  of  the  head  pain  is  in  the  region  of  the 
tumor,  in  others  the  pain  centres  in  the  brow  or  in  the  occiput,  and  in  a  large 
proportion  of  cases  it  is  diffuse.  Very  often  a  headache  which,  while  of  moder- 
ate intensity,  is  localized,  becomes,  during  exacerbation,  diffiise.  Local  pain 
cannot  alone  be  depended  upon  as  an  indication  of  the  position  of  the  tumor. 
It  acquires,  however,  in  connection  with  other  clinical  data,  some  degree  of 
value  in  this  respect.  Upon  light  percussion  with  the  finger-tips  there  is 
very  often  localized  tenderness  of  the  scalp  and  underlying  bones,  occasion- 
ally most  marked  in  the  region  corresponding  to  the  tumor.  Vomiting, 
vertigo,  hebetude,  spells  of  somnolence,  and  general  convulsions  are 
associated  symptoms.  Optic  neuritis,  almost  always  double,  occurs  in  80 
per  cent,  of  all  cases.  Focal  symptoms  are  usually  present,  though  tumors 
of  the  prefrontal  and  temporal  or  temporo-sphenoidal  areas  and  of  the  lateral 
lobes  of  the  cerebellum,  the  so-called  latent  regions,  may,  if  of  small  size, 
give  rise  to  no  localizing  phenomena. 

Headache  has  been  a  prominent  symptom  in  a  large  proportion  of  the 
recorded  cases  of  pachymeningitis  interna  hemorrhagica  (hrematoma  of  the 
dura).  The  pain  is,  in  the  earlier  stages,  usually  referred  to  the  vertex  ;  later 
it  becomes  generalized.     This  affection,  more  frequent  in  males  and  after 


934  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

middle  life,  presents  no  well-defined  symptomatology,  and  is  usually  first 
recognized  upon  the  post-mortem  table.  Cases  of  this  kind  are  very  rarely 
encountered  in  private  practice,  but  are  of  moderately  common  occurrence 
in  that  of  asylums. 

Intra-cranial  aneurisms  are  of  two  kinds :  Miliary,  which  involve  small 
arterial  twigs  within  the  brain  substance,  and  are  always  minute,  multiple, 
and  until  rupture  takes  place,  unattended  by  symptoms ;  and  arterial  dilata- 
tions of  considerable  size,  which  afiect  the  larger  arteries  at  the  base  of  the 
brain.  Even  the  smaller  aneurisms  of  this  second  group  are  frequently  also 
latent.  Those  of  larger  size  occasion  symptoms  which  are  sometimes  indefi- 
nite, sometimes  those  of  a  tumor  of  the  base.  The  most  common  symptom 
is  headache,  which  may  be  either  continuous  or  paroxysmal.  The  location 
of  the  headache,  when  circumscribed,  has  little  relation  to  the  position  of  the 
aneurism,  though  aneurisms  of  the  basilar  artery  usually  give  rise  to  occip- 
ital headache.  Giddiness,  mental  dulness,  irritability,  and  palsies  of  cranial 
nerves  may  occur.  Optic  neuritis  is  not  common.  Murmurs  have  been 
heard  upon  auscultation  of  the  head,  and  in  some  instances  perceived  by  the 
patient,  who  has  occasionally  also  felt  the  pulsations  in  his  head.  Murmurs 
are,  however,  in  the  greater  number  of  the  cases  absent. 

Caries  of  the  bones  of  the  skull,  of  which  the  common  causes  are  injury 
and  syphilis,  the  rarer  tuberculous  ulcerations  and  enteric  fever,  is  often 
attended  with  local  headache.  The  dura,  under  these  circumstances,  resists 
the  spread  of  the  local  inflammatory  process  in  a  remarkable  manner,  and 
general  meningitis  rarely  supervenes. 

Headache  attends  with  great  frequency  such  neuropathic  conditions  as 
neurasthenia,  hysteria,  and  epilepsy. 

In  neurasthenia  it  is  frontal,  occipital,  or  diffuse.  It  is  apt  to  be  continu- 
ous, and  is  aggravated  by  mental  application  and  by  physical  effort.  As  a 
rule,  it  is  of  only  moderate  intensity.  It  is  accompanied  by  sensations  of 
pressure  in  the  head,  aching  in  the  back  of  the  neck  and  sj)inal  j)ains.  Slight 
attacks  of  vertigo  are  of  frequent  occurrence. 

The  persistent  or  recurrent  headaches  so  frequently  encountered  in  recent 
years  as  a  sequel  of  influenza  are  neurasthenic.  The  infecting  principle  of 
influenza  causes  profound  nutritive  changes  in  the  tissues  of  the  nervous 
system,  of  which  headache  is  one  of  the  manifestations.  Recovery  from  this 
condition  takes  place  in  many  cases,  but  slowly. 

Hysterical  patients  suffer  during  the  inter-paroxysmal  state  much  from 
headache.  The  head  pain  is  usually  referred  to  the  vertex,  and  is  often 
severe  and  persistent.  It  is  associated  with  the  characteristic  emotional  state 
and  the  multitudinous  symptom-complex  of  hysteria. 

The  emotional  and  precocious  children  of  neurotic  parents  sometimes  ex- 
aggerate symptoms,  probably  in  themselves  trifling,  and  describe,  for  the  sake 
of  sympathy,  headaches  of  great  severity  with  associated  symptoms,  such  as 
inability  to  stand  the  light,  brow  pains,  or  pains  in  the  back  of  the  neck.  It 
will  often  be  found  upon  close  inquiry  that  such  children  have  a  parent, 
especially  a  mother,  who  suffers  from  similar  aches  and  pains  (Mills).  Mills 
has  suggested  that  these  so-called  hysteric  headaches  of  children  might  in 
most  instances  be  better  termed  imitative  headaches.  They  are  closely 
allied  in  causation  to  the  headaches  of  hysteria. 

Headache  in  many  instances  develops  in  connection  with  the  paroxysm 
of  epilepsy.  It  may  precede  or  follow  the  convulsive  attack.  In  the  latter 
case  it  is  associated  with  post-epileptic  drowsiness  and  hebetude.  It  is  also  a 
common  symptom  in  ^9eifii5  mal,  and  a  symptom  of  importance  in  the  inter- 
paroxysmal  state  of  a  considerable  proportion  of  the  cases  both  of  grand  mal 
and  petit  mal. 


SYMPTOMATIC  DISORDERS.  935 

Heat,  pressure,  and  other  abnormal  sensations  in  the  head — the  so-called 
cerebral  parsesthesise — are  common  in  neurotic  individuals  and  in  brain- 
workers.  These  sensations  do  not  amount  to  actual  pain,  though  they  fre- 
quently alternate  with  it.  They  are,  nevertheless,  often  intense  and  distress- 
ing. They  are  common  in  adolescence  and  early  adult  life  and  in  women  at 
the  time  of  or  after  the  menopause.  They  occur  more  frequently  in  men 
than  in  women  ;  in  those  of  sedentary  habits  and  intellectual  pursuits  than 
in  the  laboring  classes,  and  in  those  who  are  litheemic  or  suffer  from  gout. 
They  are  referred  to  all  parts  of  the  head,  and  described  in  the  most  varied 
terms,  most  of  which  are  clearly  exaggerated.  The  sensation  in  a  given  case 
may  persist  or  recur  for  years,  and  be  always  the  same,  or  it  may  vary  from 
time  to  time.  It  is  usually  increased  by  mental  application  and  by  disagree- 
able emotions,  and  invariably  intensified  when  the  attention  of  the  patient  is 
directed  to  it  either  spontaneously  or  through  the  inquiries  of  his  physician 
or  friends.  On  the  other  hand,  such  sensations  are  usually  not  felt  when  the 
patient's  interest  is  aroused  in  matters  outside  of  himself. 

Many  persistent  and  troublesome  headaches  are  to  be  attributed  to  reflex 
irritation.  Such  headaches  then  become  symptomatic  of  morbid  conditions 
or  functional  derangements  in  distant  parts  of  the  body.  While  headache 
of  this  kind  is  in  many  cases  an  urgent  and  distressing  symptom,  other  symp- 
toms, and  in  particular  those  of  the  local  disease,  may  be  insignificant  or 
absent  altogether.  The  causal  diagnosis  may  then  acquire  a  difficulty  equal 
to  its  importance,  and  demands  of  the  practitioner  always  the  most  pains- 
taking application  of  the  methods  of  clinical  investigation,  and  very  often 
the  co-operation  of  confreres  who  have  devoted  themselves  to  the  special  de- 
partments of  medicine. 

Errors  of  refraction  constitute  a  common  cause  of  reflex  headache.  The 
pain  is  commonly  frontal,  sometimes  in  the  temples,  frequently  occipital. 
The  patient  is  very  often  unaware  of  any  difficulty  in  accommodation,  though 
upon  inquiry  it  will  be  found  that  the  headache  is  invariably  brought  on  or 
aggravated  by  close  or  prolonged  use  of  the  eyes. 

The  head  pains  of  glaucoma  cannot  be  regarded  as  reflex.  Nevertheless 
it  seems  proper  to  mention  them  in  this  connection.  They  involve  the  dis- 
tribution of  the  trigeminus,  having  their  focus  of  intensity  in  the  eyeball  or 
at  the  supraorbital  notch.  In  the  acute  cases  pain  is  sometimes  agonizing, 
and,  is  associated  with  depression,  pallor,  nausea,  and  vomiting.  It  may,  how- 
ever, be  subacute,  and  in  chronic  glaucoma  pain  may  recur  in  paroxysms  of 
no  great  severity,  described  by  the  patient  as  attacks  of  neuralgic  headache. 
As  it  frequently  begins  on  one  side,  there  is  a  misleading  resemblance  to 
migraine.  The  importance  of  an  immediate  recognition  of  glaucoma  arises 
from  the  necessity  of  prompt  treatment  in  order  to  check  the  progress  of  the 
disease.  The  diagnosis  of  glaucoma  is  based  upon  increase  in  the  intra-ocular 
tension,  irregular,  or  dilated  pupil,  with  inactive  iris,  haziness,  and  anaesthe- 
sia of  the  cornea,  and  various  visual  derangements.  In  suspected  cases  the 
services  of  an  ophthalmic  surgeon  are  to  be  at  once  invoked. 

The  headache  which  arises  in  chronic  nasal  disease  is  usually  limited  to  the 
temporal  region  or  the  vertex.  It  is  associated  with  the  usual  signs  of  nasal 
trouble.  Nausea,  sensitiveness  of  the  nasal  wall  of  the  orbit,  and  a  hyper- 
aesthetic  area  on  the  mucous  membrane  of  the  middle  turbinated  bone,  which, 
when  touched  with  the  probe,  immediately  excites  the  localized  head  pain, 
are  common  associated  conditions. 

Among  the  manifold  derangements  of  health  which  in  children  result 
from  adenoid  vegetations  in  the  naso-pharynx,  headache  is  conspicuous. 
This  form  of  headache  is  especially  associated  with  mouth-breathing,  chest- 
deformity,  retarded  intelligence,  and  irritability,  and  constitutes  a  member  of 


936  yERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  group  often  vaguelr  spoken  of  as  school  headaches,  headaches  of  the 
period  of  growth,  and  the  like.  Carious  teeth  and  exposure  of  the  pulp  may 
be  the  occasion  for  reflex  headache.  Disease  of  the  auditors^  apparatus  may 
also  be  the  unsuspected  cause  of  persistent  headache.  The  headache  which 
arises  in  acute  indigestion  and  in  gastro-intestinal  catarrh  is  sometimes 
spoken  of  as  reflex.  It  is  probable  that  this  form  of  headache  is  often  in 
part,  and  in  most  cases  altogether,  due  to  toxaemia. 

The  part  played  by  disease  of  the  sexual  organs  in  the  causation  of  head- 
ache has  been  doubtless  fi-equently  over-estimated ;  yet  this  symptom  is 
often  prominent  in  the  general  ill-health  of  those  of  both  sexes  who  sufier 
from  actual  disease  of  the  sexual  organs  or  are  the  victims  of  disordered 
psvchical  processes  in  regard  to  them.  In  many  cases  these  headaches  are 
due  not  so  much  to  reflex  irritation  as  to  the  attendant  neuropathic  con- 
dition. 

Certain  symptoms  are  associated  with  headache  with  a  fi-equency  that  in- 
dicates a  common  causation.  The  more  prominent  of  these  are  vertigo, 
nausea,  vomiting,  drowsiness,  and  abnormal  mental  states,  such  as  irritability 
and  hebetude.  In  symptomatic  headache  these  symptoms  are,  as  a  rule,  less 
constant  and  less  severe  than  in  organic  headaches.  Vertigo  is  common  in 
headache  due  to  gastro-intestinal  disorder — the  so-called  bilious  headache ; 
nausea  and  vomiting  in  the  acute  toxaemia ;  somnolence  in  chronic  condi- 
tions, as  malaria,  anaemia,  and  syphilis.  But  this  association  of  symptoms  is 
by  no  means  constant,  and  cannot  be  relied  upon  for  the  purpose  of  diagnosis. 
In  organic  headaches,  however,  the  association  of  these  symptoms,  their  per- 
sistence and  the  change  in  mental  condition  shown  in  hebetude  and  irrita- 
bility, are  very  important  and  suggestive. 

Diagnosis.  The  direct  diagnosis  of  headache  is,  as  a  rule,  unattended  with 
difiiculty.  Diffuse  pain  in  the  head,  not  limited  to  the  branches,  but  referred 
to  the  peripheral  distribution  of  sensory  nerves,  constitutes  the  symptom. 
The  sensation  of  pain  is  usually  within  the  skull,  exceptionally  outside  of  it. 
Headache  is  more  or  less  persistent.  It  is  essentially  a  symptom,  and  care- 
ful examination  and  inquiry  should  reveal  some  general  or  local  cause. 

The  differential  diagnosis  between  headache  on  the  one  hand  and  migraine 
and  neuralgia  on  the  other,  present  little  difficulty. 

^Migraine  is  a  general  disease,  of  which  headache  is  a  principal  symptom. 
It  is  a  periodical  neurosis,  the  paroxysms  of  which  affect  not  only  the  tri- 
geminus, but  also  other  cranial  nerves,  and,  to  some  extent,  the  sympathetic. 
The  pain  of  migraine  Ls  often  unilateral,  especially  at  the  beginning  of  the 
attack.  It  is  accompanied  by  nausea,  vertigo,  and  subjective  visual  phe- 
nomena. It  lasts  a  comparatively  short  time  and  wholly  disappears  with  the 
other  symptoms  at  the  end  of  the  paroxsym,  leaving  the  patient  in  his  usual 
health.     The  paroxysms  recur  at  regular  or  irregular  intervals. 

Xeuralgia  is  due  to  irritants  acting  chiefly  upon  nerves  in  their  course. 
The  pain  is  referred  to  the  trunk  or  branches  of  the  nerve  rather  than  to  the 
terminal  distribution.  It  is  unilateral,  localized,  shaip,  or  shooting  in  char- 
acter, continuous  with  paroxysmal  exacerbations,  and  frequently  shifts  from 
one  branch  to  another  of  the  same  nerve  or  to  a  neighboring  nerve.  Char- 
acteristic tender  points  are  present.  Neuralgia  of  the  first  branch  of  the 
fifth  is  often  attended  with  suffusion  of  the  eye  and  oedema  of  the  lids. 

It  is  not  always  possible  to  distinguish  between  a  neuralgia  and  a  neuritis 
of  mild  intensity  affecting  the  nerve  trunk  ;  nor,  indeed,  is  the  pathological 
distinction  between  these  conditions  sharply  defined. 

The  causal  diagnosis  of  headache,  while  often  obvious,  is  sometimes  ex- 
tremely difficult.  Its  true  significance  in  many  cases  becomes  apparent  only 
after  an  exhaustive  study  of  the  associated  morbid  phenomena.     It  is  neces- 


S  Y MPT 031  A  TIC  DISORDERS.  937 

sary  to  bear  in  mind  that  headache  is  merely  a  symptom,  often  one  of  many 
that  make  up  the  morbid  complexus. 

The  differential  diagnosis  between  functional  and  organic  headaches  is  of 
fundamental  importance. 

The  headache  due  to  organic  intra-cranial  processes  is  usually  continuous. 
It  varies  from  time  to  time  in  intensity,  and  in  certain  cases  undergoes  vio- 
lent exacerbations,  but  it  is  rarely  absent  altogether.  The  headaches  of 
organic  disease  are  apt  to  continue  through  the  night,  and  very  often  inter- 
fere with  sleep.  Organic  headaches  are  not  only  more  persistent,  but  they 
are  also,  as  a  general  rule,  more  severe  than  functional  headaches.  Head- 
ache due  to  organic  disease  is  usually  aggravated  by  mental  or  physical 
effort,  by  excitement,  by  alcoholic  stimulants,  by  stooping  or  coughing  or 
other  influences  that  increase  the  intra-cranial  vascular  tension.  It  yields 
less  readily  than  other  forms  of  headache  to  systematic  treatment.  As  the 
processes  which  give  rise  to  it  are,  as  a  rule,  progressive,  it  tends  likewise  to 
progressively  increase  in  severity  until  at  length  it  is  replaced  by  the  stupor, 
drowsiness,  or  coma  of  the  terminal  stage  of  the  disease.  The  prominence 
and  intensity  of  the  associated  symptoms,  vomiting,  vertigo,  hebetude,  and 
irritability  are  of  diagnostic  value  ;  while  the  development  of  double  optic 
neuritis,  convulsions,  and  localizing  symptoms,  as  monospasm,  paralysis  of 
cranial  nerves,  cerebellar  titubation,  forced  movements  or  hemianopsia 
widely  separate  organic  headaches  from  the  ordinary  forms  of  functional 
headache.  It  must,  however,  be  borne  in  mind  that  double  optic  neuritis 
also  occurs  in  cases  of  chronic  lead  poisoning,  of  grave  anaemia,  and  various 
forms  of  diseases  of  the  kidneys  ;  conditions  in  which  headache  is  likewise  a 
prominent  symptom. 

The  prognosis  of  headache  is  that  of  the  underlying  condition  of  which  it 
is  a  symptom. 

Treatment.     The  treatment  of  headache  is :    1.  Symptomatic;  2.  Causal. 

1.  Whenever  headache  is  severe,  pain  becomes  the  j^rimary  therapeutic 
indication,  and  its  immediate  relief  must  be  the  first  object  of  treatment. 
For  this  purpose  the  new  analgesic  drugs  are  especially  effective.  In  point 
of  fact  the  prompt  relief  of  headache  constitutes  their  greatest  field  of  use- 
fulness. It  is  needless  to  enumerate  in  this  connection  the  already  long  and 
constantly  increasing  list  of  the  drugs  and  their  combinations.  Among  the 
most  usefiil  are  the  following : 

Antipyrin,  gr.  v  (0.3)  every  twenty  minutes  until  two  or  three,  or  at  most 
four  doses  are  taken;  phenacetin,  gr.  x-xv  (0.6-1.0)  in  a  single  dose,  or 
preferably,  gr.  iij-v  (0.2-0.3)  repeated  at  short  intervals ;  antifebrin,  gr. 
ii-iij  (0.15-0.2)  repeated  cautiously.  Exalgin,  in  ordinary  doses,  gr.  ii-iv 
(0.15-0.25),  is  less  satisfactory.  Mixtures  of  antij)yrin  and  phenacetin,  or 
of  antipyrin,  caffein,  and  sodium  bicarbonate  are  also  useful.  Caffein  and 
its  salts,  the  ammonio-citrate,  the  citrate,  the  hydrobromate  and  valerianate 
are  especially  useful  in  the  headaches  of  nervous  exhaustion  and  of  neuras- 
thenia. Combinations  of  caffein  citrate  with  sodium  salicylate  or  sodium 
benzoate  or  of  these  with  phenacetin  or  antipyrin  often  prove  more  effica- 
cious than  the  single  drugs.  Such  combinations  constitute  many  of  the 
Preparations  extensively  advertised.  Their  efficacy  is  unquestionably  en- 
anced  when  they  are  dispensed  in  the  form  of  the  popular  effervescing 
granules.  Chloralaraide,  gr.  v-x  (0.3-0.6),  repeated  at  intervals  of  an  hour 
or  two,  or  in  single  doses  of  gr.  xv-xxx  (1.0-2.0)  frequently  produce  relief, 
with  drowsiness  and  prolonged  sleep,  from  which  the  patient  awakes  free 
from  pain.  Sulphonal  may  be  used  in  the  same  way.  Chloral  and  the 
bromides,  separately  or  in  combination,  are  especially  useful  in  headache 
associated  with  g:reat  restlessness  and  insomnia.     In  cases  of  habitual  head- 


938  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

ache  the  nervous  system  becomes  accustomed  to  analgesic  and  hypnotic 
drugs,  and  they  presently  lose  their  power  to  relieve  suifering.  This  difficulty 
may  be  to  some  extent  overcome  by  frequent  change  in  the  medicament, 
or  by  varying  the  admixture  and  proportions  of  drugs,  the  danger  of  toxic 
effects  and  of  the  formation  of  a  drug  habit  being  constantly  had  in  mind. 

Local  applications  sometimes  mitigate  the  pain,  seldom  wholly  relieve  it. 
They  are,  nevertheless,  a  source  of  satisfaction  to  many  patients.  Among 
those  to  which  the  patients  willingly  have  recourse  are  the  ice-bag,  fomenta- 
tions of  hot  water,  the  menthol  pencil  moistened  Avith  alcohol  or  cologne 
water,  or  a  20  per  cent,  solution  of  menthol  in  alcohol,  chloroform,  stimulat- 
ing liniments  of  various  kinds,  especially  those  containing  chloroform,  tinc- 
ture of  aconite  and  tincture  of  belladonna.  The  impression  produced  by 
volatile  applications  of  this  kind  is  increased  by  preventing  their  evapora- 
tion, but  care  must  be  observed  lest  blistering  result. 

Among  local  measures  mustard-plasters  of  varying  strengths  are  much 
relied  upon,  especially  in  occipital  headache.  After  a  time  many  sufferers 
from  habitual  headache  narrow  the  symptomatic  treatment  to  quietude,  a 
darkened  room,  abstinence  from  food,  with  immediate  recourse  to  purgatives, 
the  salicylates,  or  such  other  treatment  of  the  underlying  constitutional  dis- 
turbance as  the  experience  of  each  suggests. 

The  immediate  treatment  of  headaches  due  to  intra-craniar organic  disease 
demands  for  the  relief  of  suffering  the  remedies  above  mentioned,  given  for 
effect.  Large  doses  are  required.  In  many  cases  it  is,  however,  necessary 
to  use  opium  or  its  derivatives  in  full  doses.  So  soon  as  it  becomes  evident 
that  ultimate  recovery  is  not  to  be  hoped  for  the  danger  of  the  formation  of 
the  opium  habit  may  be  disregarded. 

2.  The  causal  or  constitutional  treatment  must  be  based  upon  the  under- 
lying local  or  general  condition. 

Thus  in  headache  from  traumatism,  rest,  free  use  of  the  bromides,  and 
surgical  treatment  become  necessary. 

Where  the  headache  is  due  to  circulatory  disturbances  the  treatment  must 
be  directed  not  only  to  the  mechanical  condition  of  the  vascular  system,  but 
especially  to  the  etiological  factors  in  each  case.  The  cause  of  cerebral  con- 
gestion and  hyperemia  must  be  sought  out  and  relieved.  Purgatives  are 
especially  useful.     They  act  both  derivatively  and  depuratively. 

The  headaches  of  ansemia  are  increased  by  movement  and  effort.  Rest 
must,  therefore,  enter  largely  into  the  treatment  for  their  temporary  relief. 
Rest  must,  however,  be  alternated  with  carefully  regulated  and  systematized 
exercise.  Here  also  a  highly  nutritious  dietary  is  indicated.  Purgatives  are 
important  and  the  exhibition  of  suitable  salts  of  iron  in  large  doses,  with 
arsenic  in  proper  cases. 

The  headaches  of  intra-cranial  inflammatory  processes,  involving  the 
meninges,  call  for  the  administration  of  purgatives  and  in  suitable  cases  for 
the  local  abstraction  of  blood. 

In  cerebro-spinal  fever  opium  in  large  doses,  with  or  without  the  bromides, 
still  retains  the  confidence  of  practitioners. 

The  intelligent  treatment  of  headaches  due  to  toxaemia  depends  upon  the 
recognition  of  the  condition  of  which  the  headache  is  a  symptom.  In  the 
acute  febrile  infections  it  must  be  symptomatic ;  in  malaria  the  treatment 
consists  in  the  prompt  administration  of  quinine  or  other  cinchona  alkaloids ; 
the  headaches  of  syphilis  usually  yield  to  mercury  and  potassium  iodide 
properly  administered. 

The  headaches  which  arise  in  consequence  of  incomplete  or  defective 
physiological  processes  or  .of  defective  elimination  constitute  a  large  and 
important  group.     They  are  best  treated  by  regulation  of  the  diet,  purga- 


SYMPTOMATIC  DISORDERS.  939 

tives,  the  systematic  employment  of  measures  determining  to  the  skin,  in- 
cluding various  measures  of  hydrotherapy. 

The  toxsemic  headaches  which  arise  in  consequence  of  the  action  of  drugs 
and  poisons  are  to  be  treated  by  the  exhibition  of  appropriate  physiological 
antidotes  and  by  measures  of  elimination.  Acute  toxeemic  headaches  of 
this  kind  in  individuals  previously  in  good  health  tend,  if  the  dose  be  not 
lethal,  to  spontaneous  recovery.  In  the  chronic  intoxications  it  is  important 
that  the  patient  be  removed  from  conditions  which  expose  him  to  the  fur- 
ther action  of  the  poisonous  agent  and  that  continuous  systematic  treatment, 
directed  to  the  elimination  of  the  offending  substance,  be  carried  out.  Thus, 
in  chronic  lead-poisoning  the  administration  of  potassium  iodide  in  connec- 
tion with  systematic  purgation  by  means  of  salines  must  be  instituted. 

Headaches  due  to  changes  in  the  arterial  walls  are  not,  as  is  obvious,  in 
all  instances  amenable  to  treatment.  Much,  however,  can  be  done  to  miti- 
gate the  sufferings  of  the  patient  by  regulation  of  the  diet,  a  quiet  life,  occa- 
sional purgation,  and  the  use  of  those  remedies  as  the  nitrites,  the  tendency 
to  which  is  to  reduce  arterial  tension. 

The  headaches  due  to  coarse  organic  disease  of  the  brain,  such  as  tumor, 
abscess,  and  aneurisms  of  the  larger  arterial  branches,  are  capable  of  partial 
relief  by  systematic  treatment,  especially  by  the  skilful  employment  of 
opium  and  its  derivatives.  In  a  small  proportion  of  the  cases  the  conditions 
justify  surgical  intervention,  the  results  of  which  have  been  in  some  few 
instances  brilliant. 

The  surgical  treatment  of  diseases  of  the  cranial  bones  is  frequently  fol- 
lowed by  speedy  and  permanent  relief  of  headache,  together  with  the  other 
symptoms. 

The  headache  of  neurasthenia,  hysteria,  and  epilepsy  yields  only  to  the 
proper  and  judicious  employment  of  appropriate  general  measures.  Finally, 
the  headaches  of  reflex  irritation  usually  disappear  under  the  appropriate 
treatment  of  the  local  condition.  It  is  in  this  group  of  headaches,  especi- 
ally those  arising  from  disease  of  the  eyes  and  nose,  that  some  of  the  most 
satisfactory  achievements  of  modern  medicine  have  been  obtained. 


MIGRAINE. 

Definition.  An  affection  characterized  by  periodical  nervous  disturbance, 
consisting  of  severe  paroxysmal  headache,  usually  unilateral,  commonly  asso- 
ciated with  nausea  and  vomiting  and  frequently  with  disorders  of  vision. 

Synonyms.  Hemicrania ;  Sick-headache ;  Neuralgic  Sick-headache.  Eng- 
lish writers  sometimes  employ  the  word  Megrim.  The  most  complete  sys- 
tematic account  of  the  affection  is  to  be  found  in  Edward  Liveing's  work. 
Megrim,  Sick- headache,  and  Some  Allied  Disorders.  Migraine  is  a  substan- 
tive affection,  a  constitutional  neurosis,  and  is  considered  in  the  present  work 
under  the  head  of  Symptomatic  Disorders,  not  in  accordance  with  correct 
nosological  principles,  but  simply  as  a  matter  of  convenience. 

Etiology.  1.  Predisposing  influences.  Heredity  plays  an  important  part 
in  the  predisj)Osition  to  migraine.  There  is  very  often  a  history  of  direct 
inheritance,  and  not  infrequently  it  will  be  found  upon  inquiry  that  the  dis- 
ease has  shown  itself  in  several  successive  generations.  Those  who  suffer 
from  it  are  frequently  members  of  neurotic  families,  in  the  history  of  which 
neuralgia,  gout,  or  epilepsy  figure.  Many  men  of  distinguished  intellectual 
attainments,  among  whom  are  Fothergill,  Sir  John  Herschell,  Du  Bois  Rey- 
mond,  the  astronomer  Sir  George  Airy,  his  son.  Dr.  Hubert  Airy,  and  Anstie, 
have  been  sufferers  from  mio^raine. 


940  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

This  affection  is  decidedly  more  common  in  women  than  in  men,  the  pro- 
portion being  not  less  than  three  or  four  to  one.  It  may  show  itself  as  early  as 
the  second  year  of  life.  Eulenberg  early  called  attention  to  the  frequency 
of  the  affection  in  childhood.  It  almost  always  shows  itself  in  the  first  half 
of  life,  generally  at  or  a  little  before  puberty.  Late  childhood,  the  period 
of  puberty,  and  early  adult  life  constitute  the  epochs  of  onset  in  the  greater 
number  of  cases.  Much  less  frequently  the  periodical  attacks  first  show 
themselves  after  the  thirtieth  year  of  age,  and  Gowers  has  seen  a  well-marked 
case  which  began  at  sixty. 

The  attacks  are  more  frequent  in  winter  than  in  summer. 

Occupation  exerts  no  great  influence  in  predisposing  to  migraine.  It  is 
certainly  a  disease  more  common  among  refined  persons  and  those  devoted  to 
intellectual  pursuits  than  among  the  laboring  classes.  The  difference  in  the 
liability  of  the  two  sexes  is  less  in  the  higher  than  in  the  lower  walks  of  life. 

When  the  attacks  first  show  themselves  in  early  life  it  is  difiicult  to  assign 
any  immediate  cause  for  their  development ;  when  they  come  on  during 
adolescence  the  cause  may  frequently  be  found  in  overwork  at  school,  and 
in  cases  developing  later  in  life  there  is  very  often  a  history  of  over-applica- 
tion, injury,  shock,  or  wasting  disease.  A  certain  proportion  of  the  cases 
are  correctly  ascribed  to  reflex  causes,  as  disease  of  the  nose,  naso-pharynx, 
eyes,  teeth,  and  the  pelvic  organs  in  females.  Refractive  errors  and  insuffi- 
ciency of  the  eye  muscles  (accommodative  and  muscular  asthenopia)  are 
etiological  factors  in  the  development  of  migraine,  both  frequent  and  im- 
portant. 

2.  The  exciting  causes.  The  conditions  which  are  capable  of  inducing  the 
paroxysm  are  manifold.  They  vary  in  different  individuals,  but  usually 
consist  of  influences  which  produce  a  sudden  and  more  or  less  profound  im- 
pression upon  the  nervous  system.  If  the  usual  interval  between  the  attacks 
has  nearly  elapsed,  trifling  impressions  will  precipitate  the  paroxysm,  whereas, 
shortly  after  the  attack  has  passed  over,  the  same  influence,  acting  with  far 
greater  intensity,  is  without  effect.  The  attack  may  be  brought  on  by 
fatigue,  excitement,  depressing  emotions,  digestive  disturbances,  sometimes 
even  by  the  eating  of  particular  articles  of  diet.  In  some  patients  it  follows 
exposure  to  cold  ;  in  others,  certain  visual  impressions,  as  the  moving  figures 
in  a  procession  or  crowd,  or  sudden  bright  light,  or  sudden  changes  from  light 
to  darkness,  or  the  reverse ;  or,  again,  it  may  follow  loud  or  disagreeable 
noises,  or  certain  peculiar  odors.  In  many  instances,  however,  the  attack 
occurs  at  intervals,  which  may  be  constant  or  variable,  in  the  absence  of  any 
appreciable  exciting  cause.  Rachford  attributes  the  attack  to  leucomain 
poisoning,  and  has  found  paraxanthin  and  xanthin  in  the  urine. 

Pathology.  The  essential  pathological  process  is  unknown.  There  are 
no  anatomical  lesions.  Three  principal  theories  have  been  advanced  :  1. 
That  the  disease  is  a  vasomotor  neurosis,  the  early  symptoms  being  due  to  a 
vasomotor  constrictor  (angio-spastic),  the  later  to  a  vasomotor  dilator  (angio- 
paretic)  process.  2.  Migraine  has  been  regarded  as  a  form  of  neuralgia  of 
the  first  division  of  the  trigeminus.  3.  The  view  at  present  generally  ac- 
cepted is  that  of  Liveing,  that  migraine  is  a  fulgurating  neurosis  in  Avhich 
there  are  periodical  discharges  or  nerve-storms  from  sensory  centres,  corre- 
sponding to  the  periodical  discharges  from  motor  centres  in  epilepsy.  That 
is  to  say,  that  migraine  is  the  sensory  equivalent  of  epilepsy,  in  which  the 
paroxysm  corresponds  to  the  epileptic  seizure. 

Symptomatology.  Prodromes  are  very  common.  They  usually  last  for  a 
few  hours  or  perhaps  a  day,  and  consist  in  feelings  of  malaise,  dulness,  men- 
tal depression,  or  somnolence.  The  patient  is  frequently  able  to  foretell  the 
approach  of  the  attack.     The  onset  very  often  occurs  in  the  morning,  the 


SYMPTOMATIC  DISORDERS.  941 

patient  waking  up  with  pain,  usually  unilateral  and  referred  to  the  temple, 
forehead,  the  region  back  of  an  eye,  or  to  the  occiput.  This  rapidly  in- 
creases in  intensity  and  spreads  until  it  involves  the  whole  of  one  side  of 
the  head  or  both  sides.  It  is  intense,  throbbing,  blinding  in  character,  in- 
creased by  movement,  light,  and  noise.  Headache  is  the  most  constant  and 
characteristic  symptom.  It  is  always  paroxysmal  and  severe.  In  many 
attacks  it  constitutes  the  chief  or  even  the  only  symptom  ;  the  others,  with 
perhaps  the  exception  of  nausea,  being  so  subordinated  to  it  as  to  escape 
notice,  or  being  absent  altogether.  Visual  disturbances  are  present  in  about 
half  the  cases,  usually  at  the  beginning  of  the  attack.  They  take  the  form 
of  dimness  of  vision,  flashes  of  light,  variously  colored  bright  or  dark  spots, 
fortification  spectra,  and  hemianopsia,  which  is  always  homonymous.  Much 
less  common  are  visual  hallucinations,  phantasmagoria,  figures  of  animals 
and  the  like  in  crowds,  not  unlike  those  of  delirium  tremens.  Pupillary 
changes  occur  in  a  small  proportion  of  the  cases.  They  consist  of  contrac- 
tion followed  by  dilatation  of  the  pupil  in  the  affected  sides,  or  in  rare  in- 
stances of  alternate  rhythmical  contraction  and  dilatation.  In  severe 
paroxysms  the  eyeball  sometimes  appears  to  be  retracted. 

Disturbances  of  the  other  special  senses  are  rare,  though  temporary  deaf- 
ness, followed  by  noises  in  the  ear  and  loss  of  taste,  followed  by  subjective 
sapid  phenomena,  have  been  noted.  Tingling,  numbness,  and  partial  anaes- 
thesia have  been  observed  in  a  small  proportion  of  the  cases.  These  sensory 
disturbances  are  usually  limited  to  the  hand  and  arm,  face,  lips,  or  tongue  on 
one  side.  They  are  of  transient  duration,  and  are  sometimes  followed  by  a 
slight  degree  of  motor  weakness.  Transient  aphasia  occasionally  occurs, 
usually  at  the  beginning  of  the  attack.  Vertigo,  often  not  amounting  to 
more  than  mere  giddiness,  may  occur.  It  may  be  associated  with  tinnitus 
aurium. 

Psychical  disturbances  are  not  constant.  When  present  they  consist  of 
confusion  of  thought,  depression,  and  slight  stupor.  Exceptionally  there  is 
great  mental  excitement.  Nausea  occurs  in  a  large  proportion  of  the  cases. 
It  may  come  on  at  any  time,  but  as  a  rule  does  not  appear  until  the  head- 
ache has  reached  its  height.  It  is  frequently  followed  after  a  time  by  retch- 
ing and  vomiting,  the  vomited  matters  consisting  at  first  of  the  contents  of 
the  stomach  or  mucus,  later  of  bile  in  consequence  of  retro-stalsis.  Hence 
the  term  "  bilious  headache,"  frequently  applied  to  the  paroxysm.  This  term 
is  entirely  inappropriate,  for,  notwithstanding  the  frequency  of  nausea  and 
vomiting,  migraine  is  not  due  to  an  affection  of  the  liver.  Profound  nausea 
and  vomiting  are  followed  by  great  depression,  and  at  this  period  of  the 
attack  the  condition  in  many  respects  is  not  unlike  severe  sea-sickness.  It 
is  common  for  the  headache  to  commence  in  the  morning,  nausea  to  come  on 
in  the  course  of  the  day,  and  vomiting  in  the  evening  (Gowers). 

Vasomotor  phenomena  are  present.  The  face  is  usually  pale,  a  difference 
in  the  degree  of  pallor  on  the  two  sides  being  sometimes  manifest.  Toward 
the  end  of  the  attack  there  may  be  flushing,  more  marked  on  the  side  upon 
which  the  pain  first  shows  itself,  or  to  which  it  is  restricted.  The  expression 
is  that  of  acute  suffering. 

The  pulse  is  small,  tense  and  very  often  slow.  In  children  the  tempera- 
ture is  often  slightly  elevated. 

The  duration  of  the  attack  varies  from  several  hours  to  a  day  or  two.  In 
the  milder  paroxysms  the  whole  process  is  complete  in  a  period  of  from  six 
to  twelve  hours ;  in  the  more  severe  two  or  even  three  days  elapse  before  the 
patient  is  well  again.  The  decline  of  the  symptoms  is  gradual  rather  than 
abrupt.  This  period  is  very  often  covered  by  sleep.  As  the  intensity  of  the 
pain  subsides,  frequently  after  retching  or  vomiting,  the  patient  falls  asleep 


942  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

and  awakes  after  some  hours,  or  the  following  morning,  refreshed,  free  from 
pain  and  often  feeling  better  than  before  the  attack. 

The  intervals  between  the  attacks  vary  within  wide  ranges.  The  periodic- 
ity is  usually  irregular.  Sometimes,  however,  it  shows  remarkable  regularity. 
Thus  the  paroxysm  may  at  times  occur  every  week,  even  upon  the  same  day, 
or  every  fortnight,  or  once  a  month.  In  women  it  may  coincide  with  the 
menstrual  periods.  The  attacks  are  in  many  cases  absent  during  gestation. 
After  the  menopause  or  at  a  nearly  corresponding  age  in  men,  they  very 
often  cease  or  become  less  severe,  and  are  in  some  instances  replaced  by 
attacks  of  neuralgia  or  other  paroxysmal  nervous  disturbance.  I  have  re- 
cently seen  two  cases  in  which  paroxysms  of  migraine  have  been  succeeded 
by  attacks  of  severe  vertigo  without  head-pain  recurring  at  the  former  in- 
tervals. 

Other  variations  occur.  Thus,  headache  may  be  absent,  and  the  attack 
may  be  replaced  by  paroxysmal  visual  disorders  or  other  sensory  symptoms, 
by  mental  depression,  or  confusion,  or  by  an  attack  of  gout. 

Diagnosis.  The  direct  diagnosis  of  migraine  is  based  upon  hereditary 
predisposition,  the  periodicity,  the  evolution  of  the  attack,  unilateral  pain, 
nausea,  and  the  associated  visual  and  other  sensory  symptoms.  The  brief 
course  and  definite  conclusions  of  the  attack  are  important  in  diagnosis. 

The  differential  diagnosis  from  other  forms  of  headache  is  sufficiently  in- 
dicated by  the  above  points. 

In  the  absence  of  the  sensory  accompaniment,  the  paroxysmal  character 
of  the  attack,  its  periodicity,  its  severity,  and  its  definite  course  are  to  be 
taken  into  consideration. 

The  differential  diagnosis  between  migraine  and  the  headache  of  organic 
intra-cranial  disease  rests  upon  the  following  facts  :  that  in  the  latter  when 
intermissions  occurs  they  are  neither  so  long  nor  so  complete  as  are  the  inter- 
paroxysmal  periods  in  migraine  ;  that  the  periodicity  when  present  is  far  less 
definite  ;  that  the  evolution  of  the  attack  is  not  characteristic  ;  that  the  acces- 
sory symptoms  are  usually  well  marked  and  of  a  wholly  different  character 
from  those  of  migraine.  The  visual  aura  sometimes  present  in  petit  raal  may 
suggest  migraine,  but  a  careftil  study  of  the  paroxysm  shows  differences  so 
essential  that  errors  in  diagnosis  can  hardly  occur. 

The  differential  diagnosis  between  migraine  and  neuralgia  of  the  ophthal- 
mic division  of  the  trigeminus  rests  upon  clinical  and  pathological  data  so 
evident  that  they  demand  no  discussion  in  this  connection.  It  is,  however, 
to  be  borne  in  mind  that  the  same  individual  may  suffer  from  migraine  and 
other  forms  of  headache  or  from  neuralgia,  or  may  be  the  victim  of  disease 
of  the  kidneys  or  organic  brain  disease. 

Prognosis.  The  prognosis,  as  regards  the  expectancy  of  life,  is  good.  The 
recurrent  attacks  of  migraine  seem  to  have  in  the  majority  of  cases  little  or 
no  unfavorable  influence  upon  the  general  health.  As  regards  cure,  the 
prognosis  is  not  favorable.  Nevertheless,  in  a  considerable  proportion  of  the 
cases  the  paroxysms  cease  to  occur  at  or  about  middle  life,  and  in  a  larger 
proportion  their  intensity  and  frequency  are  diminished.  Many  cases  are 
improved  by  treatment,  the  prospect  of  benefit  being  greater  when  treatment 
is  instituted  shortly  after  the  development  of  the  disease,  and  especially  in 
cases  due  to  reflex  irritation,  in  those  in  which  there  are  unfavorable  condi- 
tions in  the  general  health  or  mode  of  life  that  can  be  corrected,  and  in 
those  in  whom  there  is  no  hereditary  predisposition  to  the  disease. 

Treatment.  The  children  of  neurotic  families,  or  those  in  whom  a  distinct 
hereditary  predisposition  to  migraine  exists,  should  be  carefully  watched. 
The  occurrence  of  periodical  headache,  or  of  a  single  attack  of  hemicrania, 
should,  even  in  the  absence  of  associated  symptoms,  suggest  a  careful  ex- 


SYMPTOMATIC  BISOBDERS.  943 

amination  of  the  eyes,  nose,  naso-pharynx,  or  other  region  of  possible  reflex 
irritation.  Careful  attention  should  be  paid  to  the  hygiene  in  such  cases. 
Excessive  application  to  study  and  long  hours  at  school  should  be  inter- 
dicted. 

Treatment  should  be  early  instituted.  Those  causes  which  are  known  to 
provoke  the  attack  should  be  carefully  avoided.  The  treatment  of  the  attack 
demands  absolute  rest  in  the  recumbent  posture  in  a  darkened  room,  with 
complete  abstinence  from  food.  Under  these  circumstances  alone  many  of 
the  milder  attacks  terminate  spontaneously  in  the  course  of  a  few  hours. 
When  the  attacks  are  severe  the  early  administration  of  antipyrin,  phena- 
cetin,  sodium  salicylate,  sodium  benzoate,  and  caffeine,  alone  or  in  various 
combinations,  very  often  result  in  prompt  and  decided  mitigation  of  the 
sufferings,  and  sometimes  appear  to  shorten  the  attack.  Moderate  doses  re- 
peated at  intervals  of  from  half  an  hour  to  an  hour  are  more  satisfactory 
than  single  large  doses.  The  chemical  mixture  of  antipyrin,  citric  acid,  and 
caffein,  sold  under  the  name  "  migrarin,"  exerts,  in  doses  of  a  gramme,  a 
very  decided  effect  in  relieving  the  symptoms.  When  the  attacks  are  fre- 
quent these  drugs  gradually  lose  their  power  to  alleviate  suffering,  and  new 
combinations  and  increased  doses  become  necessary.  The  internal  admin- 
istration of  guarana,  or  menthol,  or  the  exhibition  of  large  doses  of  muriate  of 
ammonia  and  the  bromides  are  also  followed  by  good  results.  Rachford 
found  potassium  permanganate  of  use,  especially  in  a  case  of  migrainous 
epilepsy,  in  which  other  treatment,  medical  and  dietetic,  failed  entirely. 

If  the  attack  develop  after  a  meal,  relief  very  often  follows  free  emesis, 
which  may  be  produced  by  a  draught  of  mustard  water,  a  dose  of  ipecacuanha 
or  the  hypodermatic  administration  of  apomorphine. 

Galvanism  yields  decided  relief  in  a  limited  number  of  cases.  Sufferers 
from  migraine  very  often  acquire  a  knowledge  of  the  use  of  analgesics  and 
narcotics  which  is  not  without  danger,  and  in  severe  attacks  learn  to  resort 
to  the  use  of  chloroform  by  inhalation  or  to  such  powerful  narcotics  as  mor- 
phine, codeine,  and  chloral,  remedies  that  are  frequently  efficient,  but  always 
attended  with  the  danger  of  the  formation  of  a  vicious  habit  and  sometimes 
with  that  of  immediately  fatal  narcosis. 

The  constitutional  treatment  during  the  intei paroxysmal  periods  includes 
the  employment  of  hygienic  measures  directed  to  the  maintenance  of  the 
general  health,  carefully  regulated  diet,  and  systematic  exercise.  Any  lesion 
capable  of  giving  rise  to  reflex  irritation,  and  especially  those  involving  the 
eyes  or  nasal  passages,  should  be  promptly  corrected.  Long-continued 
courses  of  Indian  hemp,  gr.  ^—i  (0.02-0.03),  t.  d. ;  nitroglycerin,  gr.  y^Q— 5V 
(0.006-0.003)  or  more  t.  d. ;  arsenious  acid,  gr.  -^^-^  (0.0015),  t.  d. ;  or  the 
bromides,  gr.  xv.-xx.  (1.0-1.3),  t.  d. ;  or  protracted  alternating  courses  of 
these  drugs  have  been  followed  by  a  diminution  in  the  frequency  of  the 
paroxysms  and  in  their  intensity. 

The  daily  application  of  galvanism  to  the  head  must  be  included  in  the 
list  of  measures  of  general  treatment,  though  the  proportion  of  cases  in  which 
demonstrable  benefit  has  resulted  appears  to  be  small. 


VERTIGO. 

Definition.  Vertigo,  literally  a  turning,  is  a  derangement  of  the  nervous 
mechanism  governing  the  relationship  of  the  body  to  external  objects,  char- 
acterized by  sensations  of  movement  on  the  part  of  surrounding  objects 
which  are  really  at  rest — objective  vertigo ;  or  on  the  part  of  the  person 
himself — subjective  vei'tigo. 


944  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Synonyms.     Dizziness;  Giddiness. 

Vertigo  is  a  symptom.  Although  it  is  in  many  cases  a  symptom  of  promi- 
nence, it  cannot  be  regarded  as  in  itself  constituting  a  substantive  disease. 
The  term  "  essential "  has  been  applied  to  those  cases  of  vertigo  in  which  no 
underlying  pathological  condition  has  been  discoverable.  Vertigo  may  be  a 
symptom  of  organic  intra-cranial  disease,  but  it  occurs  much  more  frequently 
as  a  symptom  of  peripheral  or  functional  disturbance. 

Etiology.  Vertigo  is  a  common  nervous  symptom ;  it  may  arise  in  the 
course  of  diverse  pathological  conditions  in  many  of  which  headache  also 
occurs.  Thus  vertigo  is  a  common  immediate  symptom  of  (1)  mild  cerebral 
concussion.  It  arises  also  (2)  from  circulatory  disturbances,  as  cerebral 
anaemia  and  hypersemia.  (3)  It  occurs  as  a  result  of  local  nerve  irritation, 
svich,  for  example,  as  irritation  or  inflammation  of  the  middle  ear,  or  that 
which  follows  the  application  of  electrical  currents  to  the  head.  A  special 
form  of  vertigo,  true  auditory  vertigo,  occurs  as  a  symptom  of  disease  of  the 
labyrinth,  implicating  the  end  organs  of  the  eighth  nerve.  (4)  Various 
toxsemic  conditions  give  rise  to  vertigo ;  thus,  vertigo  and  headache  are 
occasionally  associated  symptoms  at  the  onset  of  the  acute  infections.  Some 
degree  of  vertigo  is  a  common  symptom  in  acute  and  subacute  gastro-hepatic 
derangements  and  in  lithsemia.  Alcohol  and  tobacco  in  persons  unaccus- 
tomed to  their  use,  or  in  undue  amounts,  produce,  among  other  symptoms, 
vertigo,  and  in  many  persons  the  administration  of  narcotic  drugs,  particu- 
larly opium,  is  followed  by  this  symptom.  (5)  It  occurs  also  as  a  symptom 
of  endarteritis  and  arterio- sclerosis ;  and  (6)  in  valvular  disease  of  the  heart, 
especially  aortic  insufficiency,  and  in  degenerative  diseases  of  the  cardiac 
muscle  (fatty  heart,  chronic  myocarditis).  (7)  In  neuropathic  conditions, 
especially  neurasthenia  and  epilepsy.  (8)  In  reflex  disturbances,  such  espe- 
cially as  arise  from  disease  of  the  visual  apparatus  or  the  stomach.  (9)  In 
organic  disease  of  the  brain.  Finally  (10),  vertigo  arises  from  mechanical 
causes,  such  as  swinging,  certain  unusual  postures,  or  rapid  rotary  move- 
ments, and  in  the  irregular  disturbance  of  the  equilibrium  of  the  body  which 
occurs  at  sea. 

Pathological  Considerations.  The  equilibrium  of  the  body  is  maintained 
under  ordinary  circumstances  by  the  active  contraction  of  muscles.  The 
nicely  adjusted  and  constantly  changing  motor  impulses  by  which  the 
balance  of  the  body  in  its  ever-changing  relation  to  surrounding  objects  is 
secured  are  determined  in  cerebral  centres  in  response  to  sensory  impres- 
sions, which  are  as  constantly  in  action  as  the  motor  impulses  which  respond 
to  them. 

The  most  important  of  these  sensory  impulses  are  visual ;  that  is,  those 
from  the  eye  and  its  muscles,  and  aural,  which  proceed  from  the  semicircular 
canals  and  the  ampullae.  Scarcely  inferior,  however,  in  importance  are  the 
combined  sensory  impulses  from  the  muscles  directly  concerned  in  the  main- 
tenance of  equilibrium  from  the  joints,  from  the  skin  and  from  the  viscera. 
Any  cause  suddenly  disturbing  the  continuous  and  systematized,  though  un- 
conscious, sensory  impulses  from  these  sources,  may  cause  a  derangement  of 
the  nervous  mechanism  by  which  the  body  is  maintained  in  its  relation  to 
external  objects.  This  derangement  manifests  itself  as  vertigo.  These  sen- 
sory impressions,  except  those  from  the  skin,  are  not  felt  in  normal  conscious- 
ness. It  is  only  when  they  are  interrupted,  or  when  the  nutrition  of  the 
cortex  is  suddenly  lowered,  that  consciousness  in  regard  to  them  is  perverted 
and  vertigo  ensues.  Hence,  vertigo  implies  a  disturbance,  not  a  loss  of  con- 
sciousness. In  true  vertigo  -consciousness  is  always  retained.  Gowers  has 
pointed  out  the  fact  that  we  are  chiefly  conscious  of  the  eflect  on  the  action 
of  some  centre,  not  of  the  imperfection  (of  the  centripetal  impressions)  itself. 


S YMPTOMA  TIC  DISORDERS  945 

Clinical  Considerations.  Vertigo  varies  iu  inteusity  from  a  slight  feel- 
ing of  imperfect  equilibrium — mere  swimming  of  the  head — to  the  most 
active  and  distressing  sensations  of  rapid  or  ii-regular  movement  or  whirling 
of  the  body  itself  or  of  surrounding  objects.  The  attack  comes  on  suddenly, 
and  is  usually  of  short  duration.  The  floor  or  the  bed  upon  which  the 
patient  is  lying  appears  to  rise  and  sink,  or  objects  Avhirl  around,  usually  in 
a  definite  direction — objective  vertigo  ;  or  the  patient  himself  appears  to  be 
whirling  around  or  rising  and  sinking  in  space — subjective  vertigo.  These 
sensations  are  often  accompanied  by  compensatory  movements  on  the  part 
of  the  patient,  which  may  result  in  a  fall.  There  is  mental  confusion,  to- 
gether with  a  sense  of  alarm  and  often  faintness.  Consciousness  is  impaired 
but  not  lost.  There  may  be  nausea  or  vomiting ;  these  symptoms  are  almost 
always  present  when  the  vertigo  is  severe.  The  attacks  may  continue  to 
recur  whilst  the  condition  to  which  they  are  due  persists.  Hence  vertigo 
may  become  chronic,  and  to  the  severer  form  of  persistent  vertigo  the  term 
datm  vertiginosus  has  been  applied.  The  patient  is  often  compelled  to  keep 
the  eyes  closed.  Vertigo  is  increased  by  change  of  posture  and  particularly 
by  sudden  movements  of  the  head.  It  is  very  often  diminished,  or  ceases 
altogether,  when  the  patient  assumes  the  recumbent  posture. 

The  above-named  conditions  in  which  vertigo  often  occurs  as  a  symptom 
may  be  taken  together  as  the  basis  of  an  etiological  classification.  Though  al- 
most always  regarded  by  the  patient  and  his  friends  as  serious,  vertigo  is  in 
many  cases  an  insignificant  symptom. 

The  following  forms  of  vertigo  require  brief  separate  consideration  :  Aural 
vertigo,  including  true  auditory  vertigo— Meniere's  disease ;  toxic-  vertigo  ; 
arterio-sclerotic  vertigo  ;  cardiac  vertigo ;  neurotic  vertigo,  including  that  of 
neurasthenia,  epilepsy,  the  so-called  stumbling  or  paralyzing  vertigo  and  par- 
oxysmal vertigo  ;  reflex  vertigo  ;  the  mechanical  vertigoes ,  and,  finally,  the 
vertigoes  which  arise  in  coarse  intra-cranial  disease. 

Aural  Vertigo.  A  distinction  must  be  made  between  the  vertigo  which 
is  sometimes  symptomatic  of  irritation  or  disease  of  the  middle  ear  or  of  the 
external  auditory  canal,  and  that  which  arises  in  lesions  of  the  eighth  nerve 
involving  its  end-organs  in  the  labyrinth  or  its  nuclei.  The  latter  constitutes 
true  auditory  or  labyrinthine  vertigo,  and  is  the  chief  symptom  of  Meniere's 
disease. 

Vertigo  often  arises  from  the  pressure  of  accumulated  cerumen  in  the  ex- 
ternal auditory  canal,  especially  if  the  mass  has  become  slightly  displaced. 
Vei'tigo  may  follow  the  sudden  forcing  of  air  against  the  membrana  tyrapani 
from  a  blow  upon  the  ear,  or  the  entrance  of  water  in  diving  or  surf-bath- 
ing, or  the  forcible  injection  of  water  in  syringing.  Vertigo  may  also  arise 
from  irritation  of  the  Eustachian  tube  in  the  surgical  treatment  of  the 
middle  ear.  This  symptom  also  occurs,  though  it  is  not  common  in  cases  of 
otitis  media.  The  vertigo  arising  under  the  above  circumstances  is  usually 
slight  and  transitory.  Whether  it  is  directly  due  to  local  irritation,  or  is 
reflex,  has  not  yet  been  determined. 

^Meniere's  Disease.  An  affection  characterized  by  noises  in  the  ear, 
sudden  attacks  of  vertigo  with  nausea  and  vomiting,  and  nervous  deafness, 
which  in  many  cases  is  progressive.  The  attacks  are  often  apoplectiform 
Avith  momentary  loss  of  consciousness. 

This  affection  is  an  important,  very  often  a  serious,  disease.  It  nuist  be 
regarded  as  a  substantive  affection  of  which  vertigo  is  the  chief  symptom. 
It  Avas  first  described  as  such  by  Meniere  in  1861.  The  term  "Meniere's 
disease  "  is  frequently  applied  to  attacks  of  vertigo  occurring  in  any  disease 
of  the  auditory  apparatus.  It  should  be  restricted  to  the  affection  charac- 
terized by  the  complexus  of  symptoms  about  to  be  described. 

60 


946  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Age  plays  an  important  part  in  the  predisposition.  The  affection  is  very- 
rare  in  early  life.  In  a  large  proportion  of  the  cases  the  attacks  first  show 
themselves  between  forty-five  and  fifty-five,  but  they  may  come  on  much 
later.  Men  suffer  more  frequently  than  women.  Nothing  is  known  of  the 
exciting  causes.  The  disease  is  paroxysmal,  the  attacks  occurring  at  irregu- 
lar intervals,  and  very  often  in  series,  several  of  which  may  take  place  in  one 
day  or  on  successive  days.  Such  series  or  single  attacks  may  be  separated  by 
intervals  of  weeks  or  even  months.  The  attack  is  very  frequently  apoplecti- 
form, beginning  suddenly  with  tinnitus  aurium  and  subjective  or  objective 
vertigo  of  such  intensity  that  the  patient,  in  order  to  prevent  himself  from 
falling,  is  obliged  to  immediately  catch  some  supjDort  or  to  sit  or  lie  down.  If 
loss  of  consciousness  occur  it  is  as  a  rule  momentary.  Occasionally  ocular 
symptoms  accompany  the  attack.  These  consist  in  diplopia  or  nystagmus. 
Forced  movements  may  occur,  and  in  the  intervals  of  frequent  attacks  there 
is  an  impairment  of  equilibrium,  so  that  the  patient  walks  with  difficulty. 
The  attack  is  usually  of  short  duration.  As  the  vertigo  passes  off  the  patient 
is  pale,  breaks  into  a  profuse  sweat,  suffers  from  nausea,  or  there  may  be 
actual  vomiting.  As  a  rule,  there  is  no  disease  of  the  middle  ear.  When 
j)resent,  the  association  is  merely  accidental.  The  deafness,  which  is  nervous, 
usually  affects  one  ear  only.  It  is  progressive,  but  never  complete.  When 
deafness  becomes  complete,  the  vertigo  ceases,  the  end-organs  of  the  nerve 
being  destroyed. 

Three  principal  theories  have  been  suggested  to  account  for  the  phenomena 
of  Meniere's  disease : 

1.  That  the  symptoms  are  due  to  lesions  of  the  labyrinth.  There  is  pro- 
gressive degeneration  of  the  nerve  or  its  end-organs. 

2.  That  the  disease  is  a  vasomotor  neurosis  of  the  vessels  of  the  labyrinth. 
This  view  finds  some  support  in  the  paroxysmal  character  of  the  affection 
and  in  the  fact  that  acute  lesions  with  hemorrhage  have  been  found  upon 
post-mortem  examination. 

3.  That  the  primary  trouble  consists  in  an  affection  of  the  centres  for  hear- 
ing and  equilibration. 

Of  these  three,  the  first,  namely,  that  the  symptoms  are  due  to  lesions  of 
the  labyrinth  involving  the  end-organs  of  the  eighth  nerve,  is  at  present 
generally  accepted. 

The  direct  diagnosis  of  Meniere's  disease  rests  upon  the  paroxysmal  ver- 
tigo, the  apoplectiform  seizure,  the  occurrence  of  tinnitus,  nausea,  and  vomit- 
ing and  the  nervous  deafness,  usually  progressive.  The  differential  diagnosis 
between  the  vertigo  which  is  so  prominent  a  symptom,  and  other  forms  of 
vertigo  must  in  the  main  depend  upon  the  association  of  the  foregoing  symp- 
toms, the  paroxysmal  nature  of  the  attack  and  the  absence  of  other  patho- 
logical states  usually  attended  with  vertigo. 

The  prognosis  is  uncertain.  A  small  proportion  of  the  cases  terminate, 
after  a  variable  duration,  in  complete  recovery,  with  total  loss  of  hearing  in 
the  affected  side  ;  much  more  commonly  the  disease  proves  persistent  and  in- 
tractable, and,  with  periods  of  exacerbation  and  improvement  for  which  no 
explanation  is  to  be  found,  continues  throughout  life.  In  some  instances  the 
symptoms  are  so  severe  that  the  patients  become  bed-ridden. 

The  treatment  of  Meniere's  disease  does  not  rest  upon  a  very  satisfactory 
basis ;  nor  are  the  results  in  general  brilliant.  Nevertheless,  many  cases  are 
for  a  time  at  least,  greatly  benefited  by  systematic  medication.  As  nothing- 
is  known  of  the  cause,  nothing  is  to  be  said  of  prophylaxis.  The  general 
health  must  be  looked  after  as  in  every  chronic  disease.  The  bromides  are 
useful  in  doses  of  gr.  xx-xxx  1.5  t.  d.,  or,  when  other  plans  of  treatment  are 
employed,  in  a  larger  single  dose  at  bedtime.     Potassium  iodide  may  be  ad- 


SYMPTOMATIC  DISORDERS.  947 

ministered  in  all  cases  in  which  there  is  a  history  of  syphilis ;  its  use  has 
occasionally  been  followed  by  improvement  where  no  such  history  has  been 
elicited.  The  method  of  Charcot  consists  in  the  use  of  quinine  pushed  to 
cinchonism ;  the  drug  is  then  discontinued,  and  as  the  physiological  effects 
pass  away  improvement  is  noted.  Upon  the  recurrence  of  the  attacks,  the 
quinine  is  again  given  in  the  same  manner.  Quinine  may  be  given  in  con- 
nection with  the  bromides  or  with  hydrobromic  acid.  The  salicylates  pushed 
to  the  production  of  their  physiological  effects  have  been  followed  by  im- 
provement. Thus,  the  sodium  salicylate  may  be  given  in  gr.  x-xv  (0.6-1) 
doses  t.  d.  until  persistent  tinnitus  or  other  evidence  of  its  effect  upon  the 
nervous  system  arise,  and  then  stopped.  Pilocarpine  and  ergot  have  been 
employed,  and  I  have  seen  decided  relief  follow  the  long-continued  adminis- 
tration of  ergotin  and  cannabis  indica. 

Toxic  Vertigo.  The  vertigo  which  occurs  at  the  onset  of  the  acute 
infections  is  usually  associated  with  headache.  It  is  always  of  secondary 
importance  as  compared  with  the  general  symptoms,  and  quickly  passes  away. 
It  requires  no  special  treatment. 

Vertigo  is  a  symptom  of  gastro-hepatic  catarrh,  or  hllioimies><.  This  form 
of  vertigo  is  usually  more  troublesome  on  rising  in  the  morning,  and  is  one 
of  an  annoying  group  of  symptoms  to  which  j)ersons  of  bilious  temperament 
and  sedentary  lives  are  peculiarly  susceptible,  especially  if  they  are  given 
over  to  the  pleasures  of  the  table.  Constipation,  nausea,  a  furred  tongue 
and  foul  breath,  loss  of  appetite,  headache,  and  depression  of  spirits  make 
up  the  clinical  picture.  The  occasional  vertigo  of  lithsemic  patients  is  an 
allied  condition.  Vertigo,  sometimes  of  high  grade,  ajfeo  occurs  as  a  symp- 
tom of  acute  indigestion,  and  especially  that  following  a  surfeit.  Manj'  ver- 
tigoes now  known  to  be  due  to  other  causes  were  at  one  time  ascribed  to  gas- 
tric disorder,  and  the  vertigo  a  stomacho  laeso  of  Trousseau  occupies  a  much 
less  important  place  in  nosology  than  formerly.  Gastric  vertigo  is  probably 
in  part  reflex,  in  part  toxic. 

The  vertigo  caused  by  narcotics,  alcohol,  tobacco,  opium,  cocaine,  nitro- 
glycerin, and  many  other  drugs  is  transitory  and  demands  merely  passing- 
consideration.  Idiosyncrasy  and  habit  play  a  large  part  in  determining  the 
occurrence  and  degree  of  vertigo  as  a  drug-symptom.  A  peculiarity  of  the 
vertigo  which  in  many  persons  follows  the  administration  of  opium  and  its 
derivatives  is  the  extent  to  which  it  is  influenced  by  posture,  being  wholly 
absent  while  the  patient  remains  recumbent  and  at  rest,  and  coming  on  with 
distressing  intensity  upon  movement  or  in  the  erect  position. 

Cardio-vascular  Vertigo.  Vertigo  is  a  symptom  of  cerebral  anaemia. 
AVhen  the  cause  does  not  act  instantaneously,  swimming  of  the  head  pre- 
cedes syncope.  This  is  the  case  in  sudden  blood-loss.  Mechanical  defects 
in  the  circulatory  apparatus  produce  this  form  of  vertigo.  Cardiac  asthenia, 
whether  due  to  defective  innervation  or  changes  in  the  heart-muscle  (myo- 
carditis ;  fatty  heart),  is  frequently  attended  by  some  degree  of  vertigo. 
Upon  effort,  or  during  excitement,  or  when  the  tidal  blood  is  accumulated 
in  the  abdominal  organs  during  the  digestion  of  a  too  hearty  meal,  the  en- 
feebled heart  may  fail  to  adequately  supply  the  brain  with  blood,  and  ver- 
tigo, followed  by  faintness,  result.  Under  such  circumstances  valvular 
defects,  and  in  particular  aortic  insufficiency,  may  produce  like  effects. 
Sclerotic  changes  in  the  branches  of  the  cerebral  arteries,  producing  local 
aniemia  and  impairment  of  nutrition,  cause  vertigo.  8uch  changes  may  ))e 
brought  about  by  disease  or  by  old  age.  The  association  of  vertigo  and  tin- 
nitus aurium  as  persistent  symptoms  is  sometimes  a  very  distressing  senile 
condition. 

In  this  connection  is  to  be  noted  the  vertigo  of  aniemia  and  chlorosis,  wliich 


948  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

occurs  especially  upon  exertion,  and  is  due  to  cerebral  anaemia.  Vertigo  is 
occasionally  a  marked  symptom  in  leukaemia. 

Neurotic  Vertigo,  (a)  Epileptic  vertigo  occurs  as  an  aura ;  also  iu 
petit  mal.  (h)  Neurasthenic  vertigo  is  a  common  and  distressing  symptom. 
It  occurs  in  attacks  that  are  frequent,  but  not  usually  severe  nor  prolonged. 
Slight  nausea  may  be  present,  but  vomiting  does  not  often  take  place.  The 
vertigo  of  neurasthenia  is  frequently  reflex — ocular  or  gastric.  It  is  usually 
subjective,  (c)  Stumbling  or  paralyzing  vertigo.  There  is  a  sudden  loss  of 
jiower  in  the  legs  without  the  ordinary  sensations  of  vertigo,  though  it  is 
probable  that  there  is  momentary  impairment  of  consciousness.  This  symp- 
tom has  been  noted  in  exophthalmic  goitre,  and  has  occurred  endemically 
in  summer  in  certain  cantons  of  Switzerland,  (rf)  Paroxysmal  vertigo  occa- 
sionally occurs  in  individuals  of  nervous  temperament  after  excitement  or 
excessive  fatigue.  The  attacks  come  on  suddenly,  and  sometimes  last  for 
several  hours.  The  sensation  of  vertigo  is  very  distressing ;  it  is  accom- 
panied by  intense  nausea  and  vomiting.  All  the  symptoms  are  increased  by 
movement  and  in  the  upright  posture.  The  attacks  present  all  the  phe- 
nomena of  sea-sickness,  with  which  they  have  been  compared. 

Reflex  Vertigo  is  much  less  common  than  formerly  supposed.  Ocular 
vertigo  may  in  rare  instances  occur  alone,  more  commonly  in  connection 
with  brow-pains  or  other  forms  of  headache  as  a  symptom  of  defective  refrac- 
tion or  want  of  harmonious  action  in  the  ocular  muscles — eye-strain.  The 
close  central  anatomical  relationship  of  the  vagus  and  auditory  nerves  has 
been  invoked  to  explain  the  occurrence  of  reflex  vertigo  in  gastric  derange- 
ments. 

Mechanical  Vertigo.  This  symptom  quickly  arises  upon  certain  move- 
ments, as  sudden  lowering  of  the  head,  whirling  around,  or  swinging,  in  per- 
sons not  used  to  them,  and  as  part  of  the  morbid  complexus  in  sea-sickness, 
car-sickness,  and  in  very  susceptible  individuals  from  the  motion  of  elevators. 
Exceptionally  chronic  vertigo  of  mild  kind  troubles  those  who,  as  elevator 
boys,  are  continuously  exposed  to  such  movements. 

The  Vertigo  of  Intra-cranial  Disease.  Vertigo  is  a  very  common 
symptom  in  disease  of  the  brain  and  its  meninges.  It  is,  however,  of  inferior 
importance  as  a  rule,  both  as  regards  the  subjective  sensations  of  the  patient 
and  in  diagnosis,  to  many  of  the  symptoms,  such  as  headache,  vomiting, 
mental  hebetude,  etc.,  with  which  it  is  usually  associated.  It  occurs  in  cere- 
bral anaemia  and  hyperaemia,  in  meningitis,  in  acute  and  in  chronic  or  latent 
abscess  of  the  brain,  in  cerebral  arterio-sclerosis,  and  as  a  premonitory  symp- 
tom in  the  acute  softening  due  to  thrombosis  ;  as  a  general  symptom  of  cere- 
bral irritation  in  tumor  of  the  brain,  and  as  a  symptom  of  special  signifi- 
cance in  tumor  and  other  coarse  lesions  of  the  cerebellum.  Vertigo,  so 
common  in  arterio-sclerosis,  acquires  especial  importance  in  the  diagnosis  of 
cerebral  syphilis. 

Diagnosis.  Vertigo  is  a  morbid  j^henomenon  sui  generic,  and  may  be 
recognized  without  difficulty  from  the  description  of  the  patient.  It  is  to  be 
I'egarded  in  all  cases,  even  in  those  in  which  the  underlying  pathological 
condition  is  not  at  once  discoverable,  as  a  symptom  which  acquires  signifi- 
cance and  importance  chiefly  as  indicating  the  disease  of  which  it  is  a  mani- 
festation. The  character  of  the  vertigo  is  to  be  carefully  investigated ; 
whether  it  be  subjective  or  objective,  intermittent,  paroxysmal,  or  chronic. 
Especial  attention  must  be  given  to  the  associated  symptoms.  The  causal 
diagnosis  can  alone  afford  a  basis  for  intelligent  prognosis  and  rational 
treatment. 

Prognosis.  The  prognosis  varies  according  to  the  cause.  Many  forms  of 
vertigo  are  amenable  to  treatment.     Those  cases  in  which  the  symptom  is 


SYMPTOMATIC  DISORDERS.  949 

due  to  organic  disease  of  the  brain  or  to  epilepsy  are  not  hopefiil.  Vertigo 
caused  by  labyrinthine  disease  ceases,  as  a  rule,  when  the  hearing  upon  the 
affected  side  is  wholly  lost. 

Treatment.  The  treatment  of  vertigo  must  be  determined  by  the  cause. 
The  attack  is  best  managed  by  rest  in  the  recumbent  posture  and  the  admin- 
istration of  the  spirit  of  ammonia.  Among  merely  symptomatic  I'emedies  the 
bromides  are  the  most  useful,  their  proper  employment  being  usually  followed 
by  temporary  good  effects. 

The  vertigo  of  neurasthenia  yields  to  management  by  rest,  a  proper  and 
sufficient  dietary,  laxatives,  the  mineral  acids,  and  strychnine ;  that  of  gas- 
tric disorder  to  laxatives,  simi^le  bitters,  and  a  regulated  diet.  The  actual 
condition  of  the  stomach  must  be  ascertained  by  the  modei'n  methods  of  gas- 
tric diagnosis,  and  treated  accordingly  ;  that  of  biliousness,  lithsemia  and  gout 
by  appropriate  regimen  and  remedies  ;  that  of  old  age  and  arterio-sclerosis 
is  partially  relieved  by  nitroglycerin,  potassium  iodide,  systematic  purgation, 
and  a  restricted  diet,  from  which  meats  and  sugars  are  largely  excluded. 
In  the  last  grouj)  of  cases  cardiac  tonics  m_ay  be  indicated.  In  persistent 
vertigo,  the  cause  of  which  may  not  be  obvious,  counter-irritation  over  the 
nape  of  the  neck  or  the  mastoid  process  is  occasionally  usefiil. 


INSOMNIA. 

Definition.  Insomnia  is  a  term  used  to  designate  a  condition  of  disturb- 
ance of  the  nervous  system,  characterized  by  habitual  incomplete  sleep  or 
by  periods  of  entire  absence  of  normal  sleep. 

Synonyms.     Sleeplessness ;  Abnormal  Wakefulness  ;  Ahypnosis. 

Sleep  is  a  physiological  condition  in  which  consciousness  is  suspended,  and 
during  which  the  body  is  in  repose  while  its  constituent  elements  undergo 
nutritional  repair.  The  activity  of  the  cells  of  the  cortex  of  the  brain  is  in 
abeyance ;  the  higher  cerebral  flinctions,  and  among  them  consciousness, 
cease.  The  muscular  system  and,  to  some  extent,  other  organs  share  in  the 
repose.  On  the  other  hand,  the  intimate  physiological  activities  which  con- 
stitute processes  of  repair  go  on,  with  the  result  that  the  awaking  is  attended 
with  sensations  of  refreshment  and  renewed  vigor.  The  recurrence  of  sleep 
under  normal  conditions  is  rhythmical ;  it  is  a  manifestation  of  the  normal 
alteration  of  irritability  and  loss  of  irritability  characteristic  of  cell  life  in 
general.  In  the  highest  sense  the  changes  which  bring  about  sleep,  and 
equally  those  which  l)ring  it  to  an  end,  are  chemical  and  intra-cellular.  The 
blood  conveys  nutritive  principles,  and  may  supply  drug  principles,  as  caf- 
fein,  which  excite  irritability  and  postpone  sleep ;  or  which,  as  morphine, 
allay  it  and  hasten  sleep.  Some  degree  of  cerebral  ansemia  is  present ;  but 
there  is  no  proof  that  it  is  the  cause  of  sleep,  the  probability  being  that  the 
deficiency  of  blood  is  merely  the  result  of  the  suspension  of  functional  activ- 
ity. In  so  far  as  the  circulation  has  to  do  with  causing  or  preventing  sleep,  it 
is  not  mechanically,  that  is  to  say,  not  in  the  increase  or  decrease  in  the  amount 
of  blood  supplied'  to  the  brain,  but  in  the  composition  of  the  blood,  that  it 
acts.  Thus  drowsiness  may  be  present  with  all  the  signs  of  cerebral  congestion 
or  under  circumstances  in  which  there  is  manifest  ansemia  of  a  high  degree ; 
while  the  presence  in  the  blood  of  waste  products,  various  drugs  or  poisons, 
is  apt  to  cause  drowsiness,  pathological  sleep,  stupor,  or  coma,  according  to 
their  amount  in  relation  to  the  body-weight  of  the  individual.  Herein  is  to 
be  sought  the  essential  difference  between  normal  sleep  and  other  states  in 
which  consciousness  is  lost  and  which  are  purely  pathological.  These  states 
of  sleep,  stupor,  and  coma  are  not,  as  some  have  taught,  simply  the  expres- 


950  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

siou  of  different  degrees  of  suspension  of  the  functions  of  the  cerebral  cortex, 
but  sleep  and  the  others,  notwithstanding  their  points  of  resemblance  in  the 
sick-room,  are  essentially  different  conditions,  due  to  different  causes,  produc- 
ing diverse  effects  in  the  economy  and  terminating  in  results  that  are  not  to 
be  comjDared. 

Normal  sleep,  both  in  character  and  amount,  varies  with  age,  sex,  indi- 
vidual peculiarity,  occupation,  and  to  some  extent  with  race  and  climate.  In 
the  newborn  sleep  is  a  nearly  continuing  state,  interrupted  in  health  only 
by  the  taking  of  food  and  the  offices  of  the  toilet ;  a  little  later  there  are 
periods  of  wakefulness,  and  the  healthy  child  of  two  years  passes  half  its 
time  in  slumber.  The  adult  requires  from  seven  to  eight  hours  of  sleep  daily  ; 
aged  persons  not  more  than  five  or  six  hours.  Women  need,  as  a  rule,  more 
sleep  than  men.  Individual  peculiarities  are  observed  in  regard  to  the 
amount  of  sleep  required,  just  as  as  in  the  amount  of  food  necessary  to 
health  and  comfort.  Thus  there  are  persons  to  whom  nine  or  even  ten  or 
twelve  hours  of  sleep  are  essential,  w^hile  others  seldom  sleep  more  than  six 
hours  out  of  the  twenty-four.  Nor  is  this  difierence  to  be  explained  by  the 
completeness  of  the  sleep,  since  those  whose  sleep  is  longest  often  sleep  deeply, 
and  those  who  habitually  require  short  hours  of  sleep  are  easily  aroused. 
Those  whose  occupations  keep  them  much  in  the  open  air  and  involve  pro- 
longed muscular  effort  take  far  longer  hours  of  sleep  than  brain  workers  and 
those  of  sedentary  habits,  and  the  former  class  sleep  more  soundly.  The 
Northern  races  are  accustomed  to  longer  hours  of  sleep  than  those  who  dwell 
in  more  favored  climates. 

Under  normal  circumstances  the  sleeper  is  readily  aroused.  Sleep  Avhen 
interruj)ted  tends  to  recur,  but  maybe  postponed  by  vigorous  external  im- 
pressions or  by  the  power  of  the  will.  After  a  prolonged  period,  however, 
the  need  of  sleep  asserts  itself,  and  no  sense-impression,  no  moral  stimulant, 
no  effort  of  the  will  is  sufficiently  powerful  to  keep  the  exhausted  sufferer 
awake.  Continuous  insomnia  terminates  in  the  course  of  two  or  three  weeks 
in  fatal  exhaustion. 

The  term  insomnia  cannot  be  properly  employed  to  designate  the  tem- 
porary wakefulness  due  to  powerful  external  impressions.  Persons  who  can- 
not sleep  because  they  ai'e  disturbed,  sleep  well ,  enough  when  permitted  to 
do  so.  Those  who  suffer  from  insomnia  sleep  badly  or  not  at  all  under  the 
most  favorable  circumstances. 

Etiology.     Insomnia  may  be  simple  or  functional  and  symptomatic. 

(a)  Simple  or  functional  insomnia  occurs  in  neurotic  individuals  and  espe- 
cially in  overtaxed  brain-workers.  This  form  includes  hereditary  and  habit 
insomnia.  The  disorder  of  sleep  is  not  dependent  upon  any  discoverable 
underlying  disease  or  morbid  condition,  and  is  frequently  present  in  persons 
whose  general  health  is  in  other  respects  fairly  good.  After  a  time  habitual 
Avakefulness  produces  impairment  of  nutrition,  brain  exhaustion,  and  very 
often  severe  mental  symptoms. 

(6)  Symptomatic  insomnia.  Habitual  inability  to  sleep  is  an  important 
symptom  in  a  great  variety  of  morbid  conditions.  The  causes  may  be  ar- 
ranged in  groups  as  follows :  Nervous,  psychic,  cardio-vascular,  diathetic, 
toxic,  and  infectious.  Not  infrequently  two  or  more  of  these  conditions  act 
in  combination. 

Insomnia  is  a  prominent  secondary  symptom  in  painful  diseases,  especially 
cancer,  aneurism,  and  the  intractable  neuralgias ;  also  in  acromegaly. 

Insomnia  is  frequent  in  many  diseases  of  the  nervous  system.  It  occurs  in 
neurasthenic  subjects  usually  in  the  form  of  irregular,  fitful,  and  unrefreshing 
sleep,  troubled  with  dreams,  and  as  complete  wakefulness  after  fatigue  or 
excitement.     It  is  common  in  the  various  forms  of  insanity  both  in  the  pro- 


SYMPTOMATIC  DISORDERS.  951 

dromic  period  and  in  the  declared  disease.  It  is  sometimes  prolonged  and 
distressing  in  general  paralysis  of  the  insane,  but  is  not  common  in  focal 
lesions  of  the  brain.  It  is  a  prominent  symptom  in  acute  delii'ium  ;  while  in 
melancholia  sleep  is  broken,  unresting,  disturbed  by  dreams  of  the  most  dis- 
tressing character  ;  often  for  prolonged  periods  absent  altogether.  Diseases 
of  the  heart  and  arteries  are  not  rarely  attended  by  sleeplessness,  partly  due 
to  cerebral  ansemia,  partly  to  the  state  of  the  blood,  and  partly  to  the  ina- 
bility of  the  patient  to  assume  the  recumbent  posture.  As  these  factors 
increase,  wakefulness  is  progressively  superseded  by  somnolence,  stupor,  and 
coma.  In  this  connection  we  note  also  the  insomnia  of  chronic  nephritis, 
especially  those  forms  in  which  artero-sclerosis  is  pronounced.  The  want  of 
sleep  is  here  due  to  mechanical  defects  in  the  blood-supply  and  to  toxeemia 
(unemia),  while  the  insomnia  so  marked  in  certain  cases  of  acute  nephritis 
must  be  ascribed  chiefly  to  toxic  principles  circulating  in  the  blood.  In 
anfemia  and  chlorosis  there  is  frequently  sleeplessness  by  night  and  drowsi- 
ness by  day.  Diathetic  states,  such  as  undeveloped  gout  and  lith^emia  are 
common,  often  unsuspected  causes  of  protracted  and  tormenting  sleepless- 
ness. Disturbed  sleep,  rather  than  absolute  insomnia,  is  among  the  symptoms 
of  gastric  disorder. 

Tea  and  coffee  have  in  many  persons,  and  especially  in  those  unaccus- 
tomed to  drink  them  at  night,  the  power  of  inhibiting  sleep ;  caffeine  has 
the  same  effect.  Alcohol,  in  moderate  doses,  is  usually  sleep-compelling, 
while  excesses  stupefy,  and  complete  insomnia  is  a  conspicuous  phenomenon 
in  delirium  tremens  and  alcoholic  mania.  The  onset  of  the  acute  infectious 
diseases  is  often  marked  by  wakefulness.  The  early  stages  of  enteric  fever, 
influenza,  croupous  pneumonia,  afford  striking  instances  of  the  insomnia 
caused  by  the  toxic  agents  of  the  acute  febrile  infections.  Sleeplessness  is 
one  of  the  rare  nervous  symptoms  of  secondary  syphilis,  and  is  sometimes  the 
precursor  of  syphilis  of  the  brain.  Insomnia  occurs  in  certain  cases  of  acute 
malaria  and  in  the  malarial  cachexia,  and  is  sometimes  a  stubborn  and 
troublesome  symptom  of  trichinosis. 

The  sleeplessness  of  the  period  of  convalescence  from  acute  disease  must 
be  attributed  not  to  toxsemia,  but  rather  to  the  general  asthenia  of  the  stage 
of  recovery. 

Women  are  less  prone  to  insomnia  than  men,  children  less  than  adults, 
and  open-air  workers  than  those  engaged  in  sedentary  occupations. 

Symptomatology.  Insomnia  shows  wide  variations  in  kind  and  complete- 
ness. It  may  take  the  form  of  troubled  and  unrefreshing  sleep  of  only  a 
few  hours'  duration,  or  of  fitful  and  broken  slumber  Avith  intervals  of 
painful  wakefulness,  or  sleep  may  be  absent  for  days  together.  A  very 
common  form  of  simple  insomnia  is  that  in  which  the  patient  on  going  to 
bed  falls  asleep,  but  awakes  in  the  course  of  two  or  three  hours,  and  tosses 
until  morning.  In  the  insomnia  of  neurasthenia  there  is  often  great  but 
irregular  mental  activity,  in  which  the  cares,  anxieties,  and  worries  of  daily 
life  are  rehearsed  with  torturing  iteration.  With  this  there  is  also  great 
restlessness,  a  peculiarity  also  present  in  the  sleeplessness  of  insanity.  Queru- 
lousness  and  irritability  are  associated  moods.  Insomnia  is  comparatively 
uncommon  in  children  ;  when  present  it  is  attended  with  great  restlessness 
and  mental  excitement,  and  is  of  greater  significance  than  that  of  adults. 
The  insomnia  of  old  persons  is  usually  tranquil  and  unaccompanied  by  ex- 
citement or  irritability. 

The  differential  diagnosis  between  simple  insomnia  and  symptomatic  in- 
somnia must  be  made  by  exclusion. 

Treatment.  The  treatment  is  symptomatic  and  causal.  Both  forms  of 
insomnia,  the  simple  and  the  symptomatic,  may  require  symptomatic  treat- 


952  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

ment  for  their  successful  management ;  but  many  cases  of  the  latter  recover 
under  treatment  properly  directed  to  the  relief  of  the  morbid  condition  of 
which  the  sleeplessness  is  a  symptom.  The  subject  naturally  arranges  itself 
under  three  general  headings  :  The  general  management  of  cases  of  insomnia, 
medication  by  means  of  hypnotic  drugs,  and  the  treatment  of  the  underly- 
ing disease. 

The  General  Management  of  Insomnia.  Simple  insomnia  is  in  many 
cases  the  outcome  of  an  overtaxed  nervous  system,  too  much  work  or  too 
much  worry  ;  or  it  is  the  result  of  an  irregular  and  self-indulgent  life,  a  mere 
vicious  habit.  Under  such  conditions  the  indications  for  treatment  are 
obvious,  but  not  often  readily  carried  out.  It  follows,  however,  that  dimin- 
ished work,  especially  in  the  field  of  intellectual  endeavor,  lowered  ambi- 
tions, the  renunciation  of  efforts  after  the  practically  unattainable,  a  systema- 
tized and  regulated  life,  not  only  enable  many  individuals  to  recover  the 
sleep  habit  which  they  have  lost,  but  also  secure  to  them  a  measure  of  happi- 
ness unknown  in  the  too  earnest  struggle  for  objects  beyond  their  powers  or 
circumstances.  Simple  hygienic  measures  that  invite  calm  and  refreshing 
sleep  are  early  rising,  light  meals  of  wholesome  food,  moderate  exercise  in 
the  open  air,  systematic  bathing  and  great  regularity  in  everything.  Men- 
tal work  should  be  restricted  to  the  early  day  and  limited  to  four  or  six 
hours.  The  afternoon  should  be  spent  in  out-door  exercise ;  the  evening 
occupied  with  conversation  or  amusements  that  do  not  greatly  tax  the  atten- 
tion. Much  time  should  be  devoted  to  the  preparation  for  bed.  Let  the 
patient  potter  about  till  he  is  sleepy  with  prolonged  attention  to  the  mindless 
details  of  the  toilet ;  then,  in  a  cool  room,  with  warm  feet,  a  hard  bed,  and 
light  covering,  his  chances  of  sleep  are  at  their  best.  Above  all,  as  the 
head  touches  the  pillow  let  thought  and  the  problems  of  the  day  be  banished 
and  the  attention  given  to  the  monotonous,  inarticulate  sounds  of  the  outer 
world.  Hot  foot-baths,  warm  baths  with  cold  afflision  to  the  spine,  muscle 
beating  and  massage  are  measures  as  likely  to  arouse  and  excite  the  nervous 
system  as  to  tranquillize  it,  and,  while  sometimes  useful,  are  more  frequently 
of  doubtfiil  advantage.  A  glass  of  warmed  milk,  a  cup  of  hot  bouillon,  a 
toddy  or  a  glass  of  beer  often  aids  in  the  invitation  to  sleep.  Sometimes  the 
monotonous  reading  of  a  familiar  book  may  be  useful,  but  it  is  better  for  the 
patient  to  be  wholly  left  to  himself.  Many  persons  who  suffer  from  insomnia 
greatly  exaggerate,  without  meaning  to  do  so,  the  loss  of  sleep. 
Tea  or  coffee  taken  late  in  the  day  are  hostile  to  sleep. 
Hypnotic  Drugs.  Drugs  that  induce  sleep  are  to  be  used  with  caution. 
The  moral  effect  of  their  habitual  employment  is  bad  and  tends  to  invalid- 
ism. Their  unguarded  administration  exposes  the  patient  to  the  danger  of 
the  formation  of  the  drug-habit,  a  danger  increased  on  the  one  hand  by  the 
neurotic  temperament  and  on  the  other  by  familiarity  with  narcotics  and 
their  dosage.  They  are,  however,  in  many  cases  indispensable.  One  or 
another  may  be  employed  in  adequate  amounts  for  a  few  nights,  and  then 
abruptly  or  gradually  abandoned.  Occasionally  good  results  are  obtained 
by  a  full  dose  every  second  or  third  night ;  or,  again,  a  very  moderate  dose 
may  be  given  for  a  long  time  with  satisfactory  effects.  The  details  of  the 
proper  employment  of  narcotics  to  induce  sleep  require  great  tact  on  the 
part  of  the  physician.  Insofar  as  possible  the  precise  drug  and  the  dose  used 
should  remain  unknown  to  the  patient,  and  from  time  to  time  different  hyp- 
notics employed.  Physicians,  nurses,  and  apothecaries  who  suffer  from  in- 
somnia are  especially  liable  to  the  formation  of  habits  of  vicious  dependence 
upon  narcotics.  Opium  and  its  derivatives  and  chloral  are  in  this  respect 
most  seductive  and  dangerous.  Chloral  is,  in  the  opinion  of  the  writer,  the 
surest  of  our  modern  hypnotics  and  by  far  the  most  satisfactory  in  its  effects. 


SYMPTOMATIC  DISORDERS.  958 

The  immediate  danger  of  cardiac  depression  is  not  to  be  overlooked.  It 
can  be  guarded  against,  and  its  effect  reinforced  by  the  simultaneous  ad- 
ministration of  some  alcoholic  beverage.  In  exceptional  cases  chloral  is  fol- 
lowed by  great  excitement  and  wakefulness  or  by  symptoms  of  acute  gastric 
catarrh.  Chloralamid  is  less  active,  less  sure  in  its  effects,  but  altogether 
safe  in  proper  doses.  I  have  used  it  of  recent  years  more  than  any  other 
drug  as  a  hypnotic.  Sulphonal,  which  should  be  dissolved  in  hot  water, 
milk,  or  bouillon,  which  is  swallowed  as  soon  as  cool  enough,  is  uncertain  in 
its  effects  and  often  followed  by  headache  and  prolonged  dulness  after  wak- 
ing. Paraldehyde  is  safe  and  sometimes  a  very  effective  drug,  but  its  disa- 
greeable taste  and  still  more  disagreeable,  persistent  odor  stand  in  the  way 
of  its  general  employment.  Hyoscine  hydrobromate  is  to  be  chosen  in  those 
cases,  and  especiallv  in  the  insomnia  of  the  insanities,  in  which  great  motor 
excitement  is  present.  The  virtues  of  urethane,  amylene  hydrate,  somnal, 
trional,  and  tetronal  as  sleep-compelling  drugs  are  now  established. 

Of  inferior  value,  but  still  most  useful  in  proper  cases,  are  antipyrin  in 
large  doses,  the  bromides  and  valerian. 

Opium,  morphine,  and  codeine  alone  or  in  combination  with  chloral,  hyo- 
scine, or  the  bromides  are  to  be  reserved  for  cases  otherwise  unmanageable, 
the  insomnia  of  painful  diseases,  the  incurable  and  the  aged. 

But  the  inefficacy  of  poppies,  mandragora,  and  all  the  drowsy  syrups  of 
the  East  in  certain  cases  has  long  been  known.  In  some  of  these,  life  iu  the 
wilderness,  and  what  Mitchell  has  called  the  mindless  labor  of  the  camp,  the 
rod,  the  gun,  the  axe,  have  wooed  back  sleep. 

The  Treatment  of  the  Underlying  Disease.  The  obvious  indication  for 
treatment  in  symptomatic  insomnia  is  to  be  found  in  the  existing  patho- 
logical condition.  To  discuss  the  details  of  such  treatment  does  not  fall 
within  the  scope  of  the  present  article.  Suffice  it  to  say  that  the  phy- 
sician should  be  on  the  alert  to  discover  latent  or  obscure  maladies,  the 
phenomena  of  which  are  often  overshadowed  by  sleeplessness  and  its  attend- 
ant exhaustion  and  nervous  irritability.  Among  these  are  gastric,  cardiac, 
and  uterine  neurasthenia,  inflammatory  and  degenerative  diseases  of  the 
kidneys,  diathetic  states,  especially  lithremia,  the  alcoholism  of  secret  tip- 
pling, the  opium  and  cocaine  habits  and  syphilis. 


DISORDERS  OP   SLEEP. 

Normal  sleep  is  usually  comparatively  light  at  first,  reaching  its  deepest 
stage  in  the  course  of  an  hour  or  more  after  it  begins,  and  becoming  lighter 
■again  before  spontaneous  waking.  To  this  general  rule  there  are,  hoAvever, 
many  exceptions,  some  persons  habitually,  and  especially  after  fatigue,  fall- 
ing at  once  into  deep  and  prolonged  sleep,  or  waking  abruptly  from  sleep, 
which  appears  to  have  been  continuous  and  profound.  The  period  of  light 
initial  slumber  has  been  termed  the  prcedormitium.  At  this  time  many  per- 
sons of  nervous  constitution,  and  in  pai'ticular  brain-workers,  experience 
momentary  muscular  startings  or  shocks,  like  the  discharge  of  a  Ley  den  jar, 
which  affect  the  whole  body,  and  are  accompanied  by  disagreeable  sensations 
in  the  head.  These  attacks  are  sometimes  violent,  and  two  or  three  of  them 
may  occur  before  sleep  is  fully  established. 

Dreams.  It  is  probable  that  dreaming  does  not  occur  in  complete  sleep. 
It  is  certain  that  dreams  are  common  and  vivid  in  proportion  as  sleep  is  light, 
irregular,  and  fitful  and  in  the  lighter  sleep  which  ordinarily  precedes  waking. 
The  assumption  from  these  facts  is  warrantable  that  dreams  occur  when  the 
suspension  of  consciousness  is  incomplete.     The  starting  point  of  dreams  is 


954  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

usually  some  sensory  impression,  often  disagreeable,  arising  from  local  causes, 
as  an  uncomfortable  posture,  light  or  sound  which  is  perceived,  but  does 
not  arouse,  an  overloaded  stomach,  a  distended  bladder  or  rectum,  a  lesion 
Avhich  is  painful,  or  a  condition  which  interferes  to  some  extent  with  the  func- 
tional play  of  some  organ,  as  the  heart  or  lungs.  Such  impressions,  not  fully 
recognized  and  correlated  in  the  sub-consciousness  of  sleep,  set  in  motion  trains 
of  ideas  which  are  irregular  and  bizarre,  and  which  not  infrequently  centre 
about  some  controlling  thought  or  memory  of  waking  hours.  These  facts  serve 
to  render  intelligible  the  occasional  startling  appropriateness  and  apparent 
significance  of  dreams  and  justify  the  importance  ascribed  to  them  by  ignor- 
ant persons  and  uncivilized  tribes.  They  account  to  some  extent  for  the 
definiteness  of  dreams  in  certain  morbid  conditions,  as  in  acute  indigestion, 
the  dreams  of  which  are  usually  of  a  frightful  character,  and  of  valvular 
disease  of  the  heart,  in  which,  when  there  is  rupture  of  compensation,  the 
patient  often  dreams  of  dying.  They  account  also  for  the  recurrent 
dreams  of  fixed  character  which  sometimes  occur  before  the  definite  signs  of 
organic  disease  show  themselves,  and  which  have  been  called  prodromic 
dreams. 

Nightmare.  A  frightful  di-eam,  attended  Avith  sensations  of  great  phys- 
ical and  mental  distress,  which  take  the  form  of  an  oppressive  weight  upon 
the  chest,  intense  fear,  horror  or  anxiety,  and  inability  to  move  or  cry  out. 
The  attack  ends  in  a  groan  and  the  recovery  of  consciousness.  The  synonym 
Incubus  was  originally  the  male  demon  supposed  to  attack  women  in  their 
sleep,  lying  on  them,  and  causing  nightmare.  The  corresponding  female 
demon  that  attacked  men  was  called  Succuba.  Ephialtes,  literally  one  who 
leaps  upon,  also  expresses  the  idea  of  oppression.  The  attack  occurs  in  in- 
complete sleep.  Nervous  persons,  especially  after  unusual  fatigue  or  excite- 
ment, those  suffering  from  chronic  wasting  affections,  malaria,  cardiac  dis- 
eases, and  anaemia,  or  chlorosis  are  particularly  liable  to  nightmare.  It 
occurs  more  frequently  in  females  than  in  males  and  in  the  young,  though 
exceptionally  persons  are  encountered  who  suffer  from  attacks  of  nightmare 
throughout  life.  The  exciting  cause  may  be  gastric  repletion,  any  indigesti- 
ble article  of  food,  excesses  in  alcohol  or  tobacco,  or  the  menstrual  molimen. 
Sleeping  upon  the  back  or  in  any  constrained  or  uncomfortable  posture  in- 
creases the  liability  to  the  attack. 

Night  Terrors.  Pavor  nocturnus  occurs  in  young  children  as  a  parox- 
ysmal disturbance  of  sleep.  It  presents  points  of  resemblance  to  nightmare 
and  to  somnambulism ;  but  differs  from  the  former  in  the  gradual  rather 
than  abrupt  subsidence  of  the  attack  and  the  persistence  of  terror  and  dis- 
tress after  waking.  It  differs  from  the  latter  in  the  fact  of  the  gradual  wak- 
ing, the  less  complete  automatism  and  the  element  of  terror.  The  attack 
usually  comes  on  early  in  the  night.  The  child  starts  up  in  bed,  screaming 
with  fear.  It  runs  to  its  parents  and  seeks  protection,  trembling  and  sob- 
bing. Usually  the  dream-images  are  indefinite  ;  sometimes  they  are  ani- 
mals, hobgoblins  or  monsters,  or,  again,  persons  seeking  to  cany  it  off,  the 
form  being  largely  determined  by  the  stories  and  conversation  of  the  nur- 
sery. Although  the  child  rises  from  its  bed,  it  is  for  a  time  evident  that 
consciousness  is  in  abeyance.  The  awakening  is  gradual ;  the  terrors  of  the 
night  pass,  and  the  little  one  soon  sobs  himself  to  sleep  again.  Night  ter- 
rors occur  usually  in  delicate  or  badly-nourished  children.  They  may  be 
brought  about  by  eye-strain,  intestinal  parasites,  dentition,  an  attack  of  indi- 
gestion, or  may  follow  fatigue,  vivid  impressions  or  intense  emotion  during 
the  day.  They  are  not,  as  a  rule,  of  much  importance  ;  nor  do  they  neces- 
sarily indicate  any  serious  or  permanent  morbid  condition  of  the  nervous 
system.     As  the  child  grows  older  the  liability  to  the  disorder  diminishes, 


SYMPTOMATIC  DISOBDEBS.  955 

though  in  exceptional  cases  occasional  paroxysms  occur  later  in  life.  In  rare 
instances  the  attacks  present  characters  suggestive  of  nocturnal  epilepsy. 

Sleep-drunkenness  (Schlaftrunkenheit.)  This  term  has  been  ap- 
plied to  a  rare  condition  resembling  maniacal  delirium,  which  occurs  on 
waking  from  profound  sleep.  The  sufferer  does  not  recognize  his  surround- 
ings nor  his  friends ;  he  is  excited,  boisterous  and  incoherent,  and  labors 
under  delusions  of  immediate  danger  to  his  life  or  liberty,  in  consequence  of 
which  acts  of  violence  may  be  done. 

^Somnambulism  (Sleep-walking.)  A  disorder  of  sleep  in  which  con- 
sciousness and  volition  are  suspended  while  the  activity  of  certain  nerve- 
centres  is  exalted  and  complex  co-ordinated  movements  are  automatically 
performed.     Somnambulism  is,  in  fact,  an  acted  dream. 

It  occurs  chiefly  in  adolescents  and  young  adults,  usually  the  offspring  of 
neurotic  parents.  The  condition  itself,  in  some  instances,  affects  successive 
generations  in  the  same  family.  It  is  more  common  in  females  than  in  males. 
The  victims  are  often  sensitive  and  impressionable  persons.  The  exciting 
causes  are  those  which  ordinarily  give  rise  to  dreams  and  other  disorders  of 
sleep  ;  they  include  indigestion  from  excesses  at  table  or  unwholesome  arti- 
cles of  food,  uncomfortable  posture,  especially  sleeping  with  the  head  too 
low,  and  intense  excitement  or  violent  distressing  emotions  during  the  period 
preceding  sleep.  The  attacks  are  apt  to  be  repeated,  and  when  habitual, 
often  occur  without  discoverable  cause,  frequently  observing  a  regular 
periodicity  of  some  days  or  weeks. 

The  difference  between  sleep-talking  and  sleep-walking  is  simply  a  ques- 
tion of  the  automatic  activity  of  different  centres  during  the  unconsciousness 
of  sleep.  The  former  is  of  common  occurrence  and  attracts  little  attention  ; 
the  latter  is  fortunately  somewhat  rare  and  acquires  importance  from  the 
completeness  of  the  automatism.  The  attack  is  usually  brief,  but  may  con- 
tinue for  an  hour  or  more,  during  which  period  difficult  and  complicated  ac- 
tions are  performed  with  much  of  the  appearance  of  conscious  intention.  Yet 
the  eyes  are  closed,  or  if  open,  they  are  staring  and  fixed,  the  expression  is 
blank  and  impassive  and  the  ears  apparently  deaf  to  every  sound.  The 
somnambulist  may  traverse  difficult  passages  or  walk  upon  roofs.  From  these 
excursions,  if  undisturbed,  he  returns  to  his  bed  and  falls  into  quiet  sleep. 
He  is  aroused  with  difficulty,  and  may  when  disturbed,  become  violent.  On 
waking  he  has  no  recollection  of  his  wanderings.  Much  confusion  may 
arise  in  consequence  of  actions  performed  during  somnambulism.  The  sub- 
ject has  been  utilized  by  novelists  and  playwrights.  It  may  acquire  medico- 
legal importance,  and  not  infrequently  serious  and  even  fatal  injuries  are 
sustained  by  persons  falling  from  windows  during  the  somnambulistic  state. 

Morbid  Sleep.  Drowsiness  during  the  ordinary  waking  hours  may  oc- 
cur as  the  result  of  habitual  insufficient  sleep,  or  it  may  be  a  mere  indolent 
habit.  Usually,  however,  it  is  symptomatic  of  cerebral  malnutrition  or  some 
form  of  toxsemia.  Hence,  it  is  common  in  old  persons  with  feeble  hearts  or 
diseased  bloodvessels  and  in  malarial,  anaemic,  cholsemic  and  diabetic  toxica- 
tion.  The  drowsiness  after  a  full  meal,  that  produced  by  exposure  to  intense 
cold,  that  which  follows  excesses  in  alcohol,  are  familiar  conditions.  The 
impure  air  of  crowded  assemblies  causes  drowsiness,  and  its  effects  are  aug- 
mented by  quiet  and  lack  of  interest  in  the  proceedings.  Obese  persons  are 
apt  to  be  drowsy.  Morbid  sleep,  due  to  reflex  irritation,  is  very  rare.  Cases 
have,  however,  been  reported  in  which  prolonged  deep  sleep  has  ceased  upon 
the  discharge  from  the  bowel  of  masses  of  lumbricoid  worms. 

Narcolepsy.  This  term  has  been  applied  to  abnormal  sleep  of  unknown 
cause.  The  attacks  are  often  of  short  duration  with  intervals  of  complete 
wakefulness  or  they  may  be  prolonged  and  continuous.     In  some  instances 


25Q  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

they  occur  many  times  a  day,  or  daily  ;  or,  again,  at  longer  intervals.  Some- 
times the  spells  of  sleep  are  profound,  lasting  for  days  continuously.  Such 
cases  may  present  equally  prolonged  and  remarkable  periods  of  continuous 
wakefulness.  Instances  of  sleep,  apparently  idiopathic,  progressively  deej)- 
ening,  and  finally  terminating  in  death,  have  been  noted. 

Morbid  sleep  occurs  in  organic  brain  disease,  as  syphilis,  tumor,  or  arterio- 
sclerosis. It  is  a  symptom  in  insanity,  occurring  both  in  the  prodromic 
period  and  in  the  developed  state.  More  commonly  the  condition  in  organic 
brain  disease  and  insanity  is  one  of  hebetude  or  of  partial  coma,  which  pre- 
sents merely  a  superficial  resemblance  to  sleep. 

The  Sleeping  Sickness  of  Africa  ("  Nelavax  ;  "  Maladie  du  Som- 
MEiL ;  Sleeping  Dropsy).  A  peculiar  disorder,  probably  infectious,  en- 
demic among  the  negroes  of  the  west  coast  of  Africa,  and  occurring  occa- 
sionally in  the  West  Indies.  The  symptoms  consist  of  malaise,  headache, 
drowsiness,  at  first  after  meals ;  later,  continuous  and  progressively  deepen- 
ing congestion  and  prominence  of  the  eyes,  disturbances  of  gait  and  cervical 
adenopathy.  The  disease  is  very  fatal,  death  taking  place  during  coma  or 
in  epileptiform  convulsions.  Xo  characteristic  lesions  are  found  upon 
examination  post-mortem. 

Night  Palsy  (Sleep  Palsy.)  A  parsesthesia  affecting  one  or  more 
extremities  upon  waking.  The  sensation  is  usually  that  of  numbness,  which 
may  be  accompanied  with  tingling.  Its  distribution  usually  involves  one 
arm  or  leg,  or  it  may  afiect  the  whole  body.  In  a  little  while  it  passes  away. 
It  resembles  the  acroparsesthesia  which  occurs  at  or  after  the  climacteric  in 
nervous  and  hysterical  women,  and  is  probably  an  allied  condition.  It  is  not 
very  important. 

Paroxysmal  disturbances  of  the  nervous  system,  both  physiological  and 
pathological,  frequently  occur  during  sleep.  Thus  seminal  emissions,  the 
venereal  orgasm,  urinary  incontinence,  are  accidents  of  sleep  ;  while  epi- 
leptic seizures  are  not  uncommon,  and  sufferers  from  asthma  and  migraine 
very  often  awake  in  an  attack. 

The  treatment  of  the  disorders  of  sleep  must  be  directed  to  the  removal  of 
their  cause.  Attention  to  matters  of  hygiene  is  of  first  importance.  Open- 
au-  exercise,  a  readily  digestible  and  nutritious  diet,  light  suppers,  systematic 
bathing,  a  regulated  life,  free  from  exhausting  mental  work  and  undue  ex- 
citement are  in  many  cases  all  that  are  required  to  end  the  annoyance?  of 
evil  dreaming,  nightmare,  pavor  nocturns,  and  somnambulism.  Normal  and 
undisturbed  sleep  is  favored  by  a  cool,  well-ventilated  chamber,  a  hard  bed, 
light  covering,  and  moderately  high  pillows.  In  older  persons  change  in 
surroundings  and  the  fatigue  of  hunting  or  fishing  exert  a  very  favorable 
influence.  Drugs  are  disappointing,  but  good  effects  often  result  from  the 
combined  use  of  cardiac  tonics  and  laxatives,  or,  in  proper  cases,  from  the 
administration  of  alkalies  and  the  salicylates.  Some  of  the  accidents  of  sleep 
may  be  prevented  by  a  device  such  as  a  spool  fixed  to  a  belt  at  the  spine  in 
such  a  way  that  sleeping  upon  the  back  is  rendered  impossible. 


CHAPTER    XXXIII. 
SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES. 

By  W.  W.  keen,  M.D. 

The  surgery  of  the  nervous  system  is  peculiar  in  several  points : 

First,  in  respect  to  the  localization  of  different  functions  in  various  parts 
of  the  brain  and  cord — a  modern  discovery  of  the  greatest  importance. 

Second,  in  respect  to  the  distant  influences  of  operative  procedures,  in  that 
not  only  the  part  operated  upon  undergoes  healing,  inflammation,  and  other 
surgical  processes,  but  that  the  operative  procedures  may  be  followed  by 
results  in  far  distant  organs.  Thus,  if  a  certain  portion  of  the  brain  is  excised, 
Ave  will  have  paralysis  in  face,  arm,  or  leg ;  if  a  nerve  or  the  cord  is  operated 
upon,  sensation  in  the  skin  is  altered  or  destroyed,  and  motion  in  the  muscles 
supplied  by  that  portion  of  the  cord  or  by  the  nerve  operated  upon  may  also 
be  altered  or  destroyed.  This  is  in  sharp  contrast  to  the  surgical  results  in 
other  organs,  in  which,  as  a  rule,  the  consequences  are  limited  to  the  organ 
operated  upon. 

Third.  It  is  peculiar  by  reason  of  the  fact  that,  while  the  nerves  are 
easily  and  safely  accessible  in  their  places  amidst  the  soft  parts,  the  brain 
and  cord  are  contained  within  a  bony  case,  the  skull,  or  a  bony  canal,  the 
spinal  column,  making  access  to  the  contained  organs  difficult  and  not  sel- 
dom dangerous. 

Fourth.  It  is  peculiar  in  reference  to  many  points  of  special  surgical 
technique. 

I  propose,  therefore,  to  treat  in  this  chapter  (1)  of  the  general  surgical 
technique  of  operations  on  the  brain,  and  then  of  such  special  surgical  affec- 
tions as  require  particular  treatment ;  (2)  the  general  technique  of  opera- 
tions on  the  spine,  to  be  followed  by  a  brief  description  of  the  special  tech- 
nique of  particular  diseases  or  injuries. 

I  shall  include,  also,  in  connection  with  the  brain,  not  only  the  neurological 
affections  already  described  in  the  preceding  portions  of  this  work,  but  als<:) 
briefly  consider  the  strictly  surgical  affections,  such  as  fractures  of  the  skull, 
which  are  imj)ortant,  not  so  much  by  reason  of  the  bones  which  are  broken 
as  by  reason  of  the  possible  injury  to  the  contents  of  the  skull,  and,  in  con- 
nection with  the  spine,  the  more  strictly  surgical  injuries,  such  as  fractures 
and  dislocations  of  the  spine. 

(3)  Finally  I  shall  take  up  the  surgery  of  the  peripheral  nerves. 

SURGERY  OP  THE   BRAIN. 
General  Technique  of  Surgical  Operations. 

In  spite  of  the  rapid  progress  and  brilliant  achievements  of  modern  anti- 
septic surgery,  cerebral  surgery  made  little  advance  until  18<S().  At  that 
time  Horsley,  of  London,  and  jNIacewen,  of  Glasgow,   introduced  radical 


958  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

changes,  which  have  been  but  little  altered,  even  by  a  large  experience. 
These  are  in  brief  as  follows : 

Disinfection.  With  very  few  exceptions,  the  entire  head  should  be 
shaved.  The  loss  of  a  portion  of  the  hair  is  so  marked  and  so  grotesque 
that  it  is  better,  even  from  an  aesthetic  point  of  view,  that  the  whole  head 
should  be  shaved,  and,  surgically,  it  is  essential,  in  order  to  cleanse  the  entire 
scalp,  so  that  we  may  avoid  infection.  Even  persons  who  are  most  careful 
of  the  scalp  cannot  thoroughly  cleanse  it,  on  account  of  the  presence  of  the 
hair.  After  the  head  has  been  shaved  the  patient  should,  of  course,  wear  a 
cap  or  silk  handkerchief,  in  order  to  avoid  taking  cold. 

The  fissures  of  the  brain,  especially  the  median  fissure,  fissure  of  Rolando, 
and  in  some  cases  the  fissure  of  Sylvius,  of  Bichat,  and  others,  should  be 
marked  on  the  shaven  scalp  with  an  aniline  pencil.  The  median  fissure  lies 
about  one-eighth  of  an  inch  to  the  right  of  the  median  line,  since  the  left 
cerebral  lobe  is  slightly  larger  than  the  right.  The  fissure  of  Rolando  can 
best  be  marked  by  Horsley's  first  cyrtometer,  as  modified  by  Morris  J. 
Lewis.  This  consists  of  an  antero-posterior  arm  14  inches  long,  and  a  lateral 
arm  about  6  inches  long  (Fig,  308),     The  lateral  arm  is  fixed  at  an  angle 

Fig.  308. 


Horsley's  cyrtometer. 

of  67°,  and  starts  from  the  antero-posterior  arm  at  a  point  half  an  inch  back 
of  its  middle.  The  zero  point  of  the  scale  of  the  antero-posterior  arm  is  at 
the  middle,  and  the  scale  is  graduated  in  inches  forward  and  backward, 
The  lateral  arm  marks  the  fissure  of  Rolando,  which  is  about  3i  inches  long. 
In  using  the  instrument  the  antero-posterior  arm  is  placed  one-eighth  of  an 
inch  to  the  right  of  the  median  line,  and  in  such  a  position  that  the  inion  and 
glabella  will  each  correspond  to  the  same  figures  on  the  scale.  The  zero  point 
then  marks  the  mid-point  between  the  inion  and  the  glabella,  and  the  lateral 
arm  starts  half  an  inch  back  of  this  mid-point.  This  cyrtometer  can  be  made 
out  of  an  ordinary  piece  of  stout  paper  or  cardboard,  if  a  metal  one  is  not  at 
hand.  Buchanan,  of  Pittsburg,  has  constructed  another  form  of  cyrtometer, 
consisting  of  an  aluminum  ti-iangle  curved  to  fit  the  head,  the  angle  being- 
67°  (Fig.  309). 

Another  simpler  method  which  can  be  used  in  an  emergency  has  been 
devised  by  Chiene,  of  Edinburgh.  Fold  a  square  piece  of  paper  diagonally 
twice,  starting  from  the  same  corner.  This  divides  the  apex  into  four  angles 
of  22-2°  each  (Fig.  310).  Three  of  these  angles  give  us  672°,  which  is  within 
half  a  degree  of  the  direction  of  the  fissure  of  Rolando.  In  order  to  fix  the 
other  fissures  of  the  brain,  the  reader  is  referred  to  Gray's  Anatomy,  edition 
of  1887,  p.  681,  edited  by  the  writer. 


SUBQEBY  OF  THE  BBAIN,  SPINAL  COBB,  AND  NEBVES.      959 


The  day  before  the  operation  the  head  should  be  shaved  anew  if  necessary, 
Avell  scrubbed  with  soap  and  water,  then  with  ether,  then  with  a  sublimate 
solution,  not  stronger  than  1-2000,  lest  the  scalp  should  be  vesicated.  A  sub- 
limate dressing,  the  three  or  four  inner  layers  of  which  are  wet  with  the  solu- 
tion, should  then  be  applied  and  left  in  place  until  the  operation,  when  the 


Fir;.  309. 


Fig.  310. 


A 

\s 

-^<^^w'" 

J) 

/c 

-B 

Buchanan's  cyrtometer. 


Chiene's  method  of  fixing  the  fissure  of  Rolando. 


disinfection  should  be  repeated.  Of  course,  the  ordinary  precautions  as  to 
the  thorough  cleansing  of  the  finger-nails,  hands,  and  arms  of  the  operator 
and  his  assistants,  and  of  the  instruments,  dressings,  etc.,  should  be  scrupu- 
lously carried  out. 


Fig 


Luer's  double  rongeur  forceps. 


Position.  While  I  have  often  operated  Avith  the  patient  in  the  recum- 
bent position,  the  best  position  is  the  semi-recumbent,  in  order  to  diminish 
hemorrhage.  Practically  this  can  be  best  affected  by  placing  the  patient  on 
a  lounge,  with  a  sheet  passed  between  the  thighs  and  fastened  around  the 
head  of  the  lounge  to  prevent  his  slipping  down. 


Fig.  312. 


Keen's  rongeur  forceps. 

Marking  the  Bone.     Three  points  should  be  marked  on  the  bone :  the 
two  ends  of  the  fissure  of  Rolando  and  the  point  at  which  the  centre-pin  is 


960 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


to  be  placed,  in  case  the  trephine  is  used.  The  reason  for  marking  the  bone 
is  that  when  the  scalp  has  been  raised,  the  position  of  the  fissure  of  Rolando 
and  the  exact  point  for  the  application  of  the  trephine  are  not  easily  re- 
determined. This  marking  of  the  bone  can  be  done  by  a  small  gouge  or  by 
the  centre-pin  of  another  trephine,  the  rongeur  forceps  serving  as  a  hammer. 

Fig.  313. 


Hopkins's  rongeur  forceps,  modified  by  Weir. 


Access  to  the  Brain.  Usually  the  ordinary  operation  of  trephining 
suffices.  In  many  cases  in  which  we  simply  desire  to  get  access  to  the  skull 
cavity,  as  in  linear  craniotomy,  fractures,  etc.,  a  half-inch  or  an  inch  trephine 


Fig.  314. 


FiCx.  315. 


Hartley's  chisels. 


Pyle's  chisels. 


is  large  enough.  When,  however,  we  desire  to  expose  any  considerable  porti(^n 
of  the  brain,  we  should  use  either  a  1 2  -inch  trephine,  or  multiple  small  tre- 
phine openings  may  be  made,  the  intervening  bridges  of  bone  being  chiselled 
or  sawn  away  or  removed  by  various  rongeur  forceps  (Figs.  311,  312,  313). 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      961 

A  different  method,  however,  has  recently  gained  considerable  favor,  from 
the  large  area  of  brain  which  it  exposes,  both  for  determining  the  fissures 
and  convolutions  and  for  operative  procedures,  and  also  for  the  re-establish- 
ment of  the  integrity  of  the  skull.  Wagner  (  CentraJbl.  f.  Chir.,  1889,  No.  47) 
introduced  the  method  known  as  temporary  osteoplastic  resection.  In  this 
method  a  horseshoe  shaped  incision  is  made  through  the  soft  parts,  directly 
down  to  the  bone,  the  scalp  not  being  separated  from  the  skull.  The  ex- 
ternal table  of  the  skull  is  then  chiselled  through  with  the  chisels  employed 
by  wood  and  ivory  carvers,  which  can  be  had  at  any  good  hardware  store, 
or,  better,  by  Hartley's'  or  Pyle's'  chisels  (Figs.  314  and  315).  The  diploe 
having  been  reached,  care  should  be  taken,  in  going  through  the  vitreous 
table,  not  to  wound  the  dura.  For  this  reason  it  should  be  divided  with 
an  osteotome,  and  not  with  the  chisel.  Instead  of  the  chisel,  we  can  use 
a  rapidly  rotating  cylindrical  drill,  driven  by  the  improved  dental  engine 

Fig.  316. 


Fig.  317. 


Cryer's  drill. 


or  an  electric  motor,  or  a  suitably  guarded  circular  saw.  One  or  more 
elevators  then  being  inserted  under  the  edges  of  the  bony  flap,  the  portion 
of  bone  between  the  two  ends  of  the  incision  is  fractured,  and  the  united 
flap  of  bone  and  scalp  is  turned  downward,  the  scalp  serving  as  a  hinge 


Fig.  318. 


Osteoplastic  resection  of  skull.    Wagner-WolfPs  method     (Esmarch  and  Kowalsky.) 

(Fig.  318).  This  method  of  operation,  however,  will  be  very  difiicult  in 
very  thick  skulls.  When  the  operation  is  completed  the  bone  is  replaced 
by  simply  turning  it  back  on  its  hinge,  a  portion  of  it  being  gnawed 
away  by  the  rongeur  forceps,  if  drainage  is  to  be  employed,  and  the  flap 


1  Aunals  of  Surgery,  May,  1893. 


=  N.  Y,  Med.  Record,  Feb.  10, 1894. 


61 


962  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

held  in  place  by  ordinary  sutures  through  the  scaljD.  Care  should  be 
taken  not  to  cut  away  the  margins  of  the  vitreous  table  projecting  from 
the  under  surface  at  the  margin  of  the  o]3ening  in  the  skull,  so  that  when  the 
flap  of  bone  is  replaced  these  will  serve  as  supports.  Before  turning  the  flap 
back  into  position  the  edges  of  the  fracture  should  be  freed  from  any 
splinters. 

When  the  cranial  cavity  has  been  opened  the  dura  can  be  separated  from 
the  under  surface  of  the  bone  by  Horsley's  dural  sejDarator  (Fig.  319),  which 
will  enable  us  to  explore  the  inner  surface  of  the  skull  for  any  irregularities. 
The  little  finger  can  also  be  readily  introduced  between  the  dura  and  the 
bone,  and  later,  if  need  be,  between  the  dura  and  the  brain.  As  a  rule,  the 
dura  should  be  opened,  as  the  additional  danger  is  but  little  and  the  addi- 
tional information  may  be  very  great.  The  dura  should  be  lifted  by  rat- 
tooth  forceps  and  carefully  incised  by  a  knife,  the  rest  of  the  incision  being 
made  with  blunt-pointed  scissors  curved  in  the  flat.     The  dura  should  be 


Fig,  319. 


Horsley's  dural  separator. 

opened  parallel  to  the  opening  in  the  skull,  the  margin  being  about  a  quarter 
of  an  inch  from  the  margin  of  the  opening  on  the  bone,  so  as  to  allow  room 
for  subsequent  suturing  of  the  dura.  Great  care  should  be  taken  not  to 
wound  the  underlying  large  veins  of  the  brain.  If  we  are  dealing  with  a 
tumor  or  other  lesion  involving  increased  intra-cranial  pressure  it  is  often 
wiser  to  make  one  or  two  small  incisions  which  can  be  enlarged  or  united  if 
need  be. 

Hemorrhage  from  branches  of  the  middle  meningeal  can  be  arrested 
either  by  ligature  at  the  point  of  rupture,  or  not  uncommonly  better,  by 
passing  a  ligature  through  the  dura  and  under  the  vessel  by  means  of  the 
finest  semicircular  Hagedorn  needle.  Hemorrhage  from  the  large  vessels, 
especially  the  veins  of  the  brain  itself,  is  one  of  the  most  troublesome  diffi- 
culties in  cerebral  surgery.  Some  of  the  larger  vessels  can  easily  be  ligated, 
but  the  veins  are  extremely  fragile.  Often  they  are  best  ligated  by  passing 
a  small  semicircular  Hagedorn  needle  under  them  directly  through  the 
brain  substance.  The  ligature  should  then  be  tied  with  great  gentleness 
with  equal  traction  on  both  ends  of  the  ligature.  The  knot  vshould  not  be 
tied  too  tightly  lest  it  cut  through.  Hemorrhage  can  often  be  easily  arrested 
by  pressure,  either  by  gauze  or  sponges,  or  by  pressure  combined  with  hot 
water  (105°  to  115°  F.).  In  hemorrhage  from  the  sinuses  the  lips  of  the 
wound  can  sometimes  be  seized  by  hemostatic  forceps,  which  may  be  left  in 
place  for  thirty-six  to  forty-eight  hours,  being  of  course  entirely  enclosed 
in  the  dressing  in  order  to  prevent  infection.  Plugging  the  sinus  with  iodo- 
form gauze  is,  however,  usually  successful  in  controlling  the  bleeding.  As 
the  large  cerebral  veins  approach  the  superior  longitudinal  sinus  they  sud- 
denly broaden  into  large  bays,  called  the  j)ara-sinoidal  spaces.  These  should 
always  be  carefully  avoided  if  possible.  If  they  are  wounded  the  hemor- 
rhage can  usually  best  be  controlled  by  packing  with  iodoform  gauze  or  by 
ligature. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      963 

Condition  of  the  Brain.  The  first  point  to  be  observed  is  -whether 
the  brain  bulges,  and  the  amount  of  bulging,  which  is  an  indication  of  the 
degree  of  intra-cranial  pressure,  due  to  tumor,  abscess,  internal  hydrocepha- 
lus, etc.  If  we  have  reason  to  suspect  greatly  increased  intra-cranial  pressure, 
the  opening  in  the  dura  should  always  be  small  at  first,  lest  the  brain  should 
protrude  to  such  a  degree  as  to  make  its  replacement  difficult,  or  not  seldom 
even  impossible.  If  desirable  the  opening  can  be  enlarged  later  at  will.  The 
color  of  the  brain  may  either  be  normal,  or  livid,  yellow,  or  yellowish  brown, 
indicating  tumor,  abscess,  or  old  laceration.  CEdema  of  the  membranes  is 
not  uncommon,  and  is  sometimes  of  such  an  extent  as  to  obscure  or  even  pre- 
vent any  recognition  of  the  sulci  or  convolutions.  It  may  even  be  bloody. 
The  membranes  should  then  be  nicked  at  several  points,  when  the  serum  will 
escape,  and  the  surface  of  the  brain  may  then  be  recognized.  Absence  of  pul- 
sation of  the  brain  is  almost  always  observed  in  cases  of  large  tumors,  cysts, 
or  abscesses.     The  consistency  of  the  brain  should  be  determined  by  touch. 

Recognition  of  the  Motor  Centres  by  Faradization.  If  it  is 
desired  to  locate  the  motor  centres,  this  can  be  done  by  an  ordinary  faradic 
battery.  In  this  case  no  antiseptics  should  be  used  after  the  dura  has  been 
exposed,  as  they  diminish  the  reaction  of  the  cortex  to  electrical  stimulation. 
Recognition  of  the  motor  centres  is  also  possible  through  the  unopened 
dura.  The  electrical  current  used  in  either  case  is  generally  one  of  sufficient 
strength  to  make  the  thumb  muscles  contract.  The  ends  of  the  conducting 
cords  may  be  used,  or  a  double  brain  electrode  of  my  own  (see  Fig.  320). 

Fig.  320. 


Keen's  double  brain  electrode. 

The  metallic  points  before  being  applied  to  the  brain  should  be  sterilized  in 
carbolic  acid,  and  the  handle  wrapped  in  antiseptic  gauze.  Before  faradiza- 
tion the  face  and  the  four  extremities  should  be  uncovered,  and  one  observer 
be  requested  to  note  the  phenomena  in  each  of  these  regions.  The  points 
stimulated  by  the  battery  should  be  exactly  measured  from  the  middle  line, 
laterally,  and  antero-posteriorly  from  the  fissure  of  Rolando.  A  stenographer 
who  can  rapidly  record  the  observed  phenomena  as  they  are  dictated  is  of 
great  ser^dce. 

Removal  of  Portions  of  the  Brain.  If  it  is  desirable  to  remove 
any  motor  centre  or  any  abnormal  portion  of  the  brain,  this  should  be  done 
thoroughly ;  and  it  must  be  remembered  that  in  doing  this  we  can  remove 
the  brain  substance  much  more  freely  antero-posteriorly  than  vertically, 
since  in  the  latter  direction  we  more  quickly  encroach  upon  adjacent  centres. 
The  area  to  be  removed  is  to  be  determined  by  the  battery. 

Drainage.  Ordinarily  in  closing  the  wound,  drainage  may  be  dispensed 
with.  In  this  case  a  little  more  space  should  be  left  between  two  of  the 
sutures  anteriorlv  and  posteriorly,  for  the  escape  of  wound  fluids.  If  at  the 
end  of  twenty-four  hours  there  is  any  accumulation  of  such  fluid  under  the 
scalp,  a  pair  of  hemostatic  forceps  or  a  probe  may  be  insei'ted  between  these 
stitches  and  the  redundant  fluid  pressed  out.  In  operations  for  cysts  drainage 
is  often  required.  With  abscesses,  gunshot  wounds,  operations  for  hemor- 
rhage, etc.,  it  is  a  necessity.  Rubber  tubing  is  as  a  rule  the  best.  If  the 
bone  is  replaced  a  portion  should  be  bitten  away  at  the  edge  by  the  rongeur 
forceps  to  allow  of  the  egress  of  the  tube. 


964  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Closure  of  the  Dura.  When  the  operation  is  completed  the  dura 
should  be  sutured,  either  by  interrupted  or  continuous  catgut  sutures.  It  is 
important  to  direct  the  point  of  the  needle  toward  the  bone  in  order  to  allow 
plenty  of  room  for  manipulating  the  needle  holder  and  the  eye  end  of  the 
needle. 

Closure  of  the  Opening  in  the  Skull.  If  the  osteoplastic  method  of 
resecting  the  skull  has  been  used,  the  method  of  closing  the  opening  is  that 
already  described.  (See  page  961.)  If  a  trephine  button  has  been  removed, 
however,and  we  intend  to  replace  it,  great  care  must  be  bestowed  ujDon  it,  I 
usually  place  it  in  a  teacup  containing  a  1-2000  bichloride  solution.  The  tea- 
cup is  placed-  in  an  ordinary  basin  containing  hot  water,  the  temperature  of 
the  water  being  determined  by  a  thermometer.  It  should  be  from  100°  to 
105°  Fahr.  It  is  not  necessary  to  cut  the  bone  into  small  pieces,  as  Macewen 
first  advised.  I  have  often  replaced  a  button  an  inch  and  a  half  in  diameter, 
and  have  never  seen  it  produce  the  slightest  trouble.  If  the  bone  is  diseased 
it  should  not  be  replaced,  and  the  same  rule  should  be  followed  in  those  cases 
in  which  we  wish  to  alter  or  allow  for  increased  intra-cranial  pressure,  as,  for 
instance,  in  cases  of  headache  or  of  irremovable  tumors.  If  the  bone  is  not 
replaced  the  opening  becomes  closed  by  a  firm,  fibrous  membrane,  giving 
efficient  protection  to  the  brain  excepting  from  sharp,  penetrating  objects. 
The  opening  can  be  further  protected  by  a  piece  of  tin  sewed  inside  of  a 
skull-cap. 

In  some  cases  in  which  there  has  been  a  large  loss  of  bony  substance,  it  is 
desirable  to  close  such  bony  openings  by  secondary  operations.  For  this 
purpose  the  operation  of  Koenig  (Centralbl.  f.  Chir.,  1890,  No.  27)  is  the 
best.  The  scar  and  fibrous  tissue  having  been  removed,  a  flap  of  adjacent 
scalp,  of  similar  shape,  but  slightly  larger,  is  cut  down  to  the  bone  on  three 
sides,  but  not  separated  from  it.  The  fourth  side  serves  as  a  pedicle.  By  a 
narrow  chisel  the  outer  table  of  the  skull  lying  under  the  flap  so  outlined  is 
then  chiselled  loose  in  small  fragments  which  remain  adherent  to  the  under 
surface  of  the  flap.  This  flap  of  scalp  with  its  adhering  bony  fragments  is 
now  shifted  so  as  to  fill  the  bony  defect,  and  is  sutured  in  place.  The  raw 
surface  of  diploe  from  which  the  flap  has  been  chiselled  is  then  covered  by 
Thiersch's  method  of  skin-grafting.  The  rough  under  surface  of  transplanted 
bone  becomes  smooth  and  approximates  the  inner  table  in  its  character. 
When  the  dura  mater  has  been  removed  such  a  flap  has  even  been  placed 
directly  in  contact  with  the  brain  without  any  ill  results. 

Fragments  of  bone  have  also  been  transplanted  from  the  lower  animals. 
Decalcified  ox-bone  has  also  been  used,  and  Fraenkel  {Centralbl.f.  Chir., 
1890,  821)  has  proposed  to  insert  a  j)late  of  polished  celluloid,  a  procedure 
which  has  been  followed  with  success  in  several  instances.  In  all  these  cases 
drainage  should  be  employed  in  order  to  provide  escape  for  the  underlying 
wound  fluids. 

Completion  op  the  Operation.  The  closure  of  the  scalp  wound  should 
be  made  by  interrupted  sutures  with  silkworm-gut.  The  wound  should  then 
be  covered  with  an  ample  antiseptic  or  sterilized  dressing,  covered  by  rubber 
dam  and  retained  in  place  by  a  wet-gauze  bandage,  covered  in  turn  by  the 
ordinary  muslin  bandage,  and,  in  the  case  of  children  or  restless  adults,  by  a 
night-cap.  As  soon  as  the  dressing  becomes  moistened  to  its  edges  by  serum 
or  bloody  discharge,  the  wound  should  be  redressed,  and  attention  be  given  to 
the  evacuation  of  any  retained  wound  fluids.  If  a  drainage-tube  has  been 
used,  it  should  be  removed  at  the  end  of  from  twenty-four  to  forty-eight  hours, 
except  in  cases  of  abscess  or- other  similar  conditions,  when  it  must  remain 
for  some  time.  Usually  by  the  fifth  or  sixth  day  one-half  of  the  stitches  may 
be  removed,  and  the  remainder  on  the  seventh  or  eighth  day. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      965 

Absolute  quiet,  both  of  body  and  mind,  should  be  insisted  on,  especially 
for  the  first  week,  and  not  uncommonly  longer.  In  cases  of  severe  injury 
this  may  be  wisely  prolonged  even  for  months. 

Secondary  operations  are  occasionally  required,  in  which  the  bone  and 
the  membranes  must  be  dissected  free  from  the  brain  with  care,  lest  extensive 
injury  be  done  to  the  cerebral  centres.  After  primary  removal  of  a  motor 
centre,  paralysis  of  the  part  supplied  by  it,  and  very  frequently  of  neighbor- 
ing parts,  even  amounting  to  a  hemiplegia,  may  follow,  but,  as  a  rule,  disap- 
pears to  a  great  extent  after  some  weeks.  After  secondary  operations  this 
paralysis  or  paresis  is  apt  to  be  less  pronounced,  unless  the  brain  has  been 
extensively  injured. 

When  the  dura  has  been  removed,  and  especially  if  this  has  been  followed 
by  any  interference  with  the  brain,  there  is  always  a  marked  tendency  to 
fungus  cei'ebri.  In  order  to  prevent  this  I  suggested  some  years  ago  that 
the  gap  in  the  dura  might  be  supplied  by  a  portion  of  the  pericranium  from 
the  under  surface  of  the  flap  of  scalp.  The  osteogenetic  surface  should  be 
turned  upward  and  the  piece  of  pericranium  sewed  to  the  dura.  I  have  done 
this  successfully  in  three  cases. 

The  limits  of  operative  procedure  are  constantly  being  widened.  By  the 
dural  separator,  the  probe,  and  the  finger,  a  large  part  of  the  inner  surface 
of  the  skull  and  of  the  cortex  of  the  brain  can  be  examined.  Anteriorly, 
the  brain  can  be  lifted  as  far  back  as  the  anterior  clinoid  process.  Laterally, 
the  entire  petrous  bone  can  be  uncovered,  and  posteriorly,  both  by  the  eye 
and  the  finger,  we  can  reach  the  foramen  magnum,  both  within  and  without 
the  skull.  The  sinuses  can  be  exposed  and  the  brain  may  be  punctured 
almost  with  impunity  with  a  blunt  instrument,  such  as  the  grooved  director ; 
and  the  lateral  ventricles  can  be  tapped. 


EPILEPSY. 
Epilepsy,  in  its  various  forms,  has  been  discussed  in  Chapter  XII. 

Surgical  Treatment  of  Epilepsy. 

1.  General  Epilepsy.  For  general,  or  so-called  idiopathic  epilepsy,  no 
surgical  treatment  can  be  recommended. 

2.  Focal  Epilepsy.  The  surgical  treatment  of  this  form  of  epilepsy 
has  consisted  of  the  exposure  of  the  centre  in  which  the  attack  begins,  its  rec- 
ognition by  the  faradic  battery,  and  its  excision.  The  results  have  not  thus 
far  been  such  as  to  give  very  great  encouragement  to  the  continuation  of  this 
treatment ;  but,  on  the  other  hand,  sufficient  time  has  not  yet  elapsed  to 
determine  definitely  the  results.  The  frequent  improvement  of  epileptics 
after  any  operation,  often  far  away  from  the  head,  makes  us  suspect  that  the 
temporary  improvement  often  reported  may  be  due  to  the  operation,  irrespec- 
tive of  its  nature  or  site.  Moreover,  if  the  epilepsy  has  been  caused  by  scar 
tissue  the  oj^eration  will  be  followed  by  the  re-formation  of  a  scar  with  its 
consequent  irritation.  It  is  possible,  however,  that  the  scar  following  an  aseptic 
operation  which  results  in  immediate  primary  union  is  much  less  likely  to 
leave  an  irritating  cicatrix  than  the  coarse,  irregular  cicatrix  following  an 
infected  wound.  In  a  certain  number  of  cases  there  is,  no  doubt,  that  the 
excision  of  a  traumatic  scar  in  the  brain  has  been  followed  by  amelioration 
and  even  by  cure,  in  spite  of  the  secondary  scar  following  the  operation. 
The  tendency,  however,  of  surgeons  I  think  is  rather  toward  less  than  more 


966  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

interference  in  focal  epilepsy.  The  mortality  is  not  very  large,  and,  if 
further  experience  gives  us  fairly  good  results,  it  is  a  reasonable  risk  to 
take..  At  all  events,  it  is  unlikely  that  the  patient  would  be  made  any 
worse. 

In  doing  such  an  operation  a  large  area  of  the  brain  should  be  exposed  by 
an  opening  not  less  than  an  inch  and  a  half  in  diameter,  or  better  still,  by 
a  larger  opening  made  by  the  Wagner- Wolff  method.  We  can  thus  recog- 
nize the  convolutions,  and  then  by  the  battery,  used  in  the  manner  already 
described,  we  can  ascertain  the  exact  location  and  limits  of  the  cerebral 
centre  which  is  sought.  The  entire  centre,  and  even  a  little  more,  especially 
antero-posteriorly,  should  be  removed  by  the  methods  already  described.  In 
doing  this  we  can  sometimes  lift  the  pia  and  any  large  veins  which  run  in 
the  sulci,  and,  working  under  them,  can  remove  all  of  the  desired  portion  of 
the  cortex  without  lesion  of  the  vessels.  All  of  the  gray  matter  should  be 
removed  down  to  the  white  substance. 

The  surgical  after-treatment  is  the  same  as  that  already  described  under 
the  heading  of  Technique.  In  all  cases  medicinal  after-treatment,  espe- 
cially by  the  bromides,  and  the  dietetic  treatment  should  be  carefully  carried 
out. 

3.  Jacksonian  Epilepsy.  The  treatment  of  this  form  is  the  same  as  for 
the  last,  but  in  both  it  should  be  remembered  that  it  is  important  to  excise 
the  cerebral  centres  early,  before  the  epileptic  habit  has  been  formed.  The 
prognosis  in  Jacksonsian  epilepsy  is  better  than  that  of  focal  epilepsy,  especi- 
ally in  traumatic  cases.  The  published  results  have  been  more  favorable 
both  as  to  betterment  and  cure. 

4.  Traumatic  Epilepsy.  The  site  of  the  operation,  if  operation  is  decided 
upon,  should  be  determined  rather  by  the  localizing  symptoms  than  by  the  ex- 
ternal scar.  Moreover,  if  the  scar  is  tender,  and  especially  if  pressure  upon 
it  produce  an  attack,  the  scar  itself  should  be  excised  before  any  operation 
is  done  upon  the  brain.  If  this  minor  operation  does  not  cure,  then  the 
brain  may  be  attacked  by  the  usual  methods.  The  results  in  some  exces- 
sively severe  cases  have  been  excellent.  Thus  one  of  Mr.  Horsley's  cases 
(Brit.  Med.  Journ.,  1887,  I.  864),  following  an  old  depressed  fracture  of  the 
skull,  had  2870  convulsions  in  thirteen  days,  and  another,  related  by  Miles 
(Lancet,  1891,  II.  1159),  following  a  blow  on  the  top  of  the  head,  had  3597 
fits  in  forty-two  days,  and  as  many  as  219  in  a  single  day,  and  both  cases 
were  cured  by  operation,  the  cure  being  persistent  after  a  long  interval  of 
time.  Sometimes,  even  without  any  ajDparent  lesion  of  the  brain,  as  in  the 
case  of  Mr.  Miles,  the  trephining  may  result  in  cure. 

In  all  these  cases  of  epilepsy  it  is  desirable  to  open  the  dura  so  as  to  inspect 
the  condition  of  the  brain.  If  a  scar  exists  in  the  dura  it  should  be  excised 
and  the  gap  filled  by  the  pericanium.  If  one  exists  in  the  brain  it  should 
be  removed  down  to  the  white  matter,  or  as  deeply  as  the  scar  goes.  If  the 
bone  is  diseased  it  should  not  be  replaced,  and,  in  fact,  in  all  forms  of  epi- 
lepsy it  is  better  not  to  replace  the  bone,  at  least  if  removed  by  the  trephine. 
Even  in  the  Wagner-Wolff  method,  if  the  bone  is  found  to  be  diseased  it 
should  be  removed.  Sometimes  a  cyst  will  be  found,  in  which  case  it  should 
be  excised.  If  adhesions  have  formed.  Beach  (Boston  Med.  and  Surg.  Journ., 
April  3,  1890)  proposes  to  insert  a  piece  of  aseptic  gold  foil  between  the 
brain  and  the  dura,  a  procedure  successfully  accomplished  by  Park.  If 
there  has  been  a  primary  trephining  at  the  time  of  the  fracture  of  the  skull, 
followed  by  thickening  of  the,  edges  of  the  o|)ening,  and  also  by  the  forma- 
tion of  scar  tissue,  I  have  found  in  some  cases  that  the  simple  removal  of 
this  thickened  bone  has  been  followed  by  benefit,  amounting  sometimes 
almost  to  cure.     Possibly  the  gold  foil  might  be  of  use  here. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      967 


ARRESTED    DEVELOPMENT    AND    MALFORMATIONS,    IN- 
CLUDING PORENCEPHALUS  AND  MICROCEPHALUS. 

The  only  successfol  operation  that  I  have  seen  reported  for  a  case  of  arrested 
development  is  that  of  Felkin  and  Hare  (Manchester  Med.  Chron.,  October, 
1891,  p.'  17).  The  patient  was  a  girl  of  seventeen  years,  who  at  the  age  of 
ten  mouths  had  had  her  skull  fractured.  This  was  followed  by  paralysis  and 
imperfect  development  of  the  right  arm  and  leg.  An  extra-dural  cyst  two 
inches  in  depth  and  an  osteophyte  half  an  inch  long  were  found.  Marked 
improvement  followed  the  operation. 

In  the  congenital  cerebral  palsies  the  general  conclusion  is  against  opera- 
tion rather  than  in  favor  of  it ;  but  occasionally,  especially  in  those  few  cases 
in  which  hemorrhage  is  the  cause  of  the  palsy,  an  immediate  operation  might 
be  of  value. 

In  porencephalus  and  athetosis  it  is  doubtful  whether  any  operation  should 
be  done,  if  the  porencephalic  condition  can  be  diagnosticated  in  advance. 
Oppenheim  (Deutsch.  Med.  Woch.,  July  3, 1890,  595),  however,  has  reported  a 
case  of  athetosis  accompanied  with  cerebral  palsy  of  childhood  and  epilepsy, 
in  which  a  cyst  was  found,  and  both  the  athetosis,  the  contracture,  and  the 
epilepsy  were  improved.  Kocher  (Deutsch.  Zeit.f.  Chur.,  1893,  vol.  xxxvi,  72) 
has  reported  two  cases  of  recovery  after  operation  for  porencephalus.  The 
lateral  ventricle  was  opened  and  the  choroid  plexus  and  the  corpus  striatum 
were  seen. 

SuKGiCAL  Treatment  of  Microcephalus.  For  the  purpose  of  deter- 
mining whether  the  size  of  the  head  is  abnormally  small  or  large,  the  follow- 
ing table  from  Finlayson  (Keating' s  Encijcl.  Dis.  of  Children,  vol.  i.  p.  94, 
footnote)  is  of  value : 


No  of 
cases. 


100 
66 
75 
71 
67 
50. 
60 
46 
40 
31 


Age. 


1  day 

6   lo  12  weeks 

6    "      8  months 

11    "  13      •' 

21     "  24      " 

34    "  36      " 
'4    "      43^  years. 

6    "      6^      " 

9    "  10 

11    "  12 


Head, 

Chest, 

inches. 

inches. 

13.75 

12.94 

15.25 

14.25 

16.68 

15.58 

17.80 

17.20 

18.38 

17.85 

18.70 

18.,61 

19.20 

19.72 

19.  .51 

20. 76 

19.56 

21.31 

20.00 

23.46 

Difference  between  head 
and  chest. 


Head  more  than  chest,  0.81 
"  1.00 
"  1.10 
"  0.60 
"  0.53 
0.09 
0.50 
1.25 
1.75 
3.46 


Chest  more  than  head, 


In  microcephalus,  Lannelongue  (V  Union  Med.,  July  8, 1890),  first  proposed 
to  exsect  a  strip  of  bone  in  the  skull  about  a  quarter  of  an  inch  wide.  This 
excision  may  be  made  on  one  or  both  sides  of  the  sagittal  suture  and  pax'allel 
to  it,  extending  from  the  forehead  to  the  occiput.  To  this  antero-posterior 
groove  may  be  added  a  lateral  branch  on  each  side.  If  the  faulty  develop- 
ment preponderates  in  as  particular  region  as  in  the  frontal,  a  transverse 
groove  mav  be  made.  Soon  after  Lannelongue's  ai'ticle  appeared  reporting 
three  cases,  I  reported  a  fourth  (Med.  New.%  Nov.  29,  1890),  and  since  then 
a  large  number  of  cases  have  been  recorded.  I  have  myself  done  a  dozen 
operations.  The  result  in  general  may  be  stated  as  follows  :  The  mortality 
is  large,  averaging  from  20  to  25  per  cent.,  as  Avould  be  expected  in  children 
of  such  faulty  development.  The  loss  of  blood  is,  as  a  rule,  not  such  as  to 
imperil  life,  but  the  shock  attending  not  only  the  moderate  loss  of  blood,  but 
the  wide  separation  of  the  scalp,  which  is  inevitable,  and  the  injury  to  the 
bone,  is  very  great.     For  this  reason  it  is  therefore  never  desirable  to  operate 


968  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

on  both  sides  at  once,  but  at  an  interval  of  a  few  weeks.  Moreover  it  is 
best  not  to  subject  children  under,  say  nine  or  ten  months  of  age,  to  the  shock 
of  such  an  operation,  nor,  perhaps,  is  it  desirable  to  operate  after  nine  years 
of  age. 

The  result  as  to  the  mental  development  varies  greatly.  The  majority 
of  the  children  who  recover  are  not  improved.  A  moderate  number  show 
some  improvement ;  in  a  few  it  has  been  very  great.  Hence,  in  such  a  dis- 
tressing and  otherwise  irremediable  disease  I  think  that  operation  is  at  least 
permissible,  but  I  should  never  be  disposed  to  urge  it  against  even  the 
slighest  hesitation  of  parents.  Certain  it  is  that  the  head,  which  may  not 
have  grown  at  all  prior  to  operation,  may  after  operation  become  notice- 
ably larger. 

After  the  usual  preparation  of  the  scalp,  the  incision  should  be  made  in 
the  direction  chosen,  directly  down  to  the  bone.  If  the  incision  is  antero- 
posterior, by  making  a  lateral  incision  just  behind  the  anterior  border  of 
the  hair,  the  scalp  from  the  forehead  may  be  drawn  well  down,  so  that 
the  bone  operated  on  may  be  reached  half-way  down  from  the  hair  to  the 
eyebrows.  This  position  of  the  incisions  enables  them  to  be  hidden  by  the 
hair.  Very  frequently  the  hemorrhage  will  be  so  slight  that  no  forceps  Avill 
be  required,  but  should  there  be  any  marked  bleeding  the  vessels  shouldbe 
immediately  seized  by  the  hemostatic  forceps.  Make  a  half-inch  trephine 
opening  far  enough  from  the  median  line  to  avoid  the  superior  longitudinal 
sinus,  and  with  a  pair  of  rongeur  forceps  which  I  devised  (Fig.  307)  the 
operation  can  be  completed  in  from  twenty  to  thirty  minutes.  Only  occa- 
sionally will  any  bloodvessels  have  to  be  ligated.  The  sutures  in  the  wound 
are  usually  sufficient  to  control  the  bleeding.  Before  replacing  the  flap  it  is 
well  to  remove  the  pericranium  corresponding  to  the  groove  in  order  to  pre- 
vent the  reproduction  of  the  bone.  The  edges  of  the  wound  are  then  united 
by  sutures,  and  the  ordinary  care  of  such  a  Avound  is  carried  out. 


HYDROCEPHALUS. 

The  great  majority  of  cases  operated  on  for  hydrocephalus  have  died.  How- 
ever, Broca  {Rev.  de  Chir.,  1891,  37),  Phocas  {Rev.  Mens,  des  Malad.  de  VEii- 
fance,  February,  1892),  Mavo  Robson  {Brit.  Med.  Joiirn.,  December  6, 1890), 
Hahn  (Med.  Neios,  May  6,  1893,  500),  Soderbaum  {AnnaU  of  Surgery,  1892, 
XV.,  467)  and  McCosh  {New  York  Med.  Record,  September  16, 1893,  376,  and 
Amer.  Journ.  of  Med.  Scl,  March,  1894,  239),  have  all  reported  cases  of 
acute  or  chronic  hydrocephalus  in  which  puncture  of  the  lateral  venticles 
has  done  great  good.  The  methods  by  which  the  increased  intra-cranial 
pressure  has  been  relieved  have  been  first,  by  puncture  of  the  lateral  ventri- 
cles ;  second,  by  puncture  of  the  membranes  of  the  cord  in  the  lumbar 
region ;  and  third,  the  puncture  of  the  fourth  ventricle. 

1.  PuifCTURE  OF  THE  LATERAL  Vextricles.  In  the  Mediccil  Neios  for 
December  1,  1888,  I  published  a  paper,  read  IS'ovember  7,  1888,  before  the 
College  of  Physicians  of  Philadelphia,  in  which  was  first  distinctly  formu- 
lated the  technique  of  puncture  of  the  lateral  ventricles.  I  showed  that  the 
lateral  route  is  decidedly  the  best,  as  it  avoids  the  important  brain  centres, 
and  the  ventricles  can  with  ease  and  accuracy  be  reached.  A  half-inch  tre- 
phine opening  is  made  an  inch  and  a  quarter  behind,  and  the  same  distance 
above  the  meatus.  The  brain  is  then  punctured  by  a  tube,  about  'No.  5,  of  the 
French  catheter  scale,  or  by  a  grooved  director  or  other  suitable  instrument, 
directed  toward  a  point  two  and  one-half  inches  vertically  above  the  opposite 
external  auditory  meatus.     At  a  depth  of  one  three-quarter  or  one  one-half 


SUBGEBY  OF  THE  BBAIN,  SPINAL  COBD,  AND  NEBVES.      969 


inches  or  less,  according  to  the  distention  of  the  ventricle,  its  cavity  Avill  be 
reached.  The  moment  the  ventricle  is  reached  the  diminution  of  pressure  is 
readily  perceived  by  delicate  fingers,  and  the  immediate  escape  of  the  cerebro- 
spinal fluid  assures  us  that  the  instrument  is  in  the  ventricle.  The  ventricle 
can  of  course  be  reached,  especially  if  distended,  from  almost  any  part  of  the 
cerebral  surface.  I  have,  also,  in  a  case  which  I  trephined  and  punctured 
upon  both  sides,  washed  out  the  lateral  ventricles  from  side  to  side  with  a 
boric  acid  solution  with  subsequent  comfort  to  the  patient.  Should  it  be 
desired  to  keep  up  continuous  drainage,  this  can  be  effected  either  by  a 
rubber  tube,  or  by  horse-hairs  doubled  and  introduced  with  the  curved  end 
first.  In  the  Medical  Neivs  of  September  20,  1890,  will  be  found  the  resume 
of  a  full  paper  relating  to  this  method  of  puncture. 

2.  Puncture  of  the  Membranes  of  the  Cord  in  the  Lumbar 
Region.  Wynter  {Lancet,  1891,  1,  931),  proposed  to  substitute  for  punc- 
ture of  the  lateral  ventricles,  puncture  of  the  membranes  of  the  cord  in  the 
lumbar  region,  and  Quincke  (  Verhandl.  des  12ten  Kongress  f.  Innere  Med., 
1893,  197),  has  reported  41  operations.  Quincke  has  proposed  to  puncture 
in  the  third  or  fourth  intervertebral  space,  which  measures  18  to  20  millimetres 
transversely  and  10  vertically.     This  is  below  the  termination  of  the  cord, 

Fig.  321. 


Method  of  puncture  for  spinal  drainage  :  A,  Quincke's  method  ;  B,  Marfan's;  C,  Chipaut's. 

(Chipault.) 

and  there  is  an  interspace  of  5  mm.  between  the  two  bundles  of  the  cauda 
equina.  The  depth  of  the  puncture  to  reach  the  cord  in  infants  is  about  2 
centimetres,  and  in  adults  4  to  6  centimetres.  Chipault  has  proposed  to 
puncture  between  the  last  lumbar  and  the  first  sacral  vertebrae  by  preference, 
the  procedure  in  other  respects  being  the  same. 

Fiirbringer  {Lancet,  1895, 1, 1022),  has  reported  more  than  100  punctures, 
in  86  patients,  without  any  ill  effect.  The  bacillus  tuberculosis  was  found  in 
the  fluid  in  thirty  of  thirty-seven  cases  of  tubercular  meningitis,  in  which 
the  diagnosis  was  doubtful.  Four  cases  of  cerebral  tumor  were  relieved  by 
the  operation. 

3.  Puncture  of  the  Subarachnoid  Space.  Parkin  {Lancet,  1893,  ii. 
21),  has  proposed  and  operated  by  the  following  method  :  He  trephined  three- 


970 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


quarters  of  an  inch  below  the  superior  curved  line  of  the  occipital  bone, 
just  to  the  right  of  the  middle  line,  and  enlarged  the  opening  downward  by 
the  rongeur  forceps.  After  opening  the  dura  he  inserted  a  probe  into  the 
fourth  ventricle,  lifting  the  cerebellum  to  a  slight  extent,  when  2  to  3  ounces 


Fig.  322. 


Vertical  section  of  base  of  skull  immediately  to  the  right  of  the  median  line ;  a,  basal  sub- 
arachnoid cavity  and  its  relation  to  the  cerebellum ;  6,  fourth  ventricle  ;  c,  site  of  trephine  aperture. 
(Pakkix.) 

of  fluid  gushed  out.  Great  care  should  be  taken  not  to  wound  the  floor  of 
the  fourth  ventricle.  He  reports  four  cases  with  two  recoveries,  and  Ord 
and  Waterhouse  {Lancet,  1894,  ii.  873),  have  reported  a  successful  operation 
in  a  case  of  tubercular  meningitis. 


MENINGITIS. 


Mr.  Barker  (Brit.  Med.  Journ.,  1888,  i.  777)  has  reported  a  noteworthy 
case  in  which  he  evacuated  an  ounce  of  odorless  pus  from  the  fissure  of  Syl- 
vius, with  a  successful  result.  Sawtelle  (Occid.  Med.  Times,  Feb.,  1892,  76) 
also  evacuated  five  drachms  of  fluid,  followed  by  recovery,  and  Mr.  Parkin 
{Lancet,  July  1,  1893,  21)  has  reported  a  similar  case,  both  of  these  cases 
being  traumatic.  It  is  rare,  perhaps,  that  we  shall  be  as  successful  in  non- 
traumatic meningitis  as  Mr.  Barker  was,  but  occasionally  it  may  be  done. 
The  technique  is  simply  that  of  trephining  and  opening  the  dura,  followed 
by  jjuncture  toward  the  source  of  the  pus  or  serum,  as  in  Mr.  Barker's  case, 
should  it  be  necessary.     Fortunately,  often  simple  trephining  will  answer.^ 

Similarly  in  chronic  ossifying  pachymeningitis,  sometimes  the  remote  result 
of  injury  which  causes  thickening  and  induration  of  the  bones  of  the  skull 
and  severe  and  persistent  headaches,  simple  trephining  will  not  seldom  give 
relief.     The  bone  should  not  be  replaced  in  these  cases. 

In  persistent  meningitis  the  only  possible  relief  is  found  in  speedy  trephin- 
ing and  drainage,  without  replacement  of  the  bone.  The  chances  of  death 
are,  of  course,  much  greater  than  those  of  life,  but  the  patient  should  at 
least  have  the  benefit  of  this  small  chance. 

For  the  methods  of  operating'in  both  these  cases  see  the  section  on  Technique. 


1  See  other  cases  bv  McArdle,  Dublin  Journ.  of  the  Med.  Sci.,  1892,  xciv.  17 
Med.  Journ.,  1892,  ii.  21. 


and  Tobin  Brit. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      971 


PACHYMENINGITIS  HEMORRHAGICA. 

In  pachymeningitis  hemorrhagica,  Dennis,  (N.  Y.  Med.  Journ.,  Dec.  24, 
1892,  701)  has  urged  that  operation  should  be  undertaken,  e.  g.,  in  cases  of 
alcoholism  followed  by  such  hemorrhage.  Ceci  {Chir.  BehancU.  v.  Hirnkr. 
Bergmann,  p.  112)  has  performed  such  an  oj^eration  in  a  case  following  acci- 
dent. Buchanan  (Pittsburg  Med.  Rev.,  Sept.,  1894),  and  Harris  (Brit.  Med. 
Journ.,  1892,  i.  503)  have  reported  two  successful  cases,  and  Stewart  {Brit. 
Med.  Journ.,  1887,  i.  877)  a  fatal  case.  When  the  headache  has  been  fol- 
lowed by  paralysis,  and  the  location  of  the  lesion  is  clearly  indicated,  when 
the  pupils,  which  were  contracted  and  immobile  before  unconsciousness  super- 
vened, have  become  dilated,  when  o^^tic  neuritis,  and  finally  coma,  have  set 
in,  it  would  seem  proper  to  operate  without  further  delay.  This  might  be 
either  by  the  ordinary  trephining  or  by  an  osteoplastic  resection,  the  dura 
being  ojDened,  the  clot  removed,  and  if  need  be,  drainage  estabhshed. 


ABSCESS  OP  THE  BRAIN. 

Traumatic  Cerebral  Abscess.  In  operating  for  abscess  of  the  cere- 
brum, the  spot  selected  for  the  operation  should  be  determined  by  the 
localizing  cerebral  symptoms,  and  not  by  the  scar,  should  such  be  present, 
or  by  the  history.  If,  however,  the  abscess,  as  is  not  infrequently  the 
case,  is  situated  under  the  site  of  the  injury,  the  operation  should,  of  course, 
be  at  this  place.  The  skull  may  be  opened  by  a  half-inch  trephine,  and 
the  dura  opened  by  a  small  incision.  If  an  abscess  exists,  the  brain  will 
not  pulsate  and  will  bulge  into  the  opening  from  the  increased  pressure. 
The  brain  is  then  to  be  punctured.  The  best  instrument  for  this  purpose 
is  the  grooved  director,  since  it  allows  the  exit  of  the  pus  in  its  groove, 
and,  being  blunt-pointed,  will  not  injure  any  vessels.  Should  the  first 
puncture  not  reveal  the  abscess,  the  instrument  should  be  withdrawn  ex- 
actly in  the  line  in  Avhich  it  has  been  introduced,  so  as  not  to  wound  the 
brain  any  more  than  is  possible,  and  be  reintroduced  in  the  next  most  likely 
direction  in  the  same  manner.  A  third,  and  if  necessary  a  fourth  and  a 
fifth,,  puncture  may  be  made.  The  injury  from  the  punctures  is  but  slight, 
if  they  are  made  with  the  proper  precautions.  The  fatality  of  the  disease 
warrants  any  reasonable  interference. 

When  the  abscess  has  been  found  a  pair  of  hemostatic  forceps  should  be 
introduced  with  the  blades  closed,  the  blades  then  opened  half  an  inch  or  an 
inch,  and  so  withdrawn  in  order  to  aflx»rd  free  exit  for  the  pus.  The  wound 
may  then  be  washed  out  very  gently  with  a  boric-acid  solution,  four  or  five 
grains  to  the  ounce,  and  if  deemed  best,  the  cavity  of  the  abscess  may  be 
gently  curetted.  A  drainage-tube  should  then  be  introduced,  a  suitable 
opening  bitten  away  for  it,  if  the  lione  is  replaced,  and  a  corresponding  open- 
ing made  in  the  scalp,  the  drainage-tube  being  secured  to  the  latter  by  a 
stitch.  The  abscess  cavity  may  be  washed  out  daily,  but  with  great  gentle- 
ness, and  the  drainage-tube  gradually  shortened  as  the  amount  of  discharge 
diminishes,  and  finally  be  removed.  Should  reaccumulation  take  place,  the 
cavity  should  be  reopened  through  the  original  opening  in  the  skull.  Care 
should  he  taken  not  to  make  the  opening  in  the  skull  any  larger  than  is 
necessary,  as  a  fungus  cerebri  is  almost  certain  to  follow  if  a  large  opening 
exists.  For  the  same  reason,  if  there  is  necrosed  bone,  but  little  of  it  should 
be  removed.  When  later  the  bone  has  loosened  it  should  be  removed  by  a 
secondary  operation.     Should  the  abscess  not  l)e  found  at  the  site  of  the  first 


972 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


operation,  a  second,  and,  if  need  be,  a  third  trephine  opening  may  be  made  at 
the  next  most  probable  points.  On  no  account  should  the  abscess,  if  it 
exists,  be  left  undiscovered. 

Otitic  Abscess.  The  most  common  cause  of  abscess  in  the  cerebrum  is, 
however,  not  traumatism,  but  chronic  suppurative  otitis  media.  (See  page 
374).  In  these  cases  the  abscess  may  be  (1)  extra-dural,  that  is,  between  the 
dura  and  the  petrous  bone ;  (2),  sub-dural,  that  is,  between  the  dura  and  the 
brain,  or  (3)  in  the  substance  of  the  cerebrum,  separated  from  the  surface,  it 
may  be,  by  an  inch  or  more  of  apparently  healthy  brain  tissue.  Almost  always 
the' mastoid  will  already  have  been  opened,  but  should  this  not  have  been 
done,  it  should  be  the  first  step  in  the  operation. 

Mastoid  Abscess.  Operation.  The  external  meatus  should  first  be 
thoroughly  cleansed  antiseptically.  A  vertical  curved  incision  is  then  made 
in  the  axis  of  the  mastoid  from  its  base  to  its  tip,  the  ear  being  drawn  well 
forward.  The  vessels  are  seized  with  hemostatic  forceps,  the  bone  laid  bare, 
and  the  mastoid  antrum  first  opened  at  a  point  one-third  to  one-half  an  inch 
behind,  and  the  same  distance  above,  the  centre  of  the  meatus.     (Fig.  323). 

Fig.  323. 


a,  a.  Reid's  base  line  from  the  lower  border  of  the  orbit  through  the  meatus  :  c,  the  point  for  tre- 
phining to  reach  an  abscess  in  the  temporo-sphenoidal  lobe  or  to  puncture  the  lateral  ventricle  15^ 
inches  behind  the  meatus,  and  1^  inches  above  Reid's  base  line ;  i,  the  mastoid  vein  ;  o,  the  point 
for  trephining  to  reach  an  abscess  in  the  cerebellum :  x,  the  point  for  trephining  the  mastoid  antrum. 
(Barker.) 


This  opening  is  made  towards  the  base  of  Macewen's  supra-meatal  triangle. 
(Fig.  324).  This  triangle  is  bounded  above  by  the  root  of  the  zygoma, 
anteriorly  by  the  posterior  margin  of  the  bony  meatus,  and  posteriorly  by 
a  line  joining  these  two.  An  opening  here  is  free  from  danger  of  wound- 
ing the  sigmoid  portion  of  the  lateral  sinus,  which  always  lies  behind  the 
triangle. 

The  mastoid  antrum  and  cells  should  then  be  thoroughly  laid  open  by  the 
gouge  and  chisel,  and  the  posterior  wall  of  the  meatus  chiselled  away  to  the 
cavity  of  the  middle  ear.  Twitching  of  the  face  on  the  same  side  should  be 
watched  for,  as  it  would  indicate  proximity  to  the  facial  nerve,  and  no  more 
chiselling  should  be  done  in  that  direction.  All  the  inspissated  pus  found  in 
this  bony  cavity  should  be  thoroughly  removed  by  a  small  sharp  spoon  or 
gouge,  care  being  taken  not  to  wound  the  lateral  sinus.  The  wound  should 
then  be  lightly  packed  with  iodoform  gauze  daily. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      973 


Tempoeo-sphenoidal  Abscess.  The  mastoid  operation  may  be  sufficient 
to  relieve  the  patient,  but  if  not  the  abscess  should  then  be  sought  in  the 
temporo-sphenoidal  lobe,  unless  there  is  reason  to  believe  that  it  is  situated 
in  the  cerebellum  (vide  infra,  also  page  377).     The  axis  of  the  temporo- 


FlG.  324. 


Lateral  sinu 


Supra-meaial  triangle 


Surface  guides  for  the  sigmoid  sinus  and  the  supra-meatal  triangle.  (Macewen.) 
Three  artificial  lines  drawn  upon  the  skull  indicate  the  following :  1.  The  short  vertical  line 
from  the  posterior  border  of  the  external  auditory  meatus  to  the  posterior  root  of  the  zygoma  marks 
the  base  of  the  supra-meatal  triangle.  The  broken  line  indicates  the  anterior  border  of  the  supra- 
meatal  triangle,  Its  base  being  the  dotted  line  marking  the  part  of  the  root  of  the  zygoma.  This 
broken  line  also  indicates  the  course  of  the  facial  nerve.  2.  The  second  vertical  line,  extending 
from  the  parieto-squamo-mastoid  jianction  to  tip  of  mastoid  ;  the  upper  two-thirds  of  its  length 
indicate  the  position  of  the  sigmoid  sinus.  3.  The  oblique  line,  passing  from  the  asterion  to  upper 
limit  of  the  external  auditory  meatus,  indicates  in  its  posterior  two-thirds  the  sigmoid  sinus  from 
its  commencement  to  its  knee. 

sphenoidal  lobe  I  have  shown  to  be  a  line  drawn  from  a  point  li  inches 
above  and  l)ehind  the  external  meatus  to  the  opposite  wing  of  the  nose.  A 
half-inch  trephine  should  be  apj^lied  as  indicated  by  Barker,  1 1  inches  above 
the  external  auditory  meatus,  and  1\  inches  above  Reid's  base  line  (Fig. 
323  c).  The  dura  is  then  opened  by  a  small  cruciform  incision,  and  a 
grooved  director  inserted  in  the  axis  of  the  temporo-sphenoidal  lobe,  as 
above  indicated,  to  the  depth  of  2  or  22-  inches,  unless  the  abscess  has 
already  been  reached.  Once  that  abscess  has  been  discovered,  it  should  be 
treated  as  above  indicated.  If  the  first  puncture  does  not  reveal  the  abscess, 
it  may  be  needful  to  make  repeated  punctures. 

ExTRA-DUEAL  Abscess.  This  is  caused  not  uncommonly  by  caries  of  the 
petrous  bone  from  disease  of  the  ear.  The  temperature  in  this  form  of  ab- 
scess is  usually  102°  to  104°,  rather  than  normal  or  subnormal,  as  in  ordi- 


974  NERVOUS  DISEASES  AND  TREIB  TREATMENT. 

nary  cerebral  or  cerebellar  abscess.  The  mastoid  should  be  opened  as 
already  described,  unless  this  has  already  been  done.  The  skull  should  then 
be  opened  an  inch  directly  above  the  meatus,  unless  a  fistula  through  the 
bone  indicates  any  other  point  of  preference.  The  dura  should  then  be  sepa- 
rated from  the  bone,  but  not  opened,  and  the  abscess  cavity  irrigated  with 
an  antiseptic  solution  and  curetted.  Carious  or  necrosed  bone  should  be 
removed  and  free  drainage  provided.  Bircher  {Centralbl.  f.  Chir.,  1893, 
482)  chiselled  away  all  the  necrosed  bone,  except  the  carotid  canal. 

Cerebellar  Abscess.  An  abscess  of  the  cerebellum  is  best  reached  at 
a  point  midway  between  the  mastoid  and  the  inion,  and  sufficiently  far  below 
the  line  from  the  mastoid  to  the  inion,  which  corresponds  to  the  lateral  sinus, 
to  avoid  wounding  the  latter  (Fig.  323  o).  The  occipital  bone  is  bared  by  a, 
semilunar  incision,  with  the  convexity  upward,  and  the  bone  penetrated 
either  by  a  trephine  or  by  the  chisel,  or  in  children  simply  by  the  gouge. 
The  opening  may  then  be  enlarged  at  will  by  means  of  the  rongeur  forceps. 
The  dura  is  then  opened  to  a  small  extent.  As  in  the  cerebrum,  so  in  the 
cerebellum,  the  brain  will  bulge,  and  will  not  pulsate  if  an  abscess  is  present. 
A  grooved  director  should  then  be  inserted  in  the  axis  of  the  lobe  of  the 
cerebellum.  The  opposite  lobe  can  be  reached  by  an  oblique  puncture,  care 
being  taken  not  to  injure  the  superior  vermiform  process. 


THROMBOSIS  OP  THE  LATERAL  SINUS  AND  THE 
INTERNAL  JUGULAR  VEIN. 

Zaufal,  in  1880,  first  carried  out  the  proper  treatment  for  this  disease 
(Prager  Med.  Wocli.,  1880,  p.  576).  In  1886  Horsley  again  called  atten- 
tion to  the  method,  and  Mr.  Arbuthnot  Lane  ^British  Med.  Journ.,  1889,  i. 
997)  reported  the  second  case  soon  afterward,  with  a  favorable  result. 
From  that  date  it  has  assumed  its  proper  place  as  the  rational  treatment  of 
this  otherwise  almost  uniformly  fatal  disorder.  I  have  records  of  84  cases 
which  have  been  operated  upon,  with  56  recoveries,  a  mortality  of  only  33.8 
per  cent. 

The  operation  consists  not  only  in  the  exposure,  but  also  the  opening,  of 
the  sinus  and  the  proper  cleansing  of  its  cavity,  and  also,  if  the  internal 
jugular  vein  is  involved,  the  similar  treatment  of  this  vein.  If  the  mastoid 
antrum  and  cells  have  not  already  been  opened  and  cleansed,  this  should  be 
done  at  once.  Next  the  sinus  should  be  exposed  by  the  chisel  or  trej^hine 
at  a  point  half  an  inch  behind  and  one-quarter  of  an  inch  above  the  middle 
of  the  external  auditory  meatus  (Fig.  325  c).  The  opening  can  be  enlarged 
either  by  the  rongeur  forceps  or  tile  chisel  and  gouge.  Pus  will  very  likely 
be  found  in  the  groove  for  the  sinus.  Should  the  sinus  be  thrombosed,  it 
will  be  harder  than  normal  to  the  touch.  If  no  thrombus  has  formed,  it  will 
be  soft.  In  either  case,  should  the  symptoms  warrant  it,  it  should  be  opened. 
If  the  blood  flows  freely  it  can  be  arrested,  first  by  the  finger  and  then  with 
strips  of  iodoform  gauze,  with  which  the  sinus  should  be  j)lugged.  These 
strips  should  be  made  ready  before  the  operation  is  begun.  If  a  clot  exists 
it  will  probably  be  very  foul,  and  should  be  evacuated  by  the  small  spoon 
or  curette  and  the  sinus  then  disinfected.  Cleansing  and  disinfection  may 
have  to  go  as  far  as  the  torcular  Herophili.  The  sinus  should  be  completely 
cleaned  out,  until  free  hemorrhage  shows  that  all  the  clot  has  been  removed. 
It  should  then  be  packed,  in  oi:der  to  arrest  the  hemori-hage.  The  internal 
jugular  vein  should  next  be  exposed  in  the  neck  and  ligated  at  a  point  below 
the  thrombus,  the  extent  of  which  can  be  determined  by  touch.     This  step 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      975 

is  of  very  great  importauce,  as,  if  done  sufficiently  early  and  low  enough 
down,  it  will  prevent  the  extension  of  the  infection  to  the  lungs.     The  vein 

Fig.  325. 


Lateral  aspect  of  a  small  adult  skull.  (Ballance.) 
The  illustration  shows  the  relations  of  the  lateral  sinus  to  the  outer  wall  of  the  cranial  cavity 
and  the  position  of  the  trephine  opening  (a),  which  should  be  made  when  it  is  deemed  neces- 
sary to  expose  it.  The  base  line  (Reid's)  passes  through  the  middle  of  the  external  auditory 
meatus  and  touches  the  lower  margin  of  the  orbit :  it  is  marked  out  in  eighths  of  an  inch, 
as  are  also  the  perpendicular  lines  drawn  from  it.  The  measurements  are  made  along  the 
base  line  from  the  middle  of  the  bony  meatus.  The  drawing  also  shows  the  convolutions  of 
the  temporo-sphenoidal  lobe,  the  Sylvian  fissure,  and  the  position  of  the  lower  end  of  the  furrow 
of  Rolando  [Rol.)  s  x  indicates  the  site  of  the  tentorium  as  far  as  it  is  in  relation  to  the  external 
boundary  of  the  skull.  The  anterior  x  shows  the  point  where  the  tentorium  leaves  the  side  of  the 
skull  and  is  attached  to  the  superior  border  of  the  petrous  bone,  a,  trephine  opening  to  expose 
sinus,  five-eighths  of  an  inch  in  diameter,  its  centre  being  one  inch  behind  and  a  quarter  of  an 
Inch  above  the  middle  of  the  bony  meatus.  This  opening  can  easily  be  enlarged  upward  and 
backward  and  downward  and  forward  (see  the  dotted  lines)  by  suitable  angular  cutting  bone  for- 
ceps. It  is  always  well  to  extend  it  forward,  so  as  to  open  up  the  mastoid  antrum  (c)  and  the  gutter 
of  the  carious  bone  (if  there  be  one),  which  leads  from  the  antrum,  tympanum,  or  meatus,  down  to 
the  bony  groove.  The  position  of  the  trephine  openings,  which  must  be  made  for  the  relief  of  inflam- 
matory intra-cranial  affections,  secondary  to  disease  of  the  ear,  other  than  for  sinus  pyaemia,  have 
been  added  to  the  drawing  for  the  sake  of  contrast  and  completeness.  They  are  as  follows  :  b,  tre- 
phine opening  to  explore  the  anterior  surface  of  the  petrous  bone,  the  roof  of  the  tympanum,  and 
the  petro-squamous  fissure,  half  an  inch  in  diameter,  its  centre  being  situated  a  short  inch  (seven- 
eighths  of  an  inch)  vertically  above  the  middle  of  the  meatus.  At  the  lower  margin  of  this  trephine 
hole  a  probe  can  be  insinuated  between  the  dura  and  bone  and  made  to  search  the  whole  of  the 
anterior  surface  of  the  petrous,  c,  trephine  opening  for  exposing  the  mastoid  antrum,  a  quarter  of 
an  inch  in  diameter,  and  a  half  an  inch  behind  and  a  quarter  of  an  inch  above  the  centre  of  the 
meatus ;  or  a  quarter  of  an  inch  above  the  centre  of  the  meatus  and  a  quarter  of  an  inch  behind  its 
posterior  border.  The  trephine  should  be  directed  inward  and  slightly  downward  and  forward. 
When  a  superficial  disk  of  bone  has  been  removed  it  is  well  to  repeat  the  operation  with  the  gouge. 
A  larger  trephine  may  with  advantage  be  emplpyed,  especially  in  adults,  d,  trephine  opening  for 
temporo-sphenoidal  abscess,  half  an  inch  in  diameter.  Situation  recommended  by  Barker,  one  inch 
and  a  quarter  behind  and  one  inch  and  a  quarter  above  centre  of  meatus.  The  needle  of  the  aspirator 
is  to  be  directed  at  first  inward  and  a  little  downward  and  forward.  Birmingham  prefers  one  and 
three-fourths  of  an  inch  above,  in  order  to  avoid  the  lateral  sinus,  e,  trephine  opening  for  cerebel- 
lar abscess,  half  an  inch  in  diameter  and  one  inch  and  a  half  behind,  and  a  quarter  of  an  inch  below 
the  centre  of  the  meatus.  Birmingham  prefers  two  inches  behind  and  one  inch  below  to  avoid  the 
occipital  artery.  The  anterior  border  of  the  trephine  should  just  be  under  cover  of  the  posterior 
border  of  the  mastoid  process.  The  drawing  shows  that  a  trephine  hole  made  in  this  situation  is  far 
away  from  the  lateral  sinus,  and  that  the  trocar  and  canula  of  the  aspirator  if  directed  forward, 
inward,  and  upward,  would  hit  an  abscess  occupj'ing  the  anterior  part  of  the  lateral  lobe  of  the 
cerebellum,  which  is  the  usual  site  of  collections  of  pus  in  this  part  of  the  brain.— From  Brain 
Surgery,  by  Starr,  p.  193. 


976  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

should  then  be  cut  above  the  ligature,  the  upper  end  attached  to  the  skin, 
the  vein  and  the  sinus  being  washed  out  antiseptically  and  as  thoroughly  as 
possible. 


TUMORS  OF    THE    BRAIN,  INCLUDING  CYSTS. 

The  tumor  having  been  located  and  its  size  and  character  approximately 
determined,  the  first  step  in  the  operation,  after  the  preliminary  cleansing, 
as  described  in  the  section  on  Technique,  is  to  mark  the  median  line  and  the 
fissure  of  Eolando  on  the  shaven  surface.  The  upper  and  lower  ends  of  the 
fissure  of  Rolando  should  be  marked  by  puncturing  the  bone  by  means  of  a 
gimlet,  small  gouge,  or  the  centre-pin  of  another  trephine.  Should  it  be 
determined  to  open  the  skull  by  the  trephine,  the  centre  of  the  probable 
location  of  the  tumor  should  be  similarly  marked.  The  bone  is  then  exposed 
by  a  large  semilunar  or  horseshoe  flap,  with  the  position  of  the  tumor  as  its 
centre.  A  large  opening  should  then  be  made  in  the  skull,  from  an  inch 
and  a  half  to  three  inches  in  diameter,  either  by  a  single  or  by  multiple  tre- 
phine openings,  or  by  a  chisel.  Instead  of  this,  however,  the  skull  may  be 
opened  by  an  osteoplastic  resection  (see  p.  961).  If  a  tumor  is  present,  the 
dura  will  not  pulsate  and  will  bulge  to  a  greater  or  less  extent,  according  to 
the  size  of  the  tumor.  The  dura  should  then  be  opened  about  a  quarter  of 
an  inch  from  the  margin  of  the  opening  in  the  bone.  This  opening  should 
be  small  at  first,  until  the  size  of  the  tumor  can  be  gauged  to  some  extent 
by  the  amount  of  the  bulging.  Should  exploration  through  this  small  open- 
ing indicate  that  the  tumor  can  probably  be  removed,  the  opening  in  the 
dura  may  then  be  enlarged  to  such  an  extent  as  is  necessary.  The  tumor 
having  been  found,  if  it  extend  in  any  one  direction  beyond  the  limits  of  the 
opening  in  the  bone,  this  may  be  enlarged  at  will  by  the  rongeur. 

The  tumor  may  be  occasionally  enucleated  by  the  finger.  If  this  is  not 
feasible,  the  knife  and  scissors,  sharp  spoon,  or  the  handle  of  an  ordinary 
teaspoon  may  be  used  to  remove  it,  either  whole  or  piecemeal.  Should 
it  be  an  infiltrating  tumor,  and  therefore  probably  malignant,  unless  inop- 
erable, not  only  the  tumor  but  a  considerable  amount  of  apparently  healthy 
brain-tissue  should  be  removed  beyond  its  margins,  so  as  to  be  certain  that 
all  the  diseased  tissue  has  been  removed. 

If  subcortical  tumor  be  suspected,  an  incision  is  made  in  the  brain,  and  the 
tumor  sought  for  by  the  little  finger,  inserted  with  great  gentleness,  or  by  a 
probe  or  grooved  director,  in  order  to  recognize  its  size,  depth,  density,  etc. 
If  it  be  so  large  that  it  is  not  wise  to  attempt  its  removal  the  operation 
should  immediately  be  terminated,  the  dura  sutured  and  the  flap  of  scalp 
replaced,  the  bone  being  left  out  permanently.  In  case  of  a  large  tumor, 
sometimes  only  a  portion  has  been  removed,  with  great  benefit.  It  may  be 
attacked  a  second  or  a  third  time  in  case  of  need.  I  must  especially  draw 
attention,  however,  to  the  importance,  in  case  the  tumor  is  very  large,  of 
not  doing  too  much,  since  I  am  sure  that  death  has  followed  in  some  cases  by 
reason  of  too  extensive  interference. 

Hemorrhage  is  to  be  treated  as  has  already  been  described  under  the  head 
of  Technique.  The  closure  of  the  wound  and  after-treatment  are  described 
in  the  same  section. 

Should  the  presumed  tumor  prove  to  be  a  case  of  actinomycosis  the  diseased 
tissue  should  be  removed  if  possible.  Buzzi  and  Galli- Valerie  {Brit.  Med. 
Journ.,  1893,  ii.  epitome  23), 'refer  to  a  case  by  Van  Itersen,  and  record 
another  of  their  own  in  which,  after  the  failure  of  operation,  gr.  xxx.  of 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      977 

iodide  of  potassium  daily  effected  a  complete  cure.  Should  the  case  be  sus- 
pected to  be  one  of  actinomycosis,  the  iodide  treatment  should  of  course  be 
tried  before  operation  is  resorted  to,  especially  as  the  improyement  in  re- 
ported cases  has  begun  quickly  and  progressed  rapidly. 

In  many  cases  of  tumor  it  is  best  to  do  the  operation  in  two  stages  seyeral 
days  ajoart.  The  first  stage  consists  of  opening  the  skull  and  dura,  deter- 
mining the  site,  character,  and  size  of  the  tumor,  and  then  temporarily  clos- 
ing the  wound.  If  operable  the  remoyal  may  be  undertaken  from  three 
to  six  days  later  by  reopening  the  wound. 

Fig.  326. 


Result  seven  years  after  the  removal  of  a  large  fibroma  of  the  brain.    (Keen.) 

Fig.  326  shows  the  result  seyen  years  after  the  removal  of  a  cerebral 
fibroma  weighing  oyer  three  ounces,  which  I  reported  in  the  American  Journal 
of  the.  Medical  Sciences,  in  October,  1888.  The  operation  was  followed  by  a 
large  fungus  cerebri.  The  opening  of  the  skull  is  protected  by  a  piece  of  tin 
covered  with  silk  and  sewed  inside  a  skull  cap. 


PERSISTENT   HEADACHE. 


In  a  few  cases  of  persistent  and  severe  headache,  unconquerable  by  medical 
means,  the  patient  has  Ijeen  trephined  with  good  results,  l)y  Horsley,  Warren, 
Weir,  myself,  and  others.  The  bone  disk  should  not  be  replaced,  inasmuch 
as  change  or  relief  of  the  intra-cranial  pressure  is  sought. 

The  intense  headache  which  accompanies  tumor  of  the  brain .  has  been 
most  happily  relieved  in  a  number  of  cases  by  trephining,  even  when  the 
tumor  itself  has  not  been  removed.  Thus  Horsley  \Brit.  Med.  Journ.,  De- 
cember 6,  1890,  has  reported  a  case  in  which  he  removed  nearly  one-half  the 
occipital  bone  for  an  inoperable  intra-cranial  tumor.  The  relief  was  so  great 
that,  when  from  the  growth  of  tlie  tumor  the  headache  returned,  the  patient 
sought  relief  by  the  removal  of  the  other  half  of  the  same  bone.  The  same 
relief  has  followed  in  two  of  my  own  cases  of  irremovable  tumor. 

62 


978  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


TREPHINING  FOR  PSYCHOSES. 

These  cases  may  be  divided  into  (1)  cases  of  traumatic  insanity,  (2)  non- 
traumatic insanity,  and  (3)  general  paralysis  of  the  insane. 

In  Traumatic  Insanity  there  will  usually  be  a  scar  to  guide  us  to  the 
proper  site  of  the  operation.  The  trephining  should  be  done  in  accordance 
with  the  rules  already  laid  down  under  the  head  of  Technique.  Any  spiculse 
of  bone,  cyst  of  the  brain,  lacerated  dura,  or  injured  brain-tissue  or  brain-scar 
should  be  entirely  removed. 

Non-traumatic  Insanity.  Burkhardt  (Allgem.  Zeitschf.  Psychiat,  etc., 
1891,  463),  has  reported  6  cases  in  which  he  exposed  the  brain  and  removed 
strips  of  its  tissue  2  centimetres  in  width.  In  some  cases  he  did  multiple 
operations,  the  operations  lasting  even  over  four  hours.  It  is  doubtful,  how- 
ever, whether  such  operations  are  justifiable. 

General  Paralysis  of  the  Insane.  Mr.  Claye  Shaw  (Brit.  Med. 
Journ.,  1889,  ii.  1090),  reported  the  first  case  of  trephining  for  this  condition. 
He  removed  a  piece  of  bone  one  one-half  by  three-quarter  inches  in  size,  and 
evacuated  considerable  fluid.  The  operation  has  been  repeatedly  done,  but, 
as  a  rule,  without  any  improvement.  To  be  of  any  value  the  operation 
should  be  done  early.  The  exposure  of  the  brain,  opening  of  the  dura  and 
closure  of  the  wound  after  replacement  of  the  bone  have  already  been 
described.     (See  Technique.)     See  also  page  698. 


CEREBRAL  PALSIES. 

Occasionally,  but  very  rarely,  indications  for  surgical  interference  are 
presented  by  these  palsies.  Operation  should  be  limited  to  those  appar- 
ently caused  by  hemorrhage,  cyst,  or  tumors.  The  technique  for  exposing 
the  brain  has  already  been  described.  The  clot,  cyst,  or  tumor  should  then 
be  removed  and  the  wound  closed  as  usual.  If  the  brain  is  simply  atrophied, 
as  shown  by  a  marked  difference  in  the  size  of  the  two  sides  of  the  skull,  no 
operation  should  be  done. 


REMOVAL    OP    THE    GASSERIAN    GANGLION   FOR 
TRIGEMINAL    NEURALGIA. 

The  Gasserian  ganglion  lies  in  a  well-marked  fossa  on  the  anterior  surface 
of  the  petrous  bone,  near  its  apex.  It  lies  between  two  layers  of  the 
dura,  the  upper  one  being  the  dura  proper,  the  other  serving  as  the  peri- 
osteum of  the  fossa.  Removal  of  the  ganglion  Avas  first  suggested  by  Dr.  J. 
Ewing  Mears,  of  Philadelphia  {Trans.  Amer.  Surg.  Assoc,  1884,  p.  483). 
Mr.  Rose,  of  London,  was  the  first  actually  to  perform  the  operation  (Brit 
Med.  Journ.,  1890,  i,  1012).  Soon  afterward,  Andrews,  of  Chicago  (Journ. 
Amer.  Med.  Assoc,  1891,  ii,  168),  devised  a  similar  operation.  Hartley  (JSf.  Y. 
Med.  Journ.,  March  19,  1892,  and  Annals  of  Surg.,  May,  1893,  512)  has 
modified  the  operation,  and  Krause  (Arch.  f.  Klin.  Chir.,  1892,  vol.  xliv, 
821)  also  independently  described  a  similar  procedure. 

Rosens  Operation.  The  eyehds  were  stitched  together  by  Mr.  Rose,  but 
later  experience  seems  to  show  that  this  is  unnecessary.  An  almost  semi- 
circular incision  is  made  from  near  the  outer  canthus  to  an  ii^ch  below  the 
external  angular  process,  backward  along  the  upper  border  of  the  zygoma, 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      979 

to  its  posterior  extremity.  It  is  then  carried  down  just  in  front  of  the  ear 
to  the  angle  of  the  jaw,  then  forward  along  the  lower  border  of  the  hori- 
zontal ramus,  as  far  as  the  facial  artery.  This  flap  of  skin  is  then  dissected 
forward.  Two  holes  are  drilled  in  the  zygoma  to  facilitate  its  later  wiring, 
and  the  zygoma  is  then  divided  and  displaced  downward,  along  with  the 
masseter  muscle.  The  coronoid  process  is  then  similarly  drilled,  divided,  and 
turned  upward,  with  the  tendon  of  the  temporal  muscle.  (In  Mr.  Rose's  later 
cases  this  fragment  of  bone  was  removed  as  useless,  the  drilling  being  there- 
fore omitted.)  The  external  pterygoid  muscle  is  then  scraped  loose  from 
the  sphenoid  bone  and  the  foramen  ovale  is  found.  A  long-handled,  half- 
inch  trephine  is  used,  the  centre-pin  of  which  is  placed  a  little  external  and 
anterior  to  the  foramen  ovale,  so  that  the  edge  of  the  trephine  opening  just 
reaches  the  foramen.  The  thin  lining  of  the  fossa,  in  which  the  ganglion 
lies  (the  lower  layer  of  the  dura),  is  then  divided,  and  the  ganglion  removed 
as  far  as  possible  by  a  hook  and  curette.  If  the  internal  maxillary  artery 
or  vein  are  in  the  way  they  are  double-ligated  and  divided.  Care  should  be 
taken  not  to  divide  the  upper  layer  of  the  true  dura  above  the  ganglion,  as  by 
so  doing  the  subdural  cavity  is  opened.  The  carotid  artery  and  the  cavern- 
ous sinus  lie  immediately  to  the  inner  side  of  the  ganglion  and  should  be 
carefuUy  avoided.  The  second  and  third  divisions  of  the  fifth  nerve  are 
readily  found  and  removed  by  means  of  a  small  hook  or  sharp  spoon.  It  is 
doubtful  whether  the  motor  root  can  be  left  intact. 

A  forehead  electric  light  is  a  necessity  in  this  operation.  In  that  of 
Hartley  it  is  a  great  aid,  but  the  operation  has  been  satisfactorily  done  with- 
out it. 

Hartley's  method  is  as  follows.  An  osteoplastic  resection  of  the  skull  is 
made,  the  base  of  which  is  two  inches  antero-posteriorly,  and  its  vertical 
height  three  inches  (Fig.  327).     After  the  skull  is  opened  (Fig.  328)  the 


Fig.  327. 


Hartley's  operation  for  removal  ol  the  Gasserian  ganglion.    Chiseling  the  bony  flap. 


-dui'a  is  lifted  gently  from  the  middle  fossa  by  means  of  the  finger  until  the 
second  and  third  divisions  of  the  fifth  nerve  are  well  exposed.     Care  must 


980 


NERVOUS  DISEASES  AND  THEIR  TREATMENT 


be  taken  not  to  ruj)ture  the  middle  meningeal  artery  at  the  foramen  spinosum. 
If  ruptured  it  can  be  ligated  by  passing  a  sharply  curved  needle  under  it 
through  the  dura.  The  hemorrhage  can  also  be  arrested  by  packing  with 
iodoform  gauze.  The  ganglion  can  be  found  by  tracing  the  second  and  third 
divisions  backward  to  their  junction.  As  already  stated,  it  lies  in  a  pocket 
formed  by  the  lower  layer  of  the  dura  mater,  which  serves  as  a  periosteum  to 
the  fossa  in  the  petrous  bone  and  the  upper  layer  or  dura  mater  proper.  This 
lower  layer  must  be  perforated,  but  it  is  desirable  to  avoid  opening  the  true 
dura,  as  that  opens  the  brain  cavity  itself.  (If  there  is  not  sufficient  room, 
Tiffany  has  proposed  to  obtain  more  by  deliberately  incising  the  dura  at  the 


Fig.  328. 


Hartley's  operation  for  removal  of  the  Gasserian  ganglion.    The  flap  of  bone  and  scalp 
turned  down,  exposing  the  dura  and  the  middle  meningeal  artery. 

outer  part,  where  it  can  be  well  sutured  again,  in  order  to  evacuate  some  of 
the  cerebro-spinal  fluid.)  The  nerves  should  then  be  cut  at  their  foramina, 
the  ends  forced  downward,  the  foramina  filled  with  dental  paste,  and  the 
ganglion  and  nerve-roots  removed.  The  latter  can  be  easily  removed,  but 
the  former  must  be  broken  up  ftiecemeal.  Great  care  is  necessary  to  avoid 
wounding  the  cavernous  sinus  or  the  carotid  artery  which  lie  just  beyond  the 
ganglion  and  the  origin  of  the  second  division  of  the  fifth  nerve.  If  there 
is  too  much  hemorrhage  to  remove  the  ganglion  at  once,  the  wound  may 
be  packed  with  gauze,  the  skull  closed  temporarily,  and  reopened  three  or 
four  days  later,  when  the  operation  is  completed. 

I  have  recently  collected  all  the  reported  cases  of  removal  of  the  ganglion, 
54  in  number.  Of  these,  25  each  were  done  by  Hartley's  and  by  Rose's 
method,  with  3 ,  deaths  by  Hartley's  and  5  by  Rose's  method.  Two  were 
done  by  Horsley's  method  (opening  the  dura  and  avulsion  or  division  of  the 
nerve-roots  at  the  pons),  one  by  a  method  combining  Hartley's  and  Rose's, 
and  one  in  which  the  method  was  not  stated.    Two  of  these  last  4  cases  died. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      981 


INTRA-CRANIAL    HEMORRHAGE. 

Spontaneous  Hemorehage,  especially  in  the  form  of  the  well-known 
lesions  of  apoplexy,  arises  from  rupture  of  the  lenticulo-striate  artery  dis- 
tributed to  the  basal  ganglia  of  the  brain.  For  the  relief  of  this  surgery 
has  very  little  to  offer.  Spontaneous  rupture  of  the  artery  at  one  point  is 
almost  always  an  indication  of  widely  distributed  degeneration,  and  there- 
fore no  surgical  measure  can  be  of  any  use.  Horsley  has  recommended,  in 
the  ingravescent  forins  of  apoplexy,  ligation  of  the  common  carotid.  So  far 
as  I  know,  the  two  cases  (one  of  which  recovered)  reported  by  Dercum  and 
myself  (Jouni.  Nervous  and  Mental  Dis.,  September,  1894)  are  the  only  two 
thus  far  recorded. 

Traumatic  Hemorrhage.  This  may  be  either  (1)  extradural,  between 
the  dura  mater  and  the  skull ;  (2)  subdural,  between  the  dura  and  the  brain ; 
or  (3)  cerebral,  in  the  brain  tissue  itself. 

1.  Extradural  Hemorrhage.  The  source  of  the  hemorrhage  in  this  variety 
is  almost  invariably  the  middle  meningeal.  Not  uncommonly  the  injury 
may  be  so  slight  as  not  even  to  leave  a  bruise.  Fracture,  therefore,  although 
frequently  present,  may  be  absent.  More  commonly  by  far,  the  rupture  takes 
place  in  one  of  the  branches  rather  than  in  the  main  trunk.  Occasionally  it 
is  bilateral,  and  sometimes  there  are  multiple  ruptures. 

Symptoms.  As  a  rule,  the  patient  is  stunned  by  the  blow,  then  recovers 
consciousness,  and  finally  relapses  again  into  a  comatose  condition.  A  large 
experience  has  shown  that  this  period  of  consciousness  between  the  uncon- 
sciousness produced  by  the  blow  and  the  unconsciousness  produced  by  the 
clot  is  of  the  greatest  importance.  This  temporary  consciousness,  which  may 
not  be  absolutely  complete,  is  due  to  the  fact  that  while  the  rupture  of  the 
artery  takes  place  at  the  moment  of  the  injury,  a  certain  time  is  required  for 
the  pouring  out  of  a  sufficient  quantity  of  blood  to  produce  coma  from  pres- 
sure. The  larger  the  vessel  which  is  injured,  the  more  rapid  will  be  the 
escape  of  the  blood  and  the  more  quickly  will  unconsciousness  recur.  In 
case  one  of  the  small  branches  is  ruptured,  the  interval  of  consciousness  may 
extend  not  only  to  hours,  but  even  to  days.  If  a  large  branch  or  the  main 
trunk  is  ruptured,  the  period  of  consciousness  may  be  exceedingly  brief  or 
even  absent.  This  symptom,  therefore,  should  always  be  investigated  with 
minute  care.  If  the  rupture  takes  place,  as  usual,  in  the  neighborhood  of 
the  motor  area,  there  may  be  paralysis,  amounting,  it  may  be,  to  complete 
hemiplegia.  On  the  other  hand,  if  the  clot  begins,  for  instance,  over  the 
face  centre,  there  will  be  paralysis  of  the  face ;  as  it  extends  upward  over  the 
arm  centre,  and  finally,  the  leg  centre,  the  arm  and  the  leg  will  successively 
be  paralyzed.  If  the  clot,  instead  of  extending  upward,  gravitates  toward 
the  base,  the  pupil  on  that  side  will  be  dilated  (though  dilatation  of  the  pupil 
sometimes  occurs  when  the  hemorrhage  is  over  the  vertex)  and  immobile,  and 
if  the  rupture  be  on  the  left  side  of  the  head,  there  will  be  aphasia.  The  pulse, 
at  first  slow,  later  becomes  rapid,  the  respiration,  on  the  contrary,  slow  and 
stertorous.  The  temperature  usually  rises  to  101°  to  103°.  If  there  be  a 
compound  fracture  involving  a  perforation  of  the  skull  and  the  meninges, 
the  brain  substance  may  protrude  through  the  wound.     (See  also  page  363.) 

Treatment.  The  instant  that  the  diagnosis  is  made,  operation  should  be 
undertaken  as  quickly  as  possible.  No  other  means  will  arrest  the  hemor- 
rhage. The  statistics  of  Weissmann  show  that  of  147  cases  treated  ex- 
pectantly, 89.1  per  cent,  died,  whereas  of  110  cases  in  which  operation  was 
undertaken,  only  32.7  per  cent,  died,  and  in  the  majority  of  the  fatal  cases  the 
clot  Avas  not  reached.    The  point  at  which  the  operation  should  be  done,  it  can- 


982 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


not  be  too  strongly  stated,  is  to  be  determined  not  by  the  site  of  the  injury, 
but  by  cerebral  localization.  In  the  great  majority  of  cases  the  clot  Avill 
best  be  reached  by  trephining  11  inches  behind  the  external  angular  pro- 
cess, at  the  level  of  the  upper  border  of  the  orbit  (Fig.  329  between  B  and 
TS,  and  Fig.  330).      Should   this  o]3eniug  not  disclose  the  clot,  another 


Fig.  329. 


FR 


POf 


Head,  skull,  and  cerebral  fissures  (adapted  from  Maeshall  by  Hare). 
B  corresponds  to  Broca's  convolution  ;  EAP,  external  angular  process  ;  FR,  fissure  of  Rolando ;  IF, 
inferior  frontal  sulcus  ;  IFF,  intra-parietal  sulcus ;  MMA,  middle  meningeal  artery ;  OPr,  occipital 
protuberance  ;  PE,  parietal  eminence ;  POF,  parieto-occipital  fissure  ;  SF,  Sylvan  fissure ;  ^,  its  as- 
cending limb;  TS,  tip  of  temporo-sphenoidal  lobe.  The  pterion  (to  the  left  of  and  above  B)  is  the 
region  where  three  sutures  meet,  viz.,  those  bounding  the  great  wing  of  the  sphenoid  where  it  joins 
the  frontal,  parietal  and  temporal  bones. 


trephine  opening  should  be  made  at  the  same  level,  immediately  below  the 
parietal  boss  (Fig.  330).  These  two  oj)enings  reach  respectively  the  anterior 
and  posterior  branches  of  the  middle  meningeal  artery.  So  soon  as  the  clot 
is  discovered  it  should  be  removed,  and  if  the  opening  is  not  sufficiently  large, 
more  bone  should  be  removed  by  the  rongeur  forceps.  If  dilatation  of  the 
pupil  shows  that  the  clot  is  gravitating  toward  the  base,  the  trephine  opening 
should  be  made  half  an  inch  below  the  first  point.  After  the  removal  of  the 
clot  the  cavity  should  be  well  washed  out  with  cooled  boiled  water.  The 
artery  shotild  be  secured  if  it  is  still  bleeding,  by  means  of  the  small  semi- 
circular Hagedorn  needle.  Drainage  should  then  be  provided  for  and  the 
wound  treated  as  already  described.  It  is  sometimes  necessary  to  trephine 
on  both  sides  of  the  head. 

2.  Subdural  Hemorrhage.  This  more  commonly  follows  depressed  frac- 
tures, gunshot  fractures,  rupture  of  the  middle  cerebral  artery,  etc.  There 
are  no  means  at  present  of  distinguishing  between  subdural  and  extradural 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      983 

hemorrhage.  In  a  very  recent  case  which  I  saw,  the  diagnosis  of  the  loca- 
tion of  the  clot  was  very  accurately  made,  from  the  fact  that  the  patient  had 
hemianopsia,  the  left  half  of  each  retina  being  blind.  Trephining  below  the 
parietal  boss  would  have  disclosed  the  clot,  but  the  patient  was  moribund 
when  first  seen. 

Fig.  330. 


Points  at  which  to  trephine  in  hemorrhage  from  the  middle  meningeal  artery. 
(After  Kronlein,  Esmarch  and  Kowalsky.) 
a  b,  horizontal  line  drawn  through  the  meatus ;  c  d,  through  the  eyebrow ;  ef,  vertical  line,  5^  cm. 
behind  the  external  angular  process  ;  g  h,  immediately  behind  the  mastoid  process.    The  intersec- 
tions A  and  B  mark  the  points  for  trephining  to  find  respectively  the  anterior  and  posterior 
branches  of  the  artery. 

Treatment.  The  only  difference  in  the  treatment  of  subdural  and  extra- 
dural hemorrhage  is  that  the  dura  must  be  opened,  and  the  opening  in  the 
bone  may  require  to  be  much  larger  than  in  the  former  case.  The  vessels 
should  be  secured  by  catgut.  Not  a  little  disorganized  brain-tissue  may  have 
to  be  removed,  and  I  think  it  of  some  importance  that  all  of  this  shall  be 
removed,  if  possible,  in  order  to  lessen  the  probability  of  later  epilepsy. 

3.  Hemorrhage  into  the  Brain  Substance.  As  a  rule,  traumatisms  involv- 
ing the  brain  so  deeply  are  rapidly  fatal.  The  cases  resemble  those  of  ordi- 
nary apoplexy,  except  in  the  cause,  which  is  revealed  by  the  history. 

4.  In  addition  to  such  hemorrhages  from  arteries,  the  sinuses  of  the  brain 
may  be  injured  and  cause  violent  and  alarming  hemorrhage.  Such  wounds 
are  due  usually  to  compound  fractures,  the  superior  longitudinal  or  the 
lateral  sinus  suffering  most  frequently.  Death  may  take  place  in  a  few 
minutes,  from  loss  of  blood,  and  shock,  and  hence  the  speediest  method  of 
checking  the  bleeding  should  be  adopted. 

Not  infrequently  it  is  necessary  to  trephine  in  the  neighborhood  of  these 
sinuses.  The  trephine  should  be  so  placed  that  its  edge  is  at  a  safe  distance 
from  the  sinus.  With  the  dural  separator,  grooved  director  or  other  blunt 
instrument,  or  the  finger,  the  sinus  may  be  safely  separated  from  the  skull. 
Then  the  trephine  opening  may  be  enlarged,  as  may  be  necessary  by  the 
rongeur  forceps. 

Should  the  sinus  be  ruptured  either  by  operation  or  by  fracture,  in- 
stant packing  with  strips  of  iodoform  gauze  Avill  almost  always  control  the 
bleeding.  Occasionally,  if  the  rent  is  not  too  large,  its  margins  can  be 
seized  by  one  or  more  pairs  of  hemostatic  forceps,  which  should  be  left  for 


984  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

two  or  three  clays,  with,  of  course,  an  ample  dressing  outside  of  them.  Care 
should  be  taken  also  that  they  be  not  displaced  by  the  patient's  movements. 
Lateral  ligature  or  suture  of  the  sinuses  can  occasionally  be  adopted. 

5.  The  hemorrhage  from  pachymeningitis  hemorrhagica  has  already  been 
considered  (page  971). 


FRACTURE  OF  THE  SKULL. 

The  danger  from  fracture  of  the  skull  is  not  so  much  from  the  injury  to 
the  bone  as  from  the  injury  to  the  brain  or  its  membranes.  Even  linear 
fracture  itself  is  occasioned  by  such  serious  force  that  the  brain  is  lacerated 
to  a  greater  or  less  extent,  and  if  fragments  of  bone  are  depressed  or  de- 
tached and  driven  into  the  brain,  the  injury  becomes  instantly  severe,  and 
very  frequently  fatal.  Such  injuries  formerly  were  considered  almost  entirely 
hopeless ;  but  a  large  number  of  cases  of  recovery  after  proper  antiseptic 
treatment  have  now  been  reported,  and  the  prognosis,  even  in  cases  of  very 
widespread  injury,  is  by  no  means  so  hopeless  as  it  used  to  be.  Next  to  very 
extensive  fractures,  the  most  dangerous  ai-e  the  punctured  fractures,  such  as 
those  caused  by  a  knife-blade,  nail,  etc.,  because  they  are  very  frequently 
overlooked,  or,  if  discovered,  are  improperly  treated. 

The  division  of  fractures  into  closed  and  open,  i.  e.,  simple  and  compound, 
obtains  in  the  skull  as  elsewhere,  but  it  is  especially  to  be  remembered  that 
fractures  extending  into  the  nose,  ear,  or  mouth  are  as  truly  compound  as 
a  compound  fracture  of  the  vault,  and,  like  the  punctured  fractures,  their 
existence  is  often  overlooked,  and  hence  the  wound  becomes  infected,  and 
death  results.  I  shall. especially  dwell  upon  the  treatment,  as  the  symptoms 
and  diagnosis  are  considered  so  fully  in  works  on  general  surgery. 

Fractures  of  the  Vault.  In  fissured  fractures,  as  a  rule,  the  injury 
can  only  be  suspected.  In  a  few  cases  a  "  cracked-pot "  sound  may  be  elicited 
by  percussion  and  be  observed  even  without  the  stethoscope.  It  may  be 
heard  also  by  the  patient  as  well  as  by  the  surgeon.  If  there  is  a  depression 
it  can  usually  be  easily  felt  by  the  finger,  but  care  must  be  taken  not  to  mis- 
take the  thickened  tissue  at  the  periphery  of  the  injury  for  the  edges  of  a 
depressed  fracture,  which  they  not  uncommonly  simulate.  Fracture  of  the 
inner  table  can  likewise  only  be  inferentially  established.  Although  such 
a  diagnosis  is  rare,  a  number  of  well-authenticated  instances  are  reported, 
and  if  the  symptoms  are  such  as  to  determine  its  localization,  as  for  instance 
a  palsy  of  speech,  or  of  the  right  arm,  etc.,  and  the  site  of  the  blow  be 
over  these  centres,  we  should  be  warranted  in  an  immediate  exploratory 
operation. 

Treatment.  The  tendency  of  modern  cerebral  surgery  is  distinctly  toward 
more  frequent  interference  than  formerly.  The  objection  which  ruled  twenty 
years  ago — that  an  incision  through  the  scalp  in  a  case  of  simple  fracture 
converted  it  into  a  compound,  and,  therefore,  more  dangerous  fracture — now 
falls  to  the  ground,  since  the  danger  is  very  slightly,  if  at  all,  increased  by 
such  an  incision,  if  done  antiseptically.  Moreover,  the  need  for  the  elevation 
of  depressed  fragments  for  the  removal  of  pieces  of  bone  which  have  been 
driven  into  the  brain,  and  in  compound  fractures  especially,  the  need  for 
thorough  disinfection  of  the  wound  in  order  to  prevent  septic  inflamma- 
tion outweigh  all  other  considerations.  Fractures  which  occupy  a  limited 
area,  for  instance,  one  from  a  blow  from  a  hammer,  must  be  carefully  distin- 
guished from  those  in  which  the  "bursting"  force  of  a  difilised  injury  may 
produce  very  widespread  injury  to  both  bone  and  brain.  As  a  rule,  in  the 
latter,  operation  would  rarely  be  advisable. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      985 

The  dictum  which  seems  at  present  to  meet  with  the  approval  of  the  ma- 
jority of  surgeons  may  be  summarized  as  follows : 

If  a  fracture  of  the  vault  be  simple,  without  depression  and  without  symp- 
toms of  injury  to  the  brain,  or  if  moderate  cerebral  symptoms  have  been 
present  but  are  subsiding,  or  if  fracture  be  only  suspected,  and  no  cere- 
bral symptoms  are  present,  the  expectant  treatment  is  the  proper  one ;  but 
the  instant  that  any  serious  symptoms  of  intra-cranial  mischief  arise,  opera- 
tion should  be  resorted  to. 

If  the  fracture  be  simple,  with  marked  depression,  immediate  trephining 
should  be  done,  even  should  there  be  no  signs  of  cerebral  mischief.  Any 
injury  sufficient  to  depress  the  bone  will  undoubtedly  have  lacerated  the 
brain  substance,  and  may  be  followed  either  by  speedy  inflammation,  or  if 
recovery  ensues,  in  not  a  few  cases  by  epilepsy  or  other  nervous  sequels 
which  are  best  avoided  by  operation. 

In  all  compound  fractures  of  the  skull  operation  should  be  immediately 
done.  I  am  persuaded  that  in  many  cases  infection  follows  from  the  limited 
area  over  which  the  scalp  is  shaven  and  disinfected.  Hence,  as  a  partial 
shaving  is  equally  disfiguring,  the  proper  course  is  to  shave  the  entire  head 
and  careftilly  disinfect  it.  Even  in  women  this  rule  should  hold  good.  A 
large  incision  should  be  made  in  the  scalp.  If  the  fracture  be  found  to  be 
linear  it  must  be  carefully  disinfected,  and  if  impregnated  with  dirt,  or  if 
any  of  the  hair  has  got  into  it,  the  outer  table  at  least  must  be  carefiilly 
chiseled  away  as  a  V-shaped  groove.  The  fracture  is  of  little  importance, 
infection  of  great.  Should  a  depression  exist,  trephining  should  be  done 
and  the  bone  elevated,  independently  of  the  existence  of  any  cerebral  symp- 
toms. 

Punctured  fractures,  as  an  absolute  rule,  should  always  be  treated  by  im- 
mediate trephining  for  many  evident  reasons. 

Should  any  cerebral  mischief  arise,  even  at  a  late  period,  after  fracture, 
such  as  localized  paralysis,  epilepsy,  optic  neuritis,  etc.,  operation  should  be 
done  immediately. 

Fractures  of  the  Base.  These  fractures  may  arise  either  directly  or 
from  extension  of  fractures  of  the  vault,  or  by  indirect  violence  through  the 
spinal  column.  Occasionally  they  are  punctured  fractures,  the  vulnerating 
instrument  obtaining  access  to  the  base  either  through  the  orbit,  the  nose,  or 
the  mouth. 

Fractures  of  the  base  are  not  uncommonly  only  inferential  from  the 
violence  of  the  blow,  but  occasionally  we  may  be  able  to  follow  a  fracture 
well  toward  the  base.  It  must  not  be  forgotten  that  fractures  through  the 
cavities  just  mentioned  (orbit,  nose,  or  mouth)  may  be  overlooked  from 
the  fact  that  in  the  nose  and  mouth  the  cavity  is  closed,  and  in  the  orbit 
the  wound  in  the  skin,  by  its  resemblance  to  a  simple  cut,  may  mislead 
us  into  believing  that  there  is  no  deeper  injury.  Yet  a  splinter  of  wood 
or  a  knife  blade  may  be  hidden  deep  under  the  skin.  Of  course  the  escape 
of  brain  substance  or  cerebro-spinal  fluid  through  the  ear,  nose,  mouth,  or 
orbit,  is  positive  evidence.  If  blood  has  been  vomited  after  a  severe  injury 
to  the  head,  care,  should  be  always  taken  to  determine  whether  there  has  not 
been  a  fracture  of  the  roof  or  the  pharynx,  the  blood  being  first  swallowed 
and  then  vomited. 

The  commonest  sign  of  fracture  of  the  base  in  the  middle  fossa  is  the 
escape  of  blood  or  cerebro-sjoinal  fluid  from  the  ear.  If  either  of  these  con- 
tinues for  a  long  time,  and  especially  if  the  escape  of  the  fluid  is  affected  by 
the  position  of  the  head  and  is  inci'eased  by  any  violent  ex2:)iratory  effort, 
such  as  sneezing,  coughing,  etc.,  it  is  always  positive  evidence  of  such  a  frac- 
ture.    Sometimes,  however,  there  may  be  fracture  of  the  base  without  rup- 


986  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

ture  of  the  drum-head,  and  therefore  no  cerebro-spinal  fluid  can  escape. 
Such  fractures,  it  must  be  remembered,  are  compound,  as  they  communi- 
cate with  the  external  air  through  the  Eustachian  tube,  and  the  danger  of 
overlooking  them  is  very  great.  Injury  to  any  of  the  cranial  nerves,  espe- 
cially the  optic,  facial,  and  auditory,  is  strong  inferential  evidence  of  fracture 
of  the  base. 

In  fracture  of  the  orbit,  blood  will  appear  in  a  day  or  two  under  the  con- 
junctiva, before  it  appears  in  the  eyelid. 

In  fracture  of  the  posterior  fossa,  optic  neuritis  sometimes  occurs,  usually 
before  the  end  of  the  first  week.  It  is  extremely  important  in  fractures  of 
this  fossa  that  the  mastoid  region  should  be  examined  for  ecchymosis.  This 
is  often  overlooked  in  consequence  of  its  being  hidden  by  the  ear,  the  pillow, 
and  the  hair.  The  blood  first  appears  at  the  mastoid,  some  time  after  the 
injury,  and  spreads  chiefly  upward  and  backward,  wath  a  crescentic  border. 
As  Battle  has  shown,  the  reason  for  these  peculiarities  is  that  the  blood  can- 
not reach  the  surface  below  the  occiput  on  account  of  the  dense  cervical 
fascia,  but  follows  the  inter-muscular  planes  sidewise,  and  first  reaches  the  sur- 
face at  the  mastoid  after  two  or  three  days. 

Treatment.  These  injuries  were  formerly  excessively  fatal,  but  in  numer- 
ous recent  cases  recovery  has  followed  judicious  treatment.  First  the  cavity 
or  cavities  involved  must  be  carefully  disinfected.  The  ear  should  be  cleansed 
of  wax,  dirt,  and  blood-clot,  and  disinfected  by  prolonged  syringing  with  a 
1  to  2000  sublimate  solution.  It  should  then  be  packed  with  sublimated  cotton 
or  iodoform  gauze  and  covered  with  an  ample  sublimate  dressing.  In  frac- 
tures through  the  orbit  the  same  rule  should  be  carried  out,  and  if  the  fracture 
be  a  punctured  one,  thus  almost  positively  insuring  infection  of  the  brain, 
the  Avound  should  be  enlarged,  very  thoroughly  disinfected,  and  as  a  general 
rule,  drained,  sometimes  best  through  the  nasal  cavity. 

In  the  nose  and  mouth  there  would  of  course  be  danger  in  using  the  cor- 
rosive sublimate  solution.  They  should,  however,  be  thoroughly  washed  out 
with  hot  water  and  then  with  boric  acid  solution.  This  or  other  antiseptic 
solutions  should  also  be  sprayed  through  the  mouth  and  nostrils.  The  nose 
should  be  lightly  packed  with  sublimated  iodoform  or  sterilized  cotton. 
Boric  acid  or  iodoform  may  also  be  insufliated  into  the  naso-pharynx,  thus 
reaching  the  orifice  of  the  Eustachian  tube.  These  measures  only  result  in 
a  partial  asepsis,  but  the  danger  of  infection  is  directly  proportionate  to  the 
number  of  bacteria  introduced  into  a  wound,  and  the  results  in  treatment 
have  been  so  favorable  that  no  surgeon  would  be  excused  if  he  neglected 
them.  Of  course  the  ordinary  dietetic  and  hygienic  treatment  which  has 
long  been  applied  to  such  injuries  should  be  most  carefully  carried  out. 


WOUNDS    OP   THE    BRAIN,    ESPECIALLY    GUNSHOT 

^WOUNDS. 

In  all  wounds  of  the  brain  besides  the  usual  careful  disinfection,  all  dirt 
and  foreign  bodies  should  be  removed.  Fragments  of  bone,  which  may  have 
been  driven  into  the  brain,  should  be  removed,  search  being  made  by  the 
finger  and  groove  director,  gently,  but  thoroughly,  lest  some  of  the  frag- 
ments should  be  overlooked.  The  depressed  bone  should  be  removed.  The 
brain  tissue  itself  is  also  to  be  disinfected.  The  hemorrhage  is  arrested  by 
the  ligature,  hot  water,  or  pressure.  If  the  sinuses  have  been  wounded,  pack- 
ing with  iodoform  gauze,  or  the  application  of  haemostatic  forceps,  will 
usually  suffice.     If  the  dura  has  been  only  slightly  lacerated,  it  may  be 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      987 

sutured  with  catgut  or  fine  silk.  If  there  is  any  great  loss  of  the  dura,  this 
may  be  supplied  by  a  portion  of  the  pericranium  (see  page  965).  Drainage 
should  be  provided  by  rubber  tubing,  the  scalp  sutured,  and  an  ample  sub- 
limate dressing  be  applied.  Secondary  abscesses  are  not  uncommon  after 
such  wounds.  The  surgeon  should  be  watchful,  therefore,  and  if  any  symp- 
toms of  such  abscesses  arise,  the  wound  should  be  reopened,  and  the  jius 
evacuated  as  soon  as  possible. 

In  gunshot  wounds  the  entire  track  of  the  wound,  from  that  of  entrance 
to  that  of  exit,  or  to  the  probable  site  of  the  ball,  if  it  have  not  escaped, 
should  be  disinfected.  This  may  be  done  by  a  bichloride  solution,  1-2000, 
terminating  the  disinfection  by  washing  with  warm  boiled  water.  Should 
there  be  any  serious  hemorrhage  either  in  this  or  in  any  other  wound  of  the 
brain,  the  wound  of  entrance  or  that  of  exit,  or  both,  should  be  enlarged  by 
the  rongeur  forceps  or  by  the  trephine,  and  the  vessels  secured  as  usual.  The 
bullet  or  fragments  of  bone,  or  other  foreign  bodies,  should  be  removed.  A 
counter  opening  may  be  necessary  in  order  to  remove  the  bullet,  the  axis  of 
the  wound  having  been  determined  by  Fluhrer's  aluminum  gravity  probe. 
(See  Fig.  331.)     The  ball  is  sought  for  gently  but  thoroughly,  and  removed 

Fig.  331. 


Fluhrer's  aluminum  probe  (natural  size  except  the  length — 12  inches). 

through  the  wound  of  entrance,  or  if  it  be  much  nearer  the  opposite  side  of 
the  skull,  by  a  counter  trephine  opening  at  the  point  determined  by  prolong- 
ing the  axis  of  the  probe.  Drainage  must  be  thoroughly  carried  out,  if  need 
be  by  a  counter-opening,  the  drainage-tube  being  carried  entirely  through 
the  brain.  To  locate  the  ball  Girdner's  telephone  probe  may  be  used.  The 
mortality  in  the  cases  in  which  the  ball  is  not  removed  is  about  55  per  cent., 
of  those  in  which  it  is  removed,  about  33  per  cent.  If  the  ball  cannot  be 
found  without  too  much  laceration  of  the  brain,  the  search  for  it  should  be 
abandoned.  Thorough  disinfection  and  drainage  of  the  wound  in  a  number 
of  cases  have  been  followed  by  recovery. 


CONCUSSION  OR  LACERATION  OF  THE  BRAIN. 

The  old  term  concussion  of  the  brain,  while  very  convenient  clinically, 
conveys  pathologically  a  wrong  idea,  as  it  implies  rather  a  functional  than  a 
physical  lesion.  As  a  matter  of  fact,  almost  all  modern  surgeons  are  in  ac- 
cord in  the  belief  that  any  injury,  certainly  any  which  passes  beyond  a  very 
slight  stunning,  practically  involves  a  laceration  of  the  brain  tissue. 

The  surgical  treatment  consists,  first,  of  absolute  rest  in  bed,  together  with 
those  means  to  induce  entire  quiet  of  mind  and  body,  and  reaction  from  shock, 
which  are  well  known.  To  this  end,  hot  water  bags  should  be  placed  about 
the  patient,  great  care  being  taken  that  he  be  not  burned  by  them.  The 
most  careful  diet  with  occasional  purgatives  and  attention  to  general  hygienic 
conditions  are  necessary  for  a  more  or  less  prolonged  time.  ^  As  a  stimulant 
during  the  period  of  shock  the  aromatic  spirit  of  ammonia  is  better  than 
alcohol,  which  produces  too  much  cerebral  excitement.  As  to  the  later 
treatment,  while  there  is  considerable  difference  of  opinion  at  the  present 
time,  my  own  opinion  is,  if  serious  symptoms  arise  indicative  of  intra-cranial 


988  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

mischief,  and  particularly  if  the  symptoms  are  localized,  that  a  semicircular 
flap  of  scalp  should  be  raised  and  the  bone  inspected.  If  a  fracture  is 
discovered  an  exploratory  trephining  should  be  done,  and  the  dura  opened. 
Traumatic  inflammation  is  always  attended  with  proliferation  and  exuda- 
tion, and  if  the  exudate  be  not  afforded  the  means  of  escape  before  inflam- 
mation or  even  suppuration  have  arisen  great  danger  to  life  will  exist. 
Trej^hining  in  these  cases  is  simply  equivalent  to  an  incision  down  to  the 
focus  of  inflammation  in  the  soft  parts,  the  only  difference  being  (and  this  is 
a  serious  one)  that  in  order  to  reach  the  focus  of  inflammation  in  the  skull, 
an  opening  in  the  bone  must  be  made.  If  this  is  not  done  there  is  no  pos- 
sible means  of  escape  for  the  hemorrhage  or  the  exudate,  which  threatens 
suppuration. 

If  the  contusion  be  severe,  and  especially  if  the  swelling  of  the  scalp  is 
so  thick  and  dense  that  it  is  difficult  to  determine  whether  a  fracture  exists 
or  not,  such  an  exploratory  incision  should  undoubtedly  be  made,  and  fol- 
lowed by  trephining  if  necessary.  The  old  objection  that  we  thus  convert  a 
simple  fracture  into  a  compound  one  does  not,  at  present,  hold  good  in  view 
of  the  safety  of  modern  antiseptic  surgery,  and  even  if  there  were  consider- 
able danger,  the  dangers  of  not  operating,  and,  therefore,  of  an  uncertain 
diagnosis  and  unsuitable  treatment,  outweigh  any  possible  dangers  of  such 
an  incision  if  properly  done.  Even  after  a  long  period  an  abscess  may  arise. 
Every  case  of  severe  contusion  of  the  skull  therefore  should  be  watched  for^ 
weeks,  and  even  months,  and  at  the  first  indication  of  any  such  symptoms, 
operative  interference  would  be  justified. 


COMPRESSION  OF  THE  BRAIN. 

The  treatment  of  this  condition  depends  entirely  upon  its  cause.  If  there 
has  been  an  injury  of  the  skull  and  the  indications  are  those  of  intra-cranial 
hemorrhage,  instant  trephining  should  be  done  at  the  point  or  points  and 
in  the  manner  described  under  the  head  of  intra-cranial  hemorrhage  (p. 
981).  If  there  is  a  depressed  fracture,  trephining  should  be  done  as  indi- 
cated in  the  treatment  of  that  subject,  and  the  bone  removed  or  lifted  (p. 
984).  If  there  are  foreign  bodies  in  the  brain  they  should  be  removed  with  the 
fragments  as  stated  under  that  heading  (p.  986).  If  from  abscess  of  the  brain, 
trephining  should  be  done,  the  abscess  evacuated  and  drained  (p.  971).  If 
the  compression  arises  from  internal  hydrocephalus,  the  patient  should  be 
trephined  and  the  exudate  drained  by  puncture  of  the  ventricles  (p.  968). 
If  the  compression  is  caused  by  a  tumor,  the  tumor  should  be  removed  if 
the  case  is  one  suitable  for  such  operation  (p.  976).  The  later  treatment 
consists  of  rest,  restricted  diet,  attention  to  the  bowels  and  bladder,  the  abso- 
lute absence  of  visitors  or  anything  that  can  cause  mental  or  physical  excite- 
ment, together  with  such  general  hygienic  precautions  as  are  suitable  to  the 
case. 

SURGERY  OF   THE  SPINAL    CORD. 

The  progress  which  has  been  made  in  the  surgical  treatment  of  diseases 
of  the  spinal  cord,  especially  in  the  operative  treatment,  within  the  last  few 
years,  is  very  remarkable.  The  various  surgical  procedures  are  summarized 
as  follows : 

Spina  Bifida.  The  treatment  of  spina  bifida  by  the  injection  of  Mor- 
ton's fluid  (iodine  gr.  x.,  iodide  of  potassium,  gr.  xxx.,  glycerin  gj),  has 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      989 

j)roved  in  ver}^  many  cases  effectual.  In  1885  a  committee  of  the  Clinical 
Society  of  London  made  a  thorough  report  on  the  methods  of  treatment  of 
spina  bifida.  Only  fourteen  cases  out  of  sixty  were  known  to  have  been 
cured  spontaneously.  In  seventy-one  cases  treated  with  Morton's  fluid  the 
mortality  was  shown  to  be  38  per  cent.  ^Morton,  himself,  in  twenty-nine 
later  cases,  however,  has  reported  a  mortality  of  only  six,  or  20.7  per  cent. 
Powers  (N.  Y.  Med.  Joum.,  July  16,  1892,  page  65),  has  collected  fifteen 
more  cases  with  four  deaths,  a  mortality  of  26.66  per  cent. 

The  method  of  operating  is  as  follows :  After  thorough  disinfection  of  the 
skin  about  one  drachm  of  the  cerebro-spinal  fluid  is  evacuated  and  a  drachm 
of  the  solution  injected.  This  injection  should  be  made  at  the  side  through 
healthy  skin  and  not  through  the  membranous  portion  of  the  sac,  and  care 
should  be  taken  not  to  wound  the  nerves.  Leakage  of  the  cerebro-spinal 
fluid  should  be  prevented  by  sealing  the  opening  by  iodoform  collodion  and 
a  gauze  dressing  secured  also  with  collodion.  Later  injections,  if  needed, 
should  be  made  at  intervals  of  a  week  or  ten  days. 

The  treatment  of  this  malformation  by  operation,  however,  has  been  win- 
ning its  way  greatly  into  favor,  and  as  the  technique  improves,  it  is  fairly 
certain  that  the  percentage  of  recoveries  after  excision  will  increase  and 
make  this  the  method  of  choice.  Powers  (loc.  eit.)  has  tabulated  thirty 
cases  of  excision  with  twenty-four  recoveries  and  seven  deaths,  a  mortality 
of  22.58  per  cent.  The  mortality,  therefore,  is  about  the  same  as  that  after 
using  Morton's  fluid,  but  will  probably  improve  very  much  as  our  experi- 
ence grows.  Hildebrand  (Deutsch.  Zeitschr.f.  Chir.,  1893,  xxxvi.,  515),  has 
collected  87  operations  with  23  deaths,  a  mortality  of  26.4  per  cent. 

Of  the  three  varieties  of  spina  bifida,  meningocele,  meningo-myelocele,  and 
hydromyelocele,  only  the  first  and  second  are  amenable  to  treatment  by 
excision.  Even  in  these  two  forms,  only  those  cases  "  in  which  the  general 
condition  of  the  patient  is  good,  in  which  no  paraplegia  is  present,  in  which 
the  vertebral  fissure  is  of  moderate  extent,  and  the  communication  between 
the  sac  and  the  canal  is  narrow  "  should  be  chosen  for  operation.  (Powers.) 
In  other  cases  less  favorable  for  operation  Morton's  fluid  should  be  used. 

Operation  in  Meningocele.  An  elliptical  incision  is  made  leaving  suf- 
ficient skin  to  cover  in  the  defect.  The  sac  is  then  dissected  down  to  its  base, 
the  serous  membrane  at  its  neck  being  sutured  with  the  two  serous  surfaces 
apposed,  or  if  very  small,  the  neck  of  the  sac  may  be  ligated,  and  the  skin 
closed  over  it,  and  dressed  as  usual.  It  is  very  important,  as  far  as  possible, 
to  prevent  the  escape  of  the  cerebro-spinal  fluid,  partly  on  account  of  imme- 
diate danger  to  life,  but  especially  to  prevent  a  fistula,  which  may  later  be- 
come infected,  and  be  followed  by  a  septic  meningitis. 

Operation  in  Meningo-Myelocele.  In  this  condition  the  nerves  are 
commonly  found  attached  to  the  posterior  surface  of  the  sac.  Whether  they 
are  adherent  or  not  can  sometimes  be  determined  in  translucent  tumors  by 
transmitted  light  from  a  candle  while  the  surgeon  looks  through  a  cylinder 
of  paper  applied  at  the  opposite  side.  If  present,  the  nerve-roots  must  be 
dissected  loose  from  the  sac  and  replaced  in  the  canal.  In  other  respects  the 
operation  is  done  as  before. 

Attempts  have  been  made,  however,  within  the  last  four  years  to  close  the 
bony  opening  in  the  spine  and  not  merely  the  membranous  opening.  This 
has  been  effected  \)\  loosening  the  muscles  on  each  side  by  using  a  strip  of 
periosteum  of  the  rabbit,  the  osteogenetic  sui'face  being  turned  undermost 
and  the  piece  sutured  in  place  to  the  periosteum,  and  by  transplanting  a 
piece  of  bone  from  the  scapula  of  a  young  rabbit.  The  most  important 
modifications,  however,  are  as  follows.  Dollinger,  with  bone  forceps  divided 
the  rudimentary  portions  of  the  arches  of  the  fourth  and  fifth  luml)ar  verte- 


990  NERVOUS  DISEASES  AND  TREIB  TREATMENT. 

br^e  close  to  their  bases,  and  sutured  them  together  in  the  middle  line.  Bob- 
roff  has  chiselled  from  the  iliac  crest  a  piece  of  bone  three  centimetres  wide, 
two  long,  and  nearly  one  thick.  The  bone  was  not  chiselled  loose,  but  was 
turned  over  on  a  hinge,  formed  by  the  erector  spinse  muscles,  so  that  the 
periosteal  surface  was  next  the  cord,  the  chiselled  surface  presenting  poste- 
riorly. The  pieces  of  bone  were  then  slid  under  the  gluteus  maximus,  which 
had  been  dissected  loose  from  the  bone  and  were  held  in  position  by  sutures 
through  the  bone.  The  patient  was  kept  on  the  abdomen  for  two  months, 
at  the  end  of  which  time  consolidation  of  the  transplanted  bone  had  taken 
place,  and  he  was  allowed  to  change  his  position.  Five  mouths  after  the 
operation  the  boy  was  in  good  condition,  had  recovered  from  his  incontinence 
of  urine  and  feces  at  night,  and  of  feces  during  the  day.  In  the  dorsal 
region  the  same  author  proposes  to  obviate  the  difficulty  by  chiselling  off  the 
outer  lamellae  of  the  adjacent  ribs. 

Spinal  Drainage  for  Tubercular  Meningitis  and  Hydrocephalus. 
This  has  already  been  considered  under  the  head  of  Hydrocephalus  (page 
968). 

Intra-Spinal  Division  of  the  Nerve-Roots  in  Inveterate  Neu- 
ralgia.    This  is  considered  on  page  1002. 

Spinal  Hemorrhage.  It  is  doubtful  whether  in  the  present  state  of 
surgery  any  operation  should  be  undertaken  either  in  hsemato-myelia  or 
haematorrhachis,  though  Mills  has  suggested  the  possibility  of  trephining  the 
spine  at  two  points  to  secure  drainage.  It  is  not  impossible  that,  as  our  ex- 
perience and  technique  become  larger  and  better,  this  may  be  accomplished. 

Gunshot  Wounds  of  the  Spinal  Cord.  Many  of  these  lesions  are,  of 
course,  of  so  serious  a  character  as  to  forbid  any  interference.  But  as  Vin- 
cent has  shown  {Rev.  Chir.,  1892,  p.  89),  first,  in  those  cases  in  which  the 
cord  is  compressed  by  extravasations  of  blood,  fragments  of  bone,  or  by  the 
projectile  lying  without  the  medullary  canal,  improvement  may  possibly  be 
expected  if  we  remove  the  source  of  the  compression  by  operation  ;  second, 
if  the  projectile  has  injured  the  cord,  as  the  diagonsis  of  the  extent  of  the 
injury  cannot  be  made  without  an  operation,  exploration  may  be  done,  unless 
other  fatal,  especially  visceral,  lesions  are  present,  and  third,  if  the  j^rojectile 
lodge  in  the  spinal  canal  an  operation  is  certainly  indicated,  as  fatal  menin- 
gitis and  myelitis  with  cystitis  and  bedsores  will  undoubtedly  follow,  unless 
it  be  removed. 

Laminectomy  for  Pott's  Disease.  It  is  only  since  1883  that  such  sur- 
gical interference  in  Pott's  disease  has  been  u^ndertaken,  and  surgeons  are  not 
yet  wholly  in  accord  as  to  the  indications  for  interference.  "  So  long  as  we 
have  reasonable  or  even  moderate  hope  of  recovery  without  operation,  we 
do  not  believe  it  advisable  or  justifiable  in  the  present  condition  of  spinal 
surgery  to  perform  so  serious  an  operation  as  the  resection  of  the  laminae." 
(Burrell  and  Bullard).  "It  is  necessary  before  operating  to  have  exhausted 
all  other  methods  of  treatment,"  says  Kraske :  "I  would  say  interfere  when 
the  paralysis  of  the  bladder  is  established.  This  is  the  one  symptom  which 
is  so  serious  as  to  justify  everything,"  to  which  dictum  Lloyd  adds  "  that  the 
first  sign  of  degeneration  of  the  cord  should  indicate  immediate  operation," 
These  opinions  seem  to  me  to  indicate  the  proper  medium  between  rashness 
and  too  great  conservatism.  Ordinary  cases  of  mere  curvature  of  the  spine 
from  Pott's  disease  are  never  to  be  operated  upon,  but  only  those  in  which 
paraplegia  with  paralysis  of  the  bladder,  cystitis,  and  bedsores  have  arisen 
should  be  considered  as  justifying  operative  interference.  Of  course,  if 
there  are  other  active  tubercular  complications,  operation  is  absolutely 
contraindicated.  The  causes  of  pressure  may  be,  first,  masses  of  granu- 
lation  tissue   arising   from   the   vertebrae  within   the  spinal  canal,  or   the 


SUBGEBY  OF  THE  BBAIN,  SPINAL  COBD,  AND  NEBVES.      99 1 

thickening  which  results  from  pachymeningitis,  occasionally  amounting 
practically  to  a  tumor,  or,  secondly,  abscesses  resulting  from  the  breaking 
down  of  this  granulation  tissue.  Either  of  these  lesions,  providing  the  con- 
ditions already  stated  exist,  may  be  treated  by  laminectomy,  with  removal  of 
the  neoplasm,  the  granulation  tissue,  the  pus,  the  carious  bone,  etc.,  by  the 
usual  operative  means  (vide  infra  Technique,  page  993). 

Treatment  of  Spinal  Abscess.  Spinal  abscesses  have  been  operated 
on  for  many  years.  Until  within  a  few  years,  however,  surgeons  have  been 
content  to  evacuate  and  drain  such  abscesses  with  or  without  curetting,  or 
the  injection  of  iodoform  in  ether  or  in  olive  oil.  Mr.  Treves  (3fed.  Chir. 
Trans.,  vol.  Ixvii.,  and  Manual  of  Operative  Surgery,  ii.  731)  has  well  de- 
scribed his  improved  method.  The  parts  having  been  made  aseptic,  a  verti- 
cal incision  of  two  and  a  half  inches  is  made  upward  between  the  crest  of 
the  ilium  and  the  last  rib,  at  about  two  and  a  half  inches  from  the  lumbar 
spines.  The  lumbar  aponeurosis,  with  its  attached  muscular  fibres,  are  divided 
the  full  length  of  the  incision,  exposing  the  erector  spinee,  which  is  recog- 
nized by  the  vertical  direction  of  its  fibres.  This  muscle  is  drawn  as  far  as 
possible  toward  the  middle  line,  exposing  the  middle  layer  of  the  lumbar 
fascia.  Through  this  the  transverse  processes  of  the  lumbar  vertebrae  are 
sought  for,  especially  the  third,  it  being  the  most  conspicuous  and  easily  felt. 
This  layer  of  the  fascia  is  then  divided  to  the  transverse  processes,  exposing 
the  thin  quadratus  lumborum  muscle.  This  is  divided  close  to  the  extremity 
of  a  transverse  process,  and  the  incision  enlarged  gently  by  the  finger  to  the 
entire  extent  of  the  wound.  Care  must  be  taken  not  to  wound  the  abdom- 
inal branches  of  the  lumbar  arteries.  The  psoas  muscle,  which  overlaps  the 
quadratus,  is  now  discovered,  the  inter-muscular  interval  being  marked  by 
the  thin  but  distinct  anterior  layer  of  the  lumbar  fascia.  Some  of  the  ten- 
dinous fibres  of  the  psoas  having  been  divided  close  to  a  transverse  process, 
the  finger  is  introduced  beneath  the  muscle,  following  the  process  until  the 
anterior  aspect  of  the  bodies  of  the  vertebrae  is  reached.  The  abscess  cavity 
will  visually  have  been  entered  at  some  point,  and  should  now  be  thoroughly 
opened  and  subjected  to  prolonged  irrigation  by  a  sublimate  solution,  1-5000. 
During  the  irrigation  the  abscess  may  be  gently  curetted  by  the  finger-nail 
or  sharp  spoon,  care  being  taken  not  to  break  through  the  anterior  wall  of 
the  abscess  cavity.  The  cavity  is  then  well  scrubbed  out,  either  with  a  fine 
sponge  or  with  gauze  sponges,  every  pocket  and  diverticulum  being  pene- 
trated, the  sponge  being  changed  frequently,  and  the  sublimate  solution  con- 
tinuously used  for  flushing.  When  the  abscess  cavity  aj^pears  to  be  clean, 
as  shown  by  the  sponge  returning  perfectly  unsoiled,  it  should  be  dried  and 
closed  by  silkworm-gut,  the  sutures  being  passed  sufiiciently  deep  to  include 
the  greater  part  of  the  soft  tissues  over  it.  It  is  closed  without  drainage. 
The  after-treatment  consists  in  absolute  rest  in  the  recumbent  position  for 
months,  with  attention  to  the  favorable  dietetic,  hygienic,  and  climatic  con- 
ditions as  far  as  the  means  of  the  patient  will  allow.  If  sujjpuration  recurs 
the  wound  should  be  reopened  and  the  former  treatment  practically  repeated, 
followed  by  free  drainage. 

Retro-jiharyngeal  abscesses,  or  tubercular  abscesses,  arising  from  the  bodies 
of  the  cervical  vertebrae,  were  formerly  opened  in  the  pharynx,  but  the 
methods  proposed  by  Chieue  and  Burckhardt  are  better.  These  consist  in 
an  incision  at  the  outer  (Chiene)  or  inner  (Burckhardt)  border  of  the  sterno- 
cleido-mastoid  muscle ;  the  bodies  of  the  vertebrae  are  reached  by  a  blunt 
dissection  largely  by  the  finger,  the  vessels  in  the  neck  being  carefully 
avoided.  When  the  cavity  is  reached  it  is  to  be  treated  as  has  been  already 
described  for  lumbar  or  psoas  abscess.  The  great  advantage  of  these  meth- 
ods is  that  thorough  antisepsis  can  be  secured,  while  it  is  impossible  to  secure 


992  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

it  through  the  mouth.  The  oral  route,  however,  has  generally  a  small  mor- 
tahty,  and  in  the  case  of  a  timid  or  an  inexperienced  operator,  may  be  chosen 
by  preference. 

Fractures  and  Dislocations  of  the  Spine.  This,  again,  is  a  subject 
in  the  treatment  of  which  surgeons  are  by  no  means  in  accord,  especially  from 
the  fact  that  it  is  so  difficult  to  diagnosticate  precisely  the  nature  and  extent 
of  the  lesion.  It  is  argued  on  the  one  hand  that  in  these  destructive  lesions, 
especially  if  they  be  total  transverse  lesions  followed  by  entire  paralysis 
both  of  motion  and  sensation,  with  complete  abolition  of  the  knee- 
jerks  and  other  deep  reflexes  on  both  sides,  no  benefit  whatever  can  be 
derived  from  operation.  On  the  other  hand,  however,  the  evidences  ad- 
duced, especially  by  the  condition  of  the  knee-jerk,  it  is  argued,  are  insuffi- 
cient to  prove  absolutely  that  the  lesion  is  a  total  transverse  lesion,  entirely 
destroying  the  cord,  and  that  operation  is  the  only  means  of  determining 
whether  the  lesion  is  comj)lete ;  and  that  a  few  cases  have  been  reported  in 
which  operation,  even  when  total  abolition  of  the  knee-jerks  exists,  has  been 
followed  by  partial,  or  in  some  cases  by  complete  relief  A  notable  instance 
of  this  is  given  by  Schede  {Anyials  of  Surgery,  September,  1892,  p.  231)  in 
which  all  of  the  symptoms  above  described  were  present,  and  bedsores  had 
begun  to  form  the  next  day.  Sixteen  hours  after  the  accident  Schede 
operated,  removing  the  bony  fragments  pressing  on  the  cord,  the  dura  being 
uninjured,  but  the  cord  being  soft  and  fluctuating.  The  patient  not  only 
recovered  the  functions  of  the  bladder  and  rectum,  but  two  months  after  his 
discharge  was  in  excellent  health.  These  cases  are,  as  a  rule,  so  helpless 
without  operation,  that  my  own  feeling  is  in  favor  of  operation  in  suitable 
cases,  especially  as  the  mortality  of  the  expectant  plan  is  so  great.  Many 
surgeons  have  approved  of  the  rule  of  Lauenstein,  that  if  after  from  six  to 
ten  weeks  there  is  incontinence  of  urine  and  feces  with  cystitis  and  bedsores, 
little  is  to  be  hoped  for  from  nature's  efforts,  and  an  operation  is  justifiable. 
Horsley,  however,  is  much  more  emphatic,  and  says  "  in  all  cases  where  dis- 
placement or  crepitus  indicates  compression,  and  extension  directly  after  the 
accident  fails  to  reduce  the  displacement,"  we  should  operate.  In  view  of 
the  early  degeneration  of  the  cord,  if  the  pressure  be  not  relieved,  of  the 
great  mortality  in  such  cases  when  not  operated  on,  and  of  the  rare  but 
undoubted  instances  of  good  results  following  early  operation,  the  tendency 
of  modern  surgeons  is  toward  earlier  rather  than  later  interference,  if  any 
interference  is  considered  justifiable.  In  no  case  can  we  be  sure  that  ulti- 
mate benefit  cannot  be  obtained,  until  at  least  a  year  after  the  operation. 
For  the  technique  of  laminectomy  in  these  cases,  see  page  993.  The  dangers 
of  the  operation  as  formulated  by  Mr.  Horsley  are  hemorrhage,  difficulty  in 
clearing  the  neural  canal,  physical  difficulties  in  treating  the  fractured  verte- 
brae, damage  to  the  sj)inal  cord  in  many  cases,  and  septic  infection.  To  this 
White  has  properly  added  the  danger  of  anaesthesia  in  the  prone  position, 
the  abdominal  muscles  being  paralyzed. 

The  results  of  the  operative  and  non-operative  treatment  are  strikingly  in 
contrast.  Thus  Gurlt  has  tabulated  two  hundred  and  seventy  non-operative 
cases  with  two  hundred  and  seventeen  deaths,  a  mortality  of  80  per  cent., 
while  Thorburn,  though  he  opposes  the  operation,  has  collected  sixty-one 
operative  cases  in  which  only  thirty-five  died,  a  mortality  of  only  57  per  cent. 

In  two  cases  of  dislocation  without  extensive  injury  to  the  cord,  Wilkins 
and  Hadra  have  immobilized  the  vertebrse  by  silk  or  wire.  This  method 
possibly  merits  further  consideration.  In  a  recent  case  of  paralysis  from 
elongation  of  the  cervical  nerve-roots  as  a  result  of  dislocation,  Chipault  has 
obtained  a  brilliant  success  by  operation  and  wiring  the  spinous  processes  to 
retain  the  vertebrse  in  position. 


SUBGEBY  OF  THE  BBAIN,  SPINAL  COBB,  AND  NEBVES.      993 

Tumors  of  the  Spinal  Cord.  Though  operation  was  performed  iu  1887 
by  Johnson,  the  modern  surgery  of  spinal  tumors  practically  dates  from  the 
brilliant  paper  of  Gowers  and  Horsley  {Med.-  Ghir.  Trans.,  1 888 ).  Minute  care 
is  necessary  in  the  location  of  the  tumor.  As  a  rule,  as  has  been  shown  by 
Horsley  and  Gowers,  we  are  apt  to  attack  the  spine  too  low,  and  if  the  tumor 
be  not  found  at  the  level  at  which  it  is  presumed  to  exist,  the  cord  should  be  ex- 
posed further  upward  rather  than  downward.  The  means  for  location  of  the 
tumor  have  been  already  described  on  pages  608,  616,  and  617,  attention 
being  especially  paid  to  the  exact  location  of  the  upper  border  of  even  the 
slightest  parsesthetic  zone.  The  favorite  position  of  such  tumors  is  either 
below  the  middle  of  the  cervical  region,  or  at  the  two  extremes  of  the  dorsal 
region,  occasionally  in  the  cauda  equina  and  elsewhere.  In  tumors  involv- 
ing the  cauda  equina,  which  consists  practically  of  peripheral  nerves,  the 
prognosis  is  much  better  than  in  those  tumors  which  affect  the  spine  proper. 
The  operation  consists  in  a  laminectomy  (mrfe  infra  Technique)  exposing  the 
cord.  If  it  is  deemed  advisable  the  dura  is  opened  and  the  tumor  treated  in 
accordance  with  what  is  found.  If  the  tumor  be  distinct  from  the  cord  it 
may  be  removed,  but  if  it  involve  the  cord  itself  it  is  usually  inoperable. 
If  opened,  the  dura  is  to  be  sutured  and  the  wound  treated  as  usual. 

Syringomyelia.  Abbe  has  reported  the  only  case,  so  far  as  I  know,  in 
which  an  operation  has  been  done  in  this  form  of  glioma.  I  have  myself 
operated  on  one,  not  yet  reported,  and  a  second  which,  I  believe,  was  prob- 
ably a  syringomyelia.  No  benefit  followed  Abbe's  operation,  and  but  little 
my  own  second  operation.  My  first  case  died  in  five  days.  It  would  seem 
best,  therefore,  not  to  operate  in  such  cases. 

Technique  of  Laminectomy.  Shaving  if  necessary,  and  extensive  disin- 
fection of  the  back  should  precede  the  operation.  The  ordinary  antiseptic 
preparation,  also,  of  the  hands,  instruments,  and  dressings,  is,  of  course,  to 
be  insisted  upon.  About  two  dozen  haemostatic  forceps,  and  various  rongeur 
and  other  bone  forceps  and  raspatories  should  be  provided.  Of  the  rongeur 
forceps,  the  double  rongeur  and  the  rongeur  forceps,  which  I  originally  de- 
vised for  linear  craniotomy,  and  which  I  have  found  to  be  the  best  for  removing 
the  laminae  of  the  vertebrae,  and  the  Hopkins  rongeur  forceps  are  among 
the  most  useful  (see  Figs.  311,  312,  and  313,  pp.  959  and  960).  The  patient 
is  placed  on  the  abdomen,  the  anaesthetic,  therefore,  being  administered  in 
the  most  unfavorable  position.  If  the  injury  is  in  the  upper  spine,  the  muscles 
of  the  abdomen  and  chest  are  paralyzed,  and  no  one  should  administer  the 
anaesthetic  but  a  reliable  man,  of  large  experience  and  good  judgment. 
Strychnine,  digitalis,  and  atropine  are  to  be  administered  as  needed.  The 
patient  should  also  be  well  protected  from  cold  by  blankets  and  hot  water 
bottles.  An  incision  is  made  in  the  middle  line  four  inches  or  more  in  length, 
according  to  the  extent  of  the  spine  to  be  attacked.  Various  other  incisions, 
T,  V,  and  H  in  shape,  have  been  proposed.  The  H  incision  of  Bullard  and 
Burrell  allows  the  posterior  arches  to  be  lifted  with  the  muscles  and  replaced 
later.  This,  however,  seems  to  me  to  be  of  no  special  advantage,  and  I 
have  always  operated  by  a  single  median  incision  which  has  proved  quite 
satisfactory.  If  the  edges  cannot  be  separated  widely  enough  a  transverse 
incision  may  be  made  through  the  fascia.  The  laminae  on  one  side  of  the 
spine  are  bared  partly  by  the  knife  and  partly  by  the  raspatory.  So  far  as 
possible  the  muscles  should  be  separated  from  the  bone  by  the  knife,  blunt 
dissection  being  avoided,  as  it  tears  the  fascia  and  muscles  into  fragments, 
which  are  apt  later  to  undergo  necrosis  with  probable  suppuration.  When 
the  muscles  have  been  cut  away  the  raspatory  is  then  used  in  order  to  ex- 
pose the  arches  cleanly.  As  soon  as  one  side  has  been  cleared  it  is  to  be 
packed  with  sponges  wrung  out  of  water  as  hot  as  can  be  borne,  to  check 

63 


994  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

the  hemorrhage  while  the  opposite  side  is  being  cleared.     When  this  has 
been  done  a  clean  field  is  secured.     The  interspinous  ligaments  are  then  to 
be  cut,  care  being  taken  especially  in  the  cervical  and  lumbar  regions  not  to 
penetrate  the  canal  and  possibly  wound  the  dura  and  cord.    By  the  double  ron- 
geur forceps  one  of  the  spines  is  gnawed  away  with  a  part  of  one  of  the  arches ; 
as  soon  as  the  lower  blade  of  my  rongeur  forceps  can  be  inserted  under  the 
lamina  it  can  be  bitten  away  rapidly,  thus  opening  the  spinal  canal  and 
exposing  the  fatty  tissue  between  the  theca  and  the  bones.     This  fatty  tissue 
is  to  be  divided  in  the  middle  line  and  gently  crowded  to  each  side  of  the 
theca  with  small  bits  of  gauze  or  sponge.     This  removes  the  fatty  tissue 
mechanically,  and  at  the  same  time  checks  its  hemorrhage.     It  should  be 
noticed  then  whether  the  dura  pulsates  or  not.     Often  there  are  adhesions  or 
other  causes  of  interference  in  the  continuity  of  the  subdural  space.     The 
color  of  the  dura  may  indicate  the  presence  of  blood  or  pus.     Its  tension 
will  show  whether  there  is  an  excess  of  cerebro-spinal  fluid  or  not.     This  is 
determined  by  touch,  but  it  must  be  remembered  that  the  cord  may  be 
thickened  by  a  syringomyelia,  which  will  simulate  very  much  the  presence 
of  fluid.     A  tumor  or  thickening  of  the  dura  itself  can  usually  be  appre- 
ciated, to  some  extent,  by  touch.     If  it  be  desired  to  examine  the  bodies  of 
the  vertebrae,  the  cord  and  its  membranes  can  be  carefully  drawn  to  one 
side  by  means  of  an  aneurism  needle,  so  as  to  expose  the  bodies  of  the  ver- 
tebrae for  observation,  and  if  need  be,  for  operation.     The  nerves  are  suffi- 
ciently elastic  to  allow  of  moderate  stretching.     If  a  tumor  of  granulation 
tissue  exist  on  the  surface  of  the  dura,  it  is  now  to  be  removed.     Any  dislo- 
cated or  fractured  arches  of  the  vertebrae  should  be  removed.     The  opening 
of  the  spinal  dura  is  more  serious  than  that  of  the  brain.     In  the  latter  the 
opening  can  be  closed  without  drainage,  thus  preventing  the  continuous 
escape  of  the  cerebro-spinal  fluid.     In  the  spine,  the  wound  through  the 
thick  muscles,  which  are  often  seriously  injured  in  cleaning  them  from  the 
bone,  require  drainage,  and  often  will  not  unite  by  first  intention.     As  long 
as  the  fluid  escapes  there  is  much  danger  of  a  fistula,  which  not  only  is  a 
source  of  irritation  to  the  skin  and  an  annoyance  from  the  constant  dressing 
it  requires,  but  is  a  source  of  serious  danger  from  subsequent  infection  and 
meningitis.     The  mere  escape  of  the  fluid  itself  is  not  very  dangerous.     In 
spite  of  these  objections,  however,  it  is  usually  best  to  open  the  dura.     After 
such  treatment  as  is  necessary  it  is  to  be  closely  sutured  with  a  continuous 
catgut  suture.     When  it  has  been  opened  the  dural  separator  of  Horsley 
(see  Fig.  319,  p.  962)  or  an  ordinary  probe  bent  at  a  suitable  angle,  should 
be  inserted  upward  and  downward  to  explore  the  condition  of  the  subdural 
space.     If  a  tumor  of  the  cord  has  been  suspected,  but  not  found,  it  is  to  be 
again  remembered  that  it  is  much  more  aj^t  to  be  higher  up  than  lower  down. 
When  found,  if  it  be  on  the  surface  of  the  cord,  it  may  be  removed,  not  un- 
commonly, quite  easily,  but  if  it  infiltrate  the  substance  of  the  cord  it  is  in- 
advisable to  attempt  its  removal.     If -the  cord  has  been  injured  or  crushed 
little  can  be  done  beyond  freeing  it  from  pressure.     Suture  of  the  cord  has 
been  attempted  but  not  successfully.     The  nerves  have,  however,  been  sutured 
by  Tuffier. 

Occasionally  where  it  is  desired  to  relieve  pressure  the  dura  may  be  left 
open.  In  one  case  of  my  own  I  left  it  open  for  the  space  of  two  inches. 
Horsley  has  left  it  unsutured  for  four  inches.  For  the  suture  the  finest  semi- 
circular Hagedorn  needle  and  a  needle  holder  are  the  best  means.  No  drain 
should  be  inserted  under  the  dura,  but  for  twenty-four  or  forty-eight  hours 
it  is,  as  a  rule,  best  to  drain  the  muscular  wound.  The  muscles  should  be 
approximated  by  buried  catgut  sutures,  the  skin  being  sutured  by  silkworm- 
gut  and  the  usual  dressings  applied. 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES      995 

After-treatment.  Within  the  first  twenty-four  hours  the  oozing,  and  the 
probable  escape  of  some  cerebro-spinal  fluid  will  be  so  free  as  to  require  one 
or  two  dressings.  The  greatest  care  should  be  observed  in  these  redressings, 
lest  infection  should  occur.  Especial  care  should  be  taken  that  this  con- 
tamination does  not  arise  from  any  bedsores,  which  are  so  often  present,  nor 
from  the  urine  or  feces  if  control  of  the  bladder  and  bowels  has  been  lost. 
During  the  operation  any  bedsores  should  be  carefully  covered  by  bichloride 
towels,  and  the  wound  should  be  dressed  sufficiently  frequent  to  prevent  con- 
tamination through  soiling  of  the  dressings  from  any  of  these  causes.  Thor- 
burn  has  proposed  to  drain  the  bladder  by  a  supra-pubic  cystotomy  to  pre- 
vent the  constant  wetting  of  the  wound  from  the  incontinence  of  the  urine. 
I  do  not  know  of  any  case  in  which  it  has  been  done,  though  the  suggestion 
seems  reasonable.  A  marked  improvement  often  takes  place  in  the  bed- 
sores, not  uncommonly  even  to  complete  cure.  Scrupulous  attention  should 
be  paid  to  the  diet  and  the  general  hygienic  conditions. 


SURGERY  OP  THE  NERVES. 

The  surgical  treatment  of  diseases  and  injuries  of  the  nerves  concerns  the 
various  forms  of  neuralgia,  such  as  tic  douloureux,  trifacial  or  trigeminal 
neuralgia,  sciatica,  the  neuralgia  of  stumps  and  scars,  local  spasms,  such  as 
facial  or  spinal  accessory  spasm,  tumors  of  the  nerves,  and  finally  wounds  of 
the  nerves. 

The  various  forms  of  neuralgia,  after  all  medical  means  have  been  ex- 
hausted, are  treated  surgically,  either  by  nerve-stretching  (neurectasy),  by 
division  of  the  nerves  (neurotomy),  or  by  exsection  of  the  nerves  (neurec- 
tomy). The  methods  of  doing  these  various  operations  will  be  described 
later  (p.  996). 

TuMOES  OF  Z^ERVES,  OR  Xeuromata.  These  are  not  uncommon  in  stumps, 
inasmuch  as  the  proximal  end  of  a  divided  nerve  generally  undergoes  a 
bulbous  enlargement,  which  more  commonly  is  a  false  neuroma,  i.  e.,  it  has 
no  true  nerve  tubules,  but  consists  generally  of  connective  tissue.  In  a  few 
cases,  however,  as  Bowlby  has  shown,  true  nerve-fibres  are  found.  IS^euromata 
also  occur  in  the  continuity  of  nerves,  and  are  usually  made  up  of  fibrous 
tissue,  though  they  may  be  sarcomatous,  carcinomatous,  myxomatous,  etc. 
(See  page  740.)  More  commonly  they  are  single,  but  occasionally  they  are 
multiple. 

Should  such  neuromata  produce  no  pain  or  other  annoying  symptoms,  it 
is  best  not  to  interfere  with  them  ;  but  if  they  give  rise  to  any  serious  pain, 
the  tumor  with  a  portion  of  the  nerve  in  which  it  is  developed  should  be 
removed.  In  a  stump  this  can  usually  be  done  by  dissecting  down  to  them, 
generally  best  by  an  elliptical  incision  including  the  scar  of  the  amputation, 
and  exsecting  the  tissues,  especially  the  nerves,  at  a  point  above  their  bul- 
bous ends. 

If  the  tumor  exists  in  the  continuity  of  the  nerve  it  should  be  exsected, 
and  the  various  procedures  described  under  Nerve-suture  or  Nerve-grafting, 
should  be  employed  (pp.  996  and  997). 

Paixful  Subcutaneous  Tubercle.  One  peculiar  form  of  very  small 
tumor,  usually  a  fibroma,  is  connected  occasionally  with  suljcutaneous  nerves, 
and  is  known  by  the  name  of  painful  sul)cutaneous  tubercle.  From  its 
excessive  tenderness  and  pain,  it  is  a  source  of  great  annoyance.  The  treat- 
ment is  excision  of  the  tumor,  and  a  pai't  of  the  nerve.  The  resulting  anes- 
thesia is  of  small  moment,  and  disappears  with  time. 


996  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Wounds  of  jSTeeves.  In  every  case  in  which  a  nerve  is  divided  it  can- 
not be  too  strongly  insisted  upon  that  nerve  suture  should  be  done  immedi- 
ately. By  so  doing,  the  nerve  will  be  re-established  in  its  integrity  far  bet- 
ter than  by  any  secondary  operation.  The  methods  by  which  it  is  done  are 
described  under  Nerve-suture  (see  below)  and  Nerve-grafting  (p.  997). 
The  tendons,  which  are  frequently  divided  by  the  same  accident,  should 
also  be  sutured  immediately,  thus  restoring  the  continuity  of  each  muscle. 


OPERATIONS  ON  NERVES. 

I.  Nerve  Suture.  This  may  be  either  primary  or  secondary.  By  primary 
suture  is  meant  suture  of  the  nerve  at  the  same  time  when  the  wound 
itself  is  treated  surgically,  or  very  shortly  afterward.  If  this  is  not  done, 
the  ends  of  the  nerves  are  not  only  separated  from  each  other,  but  may  be- 
come attached  to  tendons,  connective  tissue  or  other  structures,  and  are  only 
found  and  dissected  out  with  difficulty  at  a  later  oj)eration.  By  secondary 
suture  is  meant  dissection  and  suturing  of  the  nerve  at  a  period  more  or 
less  remote  from  the  primary  injury.  Primary  suture  is  always  to  be  pre- 
ferred, if  it  is  at  all  possible. 

(a)  Primary  Suture.  If  the  nerve  is  merely  divided  without  any  loss 
of  substance,  the  ends  should  be  approximated  by  two  or  three  sutures 
passed  not  merely  through  the  sheath  of  the  nerve,  but  through  its  substance. 
The  suturing  material  is  best  of  fine  silk  or  other  absolutely  aseptic  and 
somewhat  durable  material.  The  limb  is  then  to  be  placed  on  a  splint  at 
such  an  angle  as  to  relax  the  nerve.  Especial  attention  should  be  paid  to 
the  asej^tic  condition  of  the  parts,  as  suppuration  around  the  sutured  ends 
may  wholly  defeat  the  object  for  which  the  operation  has  been  done.  If 
the  ends  are  separated  to  any  distance,  one  or  both  ends  of  the  nerve  should 
be  stretched  until  they  can  be  placed  in  contact  and  sutured.  The  results 
of  primary  suture  have  been  very  gratifying.  In  a  few  instances  the  func- 
tion of  the  nerve  seems  to  have  been  restored  very  quickly,  but  commonly 
a  few  weeks,  and,  possibly,  even  a  few  months  elapse  before  the  nerve 
resumes  its  function.  In  81  cases  of  primary  suture  analyzed  by  Bowlby 
32  were  entirely  successful,  34  were  partially  successful,  and  14  were  fail- 
ures, the  result  in  one  not  being  recorded. 

After-treatment.  When  the  nerve  has  been  sutured  and  the  wound  is 
healed,  the  after-treatment  is  of  the  utmost  importance,  and  should  be  con- 
tinued for  months,  or  even  for  a  year  or  more,  before  we  despair  of  suc- 
cess. This  after-treatment  consists  in  the  daily  use  of  electricity,  the  faradic 
current  if  the  muscles  respond  to  that,  or  if  they  do  not,  the  galvanic  cur- 
rent until  the  faradic  becomes  practical.  Massage,  and  the  hot  and  cold 
douche,  should  be  assiduously  employed.  The  patient  should  also  make  a 
persistent  attempt  to  use  the  muscles  which  have  been  paralyzed.  For  sen- 
sation the  use  of  the  electric  brush  to  the  well-dried  skin  will  often  be  of 
service. 

(h)  Secondary  Suture.  Months  and  even  years  after  an  injury  to  the 
nerve,  secondary  suture  has  been  followed  so  often  by  success  that  it  should 
always  be  attempted.  The  nerve  having  been  exposed,  the  two  ends  are  to 
be  loosened  from  their  attachments.  The  proximal  end,  as  a  rule,  is  bulbous, 
and  can  be  found  with  ease,  -whereas,  the  distal  end  is  often  found  with  con- 
siderable difficulty.  When  the  latter  cannot  readily  be  found  the  nerve  should 
be  cut  dowai  upon  beyond  the  site  of  the  injury,  where  it  lies  in  its  normal  re- 
lations, when  the  trunk  can  be  followed  up  to  the  lower  divided  extremity. 


SURGERY  OF  THE  BRATN,  SPINAL  CORD,  AND  NERVES.      997 

The  whole  of  the  bulbous  extremity  of  the  proximal  end  should  be  removed, 
but  only  about  a  quarter  of  an  inch  of  the  distal  end.  The  two  ends 
should  then  be  approximated  by  stretching,  and  sutured  as  above  described. 
The  later  treatment  is  identical  with  that  which  should  follow  primary 
suture.  In  seventy-three  cases  of  secondary  suture,  Bowlby's  tables  give 
as  a  result  thirty-two  successes,  twenty-six  partial  successes,  and  fifteen 
failures. 

II.  Nerve-grafting.  If  the  ends  of  the  nerve  after  stretching  cannot  be 
brought  into  apposition,  thi'ee  different  methods  may  be  adopted. 

(a)  The  nerve  may  be  split  a  suitable  distance  above  its  end,  the  flap 
turned  down  and  sutured  to  the  distal  end.  The  results  of  this  method  of 
treatment  have  not  been  very  successful. 

(6)  A  suitable  nerve  may  be  removed  either  from  one  of  the  lower  ani- 
mals or  from  a  limb  which  has  been  amputated  from  the  human  subject  at 
the  time  that  the  nerve-grafting  is  to  be  done,  and  a  portion  of  the  nerve 
transplanted.  Whether  the  nerve  is  sensory,  motor,  or  mixed  seems  to  make 
no  special  difference.  The  results  from  this  method  also  have  been  partially 
satisfactory ;  but  in  only  a  few  cases  has  the  method  been  tried. 

(c)  The  gap  between  two  ends  of  the  nerve  may  be  bridged  by  a  few 
strands  of  catgut,  either  applied  alone  or  in  a  cylinder  of  decalcified  bone, 
in  the  hope  that  these  will  form  a  scaffolding  on  which  the  reconstruction  of 
the  nerves  will  take  place.  The  results  in  the  few  reported  cases  have  also 
been  fairly  satisfactory. 

III.  JVeurectasy  or  JVer^ve-str etching.  This  operation  was  introduced  by 
Nussbaum  in  1872,  and  has  given  excellent  results  in  a  certain  number 
of  cases.  It  has  been  tried,  but  seems  to  have  done  little  good,  in  ataxia,  in 
paralysis  agitans,  epilepsy,  tetanus,  etc.  In  tic  convulsif  or  spasm  of  the 
facial  muscles,  the  facial  nerve  has  been  stretched  in  over  a  score  of  cases.  The 
relief  has  usually  continued  over  a  few  months,  and  in  one  case  (Southam's) 
for  five  years.  As  a  rule,  however,  relapse  will  follow,  but  the  relief,  even  if 
temporary,  justifies  the  operation.  In  a  few  cases  of  wry-neck  or  torticollis 
neurectasy  of  the  spinal  accessory  nerve  has  been  done  with  benefit,  or  even 
cure.  In  anaesthetic  leprosy,  also,  neurectasy  has  given  good  results.  Inas- 
much as  it  is  a  less  serious  and  less  disabling  operation  than  neurectomy,  as  a 
rule,  it  would  be  desirable  to  perform  neurectasy  before  neurectomy  is  done. 
There  are  two  modes  of  doing  the  operation.  First,  by  the  bloodless  method, 
i.  e.,  without  a  cutting  operation.  This  is  only  applicable  to  the  great 
sciatic  nerve.  The  patient  being  etherized,  and  the  leg  kept  extended  at 
the  knee,  the  entire  lower  extremity  is  carried  into  forced  flexion  at  the 
hip-joint.  In  a  few  cases  this  method  has  given  good  results.  In  adults  it 
must  be  attended  by  considerable  rupture  of  the  bellies  of  the  hamstring 
muscles.  Two  deaths  have  been  reported.  It  is  not,  therefore,  wholly  with- 
out danger. 

Secondly,  by  operation.  The  trunk  of  the  nerve  to  be  stretched  is  ex- 
posed and  loosened  from  the  surrounding  parts.  It  may  then  be  hooked  up 
by  the  fingers,  or,  in  a  small  nerve  like  the  seventh,  by  an  ordinary  pocket 
button-hook  or  similar  instrument,  or,  better  for  the  larger  nerves,  by  Hors- 
ley's  saddle-shaped  nerve  hooks.  The  amount  of  force  which  can  be  applied 
to  the  different  nerves  varies  of  course.  The  following  table  from  Marshall 
gives  the  breaking  strain,  in  pounds,  of  human  nerves  as  determined  post 
mortem.  Probably  it  would  be  somewhat  greater  in  the  living  than  in  the 
dead  subject. 

The  facial  nerve,  which  does  not  appear  in  Marshall's  table,  will  bear  a 
strain  of  about  5  to  12  pounds,  the  latter  being  more  than  the  weight  of  the 
head. 


998  NERVOUS  DISEASES  AXB  THEIR  TREATMENT. 


COHESION  OF  HUMAX  XERTES  AFTER  DEATH,  BREAKING  STRAIX  IN  POUNDS. 

Supraorbital 6      pounds. 

Infraorbital            12  " 

Mental 5^  " 

Brachial  plexus 50-64  " 

Ulnar      ...                58  " 

Musculo-spiral 61  " 

Median 84  " 

Crural 83  " 

Internal  popliteal 114  " 

Great  Sciatic— Symington 86-17fi  " 

Tillaux 118-127 

"           "         Gillette 165  " 

"           "         Trombetta 82-288 

"           "         Ceccherelli 154-220 

The  great  sciatic  nerve,  which  is  frequently  stretched,  has  so  high  a 
breaking  strain  that  it  is  generally  a  safe  rule  to  lift  the  leg  and  pelvis  by 
traction  upon  it.  In  a  number  of  cases  in  which  I  have  done  it  by  means  of 
a  spring  balance  I  have  found  that  25-30  pounds  will  nearly  lift  the  pelvis 
from  the  table.  Eleven  deaths  from  lesions  of  the  spinal  cord  have  been  re- 
corded after  nerve-stretching.  As  a  rule,  however,  it  is  a  very  harmless 
operation.  If  it  is  done  for  pain,  the  nerve  should  be  preferably  drawn  from 
the  spine,  if  for  spasm,  the  traction  should  be  toward  the  spine. 

IV.  Neiiroiomy  and  Neurectomy.  Neurotomy  is  now  rarely  done,  inasmuch 
as  its  effect  is  very  fugitive.  As  a  rule,  it  is  much  better  to  do  neurectomy. 
In  cases  where  several  nerves  lie  close  together,  as  in  the  armpit,  in  order  to 
exclude  any  doubt  as  to  the  proper  nerve,  the  faradic  battery  should  be 
resorted  to.  Neurectomy  may  be  performed  on  the  trunk  or  on  the  roots 
of  nerves,  or  in  certain  cases,  especially  the  fifth  nerve,  by  the  removal  of 
the  sensory  ganglion.     (Page  978.) 

The  various  operations  which  have  been  above  alluded  to  may  be  applied 
to  any  of  the  principal  nerves  of  the  body.  The  mode  of  access  to  each 
nerve  will  now  be  described,  it  being  understood  that  the  process  is  practi- 
cally the  same  whether  the  nerve  is  to  be  sutured,  grafted,  stretched,  divided, 
or  resected. 

Supraorbital  Nerve.  The  jDoint  of  emergence  is  through  the  supra- 
orbital foramen  or  notch  at  the  junction  of  the  inner  and  middle  thirds  of 
the  eyebrow.  A  curvilinear  incision,  about  one  and  a  half  inches  in  length, 
in  the  eyebrow,  so  that  it  will  be  hidden  by  the  hair,  enables  us  to  find  the 
upper  border  of  the  orbit.  The  tissues  should  be  now  drawn  upward  and 
the  nerve  discovered  in  the  orbit. 

The  ■supratrochlear  nerve,  lying  at  the  inner  end  of  the  eyebrow,  can  be 
reached  at  the  same  time  and  by  the  same  incision  prolonged  nearly  to  the 
nose. 

The  Infraorbital  Nerve.  A  line  from  the  supraorbital  notch  to  the 
space  between  the  two  lower  l^icuspid  teeth  intersects  the  infraorbital  and 
mental  foramina  from  which  the  infraorbital  and  the  mental  nerves  escape. 
The  infraorbital  nerve  2:)asses  through  the  infraorbital  canal  and  foramen. 
A  curved  incision  one  and  a  half  inches  long  is  made  just  below  the  inferior 
border  of  the  orbit.  The  nerve  lies  deep,  next  the  bone,  under  the  levator 
labii  superioris.  The  nerve  having  been  found,  a  silk  thread  is  passed  under 
it  for  identification  and  traction.  Having  raised  the  upper  border  of  the  in- 
cision by  a  retractor,  the  periosteum  covering  the  floor  of  the  orbit  is  lifted  by 
Allis'  blunt  dissector  or  other  similar  instrument,  and  held  out  of  the  way  by 
a  flat  retractor.  Too  much  traction  is  to  be  avoided  lest  the  eye  itself  be 
injured.  The  canal  for  the  nerve  can  be  readily  found  in  the  floor  of  the 
orbit  and  broken  in  by  pressure  with  a  grooved  director  or  the  Allis'  blunt 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.      999 

dissector.  By  a  small  hook  the  nerve  is  lifted  up  from  its  bed  and  divided 
toward  the  back  of  the  orbit  by  means  of  curved  scissors.  The  entire  nerve 
is  then  drawn  out  by  traction  on  the  anterior  end.  The  bleeding  is  readily 
arrested  by  ]Dacking  with  a  little  gauze. 

Removal  of  Meckel's  Ganglion.  This  is  done  for  tic  douloureux. 
There  are  several  methods  of  reaching  the  ganglion.  I  shall  only  mention 
one,  Chavase's  modification  of  Carnochau's  method.  A  T-incision  is  made 
on  the  cheek,  the  horizontal  portion  extending  from  just  below  one  canthus 
to  a  similar  point  below  the  other.  The  vertical  portion  of  the  incision 
reaches  nearly  to  the  mouth,  but  it  should  not  enter  the  cavity  of  the  mouth. 
The  infra-orbital  nerve  being  found  as  before,  the  anterior  wall  of  the  antrum 
is  trephined  by  a  f-inch  trephine,  or  opened  by  a  chisel,  including  the  infra- 
orbital foramen,  care  being  taken  not  to  divide  the  nerve.  The  posterior 
wall  of  the  antrum  is  then  trephined  by  a  5 -inch  trephine  or  opened  by  a 
chisel,  care  being  taken  not  to  wound  the  internal  maxillary  artery  just  be- 
hind it.  After  breaking  through  the  groove  in  the  floor  of  the  orbit  the 
nerve  is  drawn  downward  and  traced  into  the  spheno-maxillary  fossa.  It  is 
then  to  be  divided  close  to  the  foramen  rotundum,  and  Meckel's  ganglion  is 
to  be  isolated  if  possible ;  if  not,  the  nerve  with  its  branches  and  the  gan- 
glion are  drawn  out.  The  wound  is  then  lightly  packed  with  iodoform 
gauze.  It  need  not  be  sutured  until  the  gauze  is  removed,  forty-eight  hours 
later.  No  pain  is  caused,  of  course,  by  these  sutures,  the  parts  being  now 
ansesthetic.  A  forehead  electric  light  or  a  forehead  mirror  is  of  great  service 
in  illuminating  the  deep  parts  of  the  wound.  Care  should  be  taken  to  inflict 
no  harm  on  the  eyeball.  In  one  of  my  cases  the  retina  was  detached  by  an 
effusion  of  blood,  although  the  operation  was  conducted  with  the  greatest 
care,  and  I  have  since  seen  a  second  case  in  which  sight  was  destroyed. 

The  Inferior  Dental  Nerve.  Of  the  numerous  methods  for  the 
resection  of  this  nerve  the  best  is  as  follows:  An  incision  is  made  just 
underneath  the  lower  border  of  the  jaw  from  the  angle  nearly  to  the  chin. 
This  position  is  chosen  in  order  subsequently  to  hide  the  scar.  The  upper 
border  of  the  wound  is  then  drawn  upward  and  the  bone  is  entirely  exposed. 
A  half-inch  trephine  is  then  applied  one  and  a  quarter  inches  above  the 
angle  of  the  jaw.  This  will  disclose  the  nerve  at  its  entrance  into  the  infe- 
rior dental  foramen.  The  dental  nerve  making  its  exit  at  the  dental  fora- 
men is  then  exposed  by  blunt  dissection,  and  a  similar  small  trephine-opening 
is  made  just  postex'ior  to  the  foramen.  Care  must  be  taken  not  to  go  so 
deeply  as  to  divide  the  nerve  by  the  trephine  or  to  penetrate  the  bone.  If 
necessary,  a  third  button  may  be  removed  half  way  between  the  two,  or  the 
outer  border  of  the  entire  canal  is  chiselled  away,  the  chisel  being  guided  by 
the  nerve.  The  nerve  is  now  lifted  from  its  bed  and  removed.  It  is  often 
best  to  fill  the  two  ends  of  the  canal  either  by  dental  paste  or  by  gold  foil, 
so  as  to  prevent  any  possible  reunion.  The  hemorrhage  from  the  inferior 
dental  artery  is  usually  easily  controlled  by  packing  and  hot  water ;  some- 
times it  will  require  to  be  ligated. 

Removal  of  the  Gasserian  Ganglion.     (See  page  978.) 

Resection  of  both  the  Second  and  Third  Divisions  of  the  Fifth 
Nerve.  Mixter,  of  Boston,  has  performed  the  following  operation :  A 
curved  incision  is  made  through  the  region  of  the  temporal  nuiscle,  begin- 
ning and  ending  over  the  zygoma,  which  may  be  previously  drilled  for  later 
wiring.  The  zygoma  is  sawn  through  at  each  end,  care  being  taken  not  to 
involve  the  articulation,  as  would  be  done  by  going  behind  the  tubercle. 
The  temporal  and  pterygoid  muscles  being  turned  down  with  the  zygoma, 
both  nerves  can  be  reached  at  the  foramen  rotundum  and  foramen  ovale  by 
blunt  dissection. 


1000  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

AuEicuLO-TEMPORAL  Neeye.  TMs  nerve  lies  immediately  behind  the 
temporal  artery  just  in  front  of  the  ear.  A  slightly  oblique  incision  dis- 
closes the  artery,  and  back  of  it  the  nerve. 

LixGUAL  Xeeye.  This  nerve  is  occasionally  resected  for  the  rehef  of 
pain  in  cancer  of  the  tongue.  The  tongue  is  drawn  forcibly  toward  the 
opposite  side  by  means  of  a  suture  passed  through  its  substance.  This  makes 
the  lingual  nerve  tense,  and  it  can  generally  be  felt  as  a  firm  band  beneath 
the  mucous  membrane  in  the  floor  of  the  mouth.  An  incision  is  made  over 
it  and  the  ner^^e  secured  by  a  hook.  If  the  tongue  is  fixed  by  the  growth 
the  nerve  may  be  exposed  where  it  lies  in  contact  with  the  lower  jawbone 
just  under  the  mucous  membrane  below  the  first  molar  tooth. 

The  Facial  Xerve.  This  nei-^^e  is  occasionally  stretched  or  resected  in 
case  of  facial  spasm  or  tic  convulsif.  The  best  method  is  that  of  Baum,  as 
the  scar  is  hidden  by  the  ear,  and  the  nerve  is  more  readily  found  than  by 
Hiiter's  method. 

Baiim's  method.  An  incision  is  made  behind  the  ear  two  and  a  half  inches 
long.  The  posterior  border  of  the  parotid  gland  is  first  disclosed.  Drawing 
this  forward  the  shining  aponeurosis  of  the  sterno-cleido-mastoid  at  its  inser- 
tion on  the  mastoid  process  is  next  seen.  A  blunt  dissection  is  then  made 
in  the  interspace  between  these  two  landmarks,  when  the  prevertebral  mus- 
cles and  their  fascial  covering  will  be  seen  at  a  depth  of  one  to  one  and  a  half 
inches.  The  nerve  crosses  the  narrow  interspace  between  the  mastoid  and 
vertical  ramus  of  the  jaw  external  to  this  fascia.  A  ver}^  weak  electric 
current  will  disclose  the  exact  point  where  the  nerve  crosses  this  space,  but 
usually  it  is  readily  found  without  this.  The  wound  should  be  veiy  dry  ;  a 
sponge  electrode  is  placed  on  any  indifferent  point.  To  the  other  conductor 
a  piece  of  disinfected  copper  wire  is  attached,  and  the  tissues  are  touched  at 
various  points.     An  electric  light  is  of  great  advantage. 

Huier's  method.  A  vertical  incision  is  made  in  front  of  the  ear.  The 
parotid  gland,  in  which  the  nerve  divides  into  its  main  branches,  is  exposed 
and  one  of  the  branches  sought  for.  Any  one  of  the  latter  followed  back- 
ward will  disclose  the  main  nerve. 

The  Spinal  Accessory  Xerye.  This  nerve  has  been  operated  on  for 
spasmodic  wryneck  by  stretching  or  excision.  It  enters  the  sterno-cleido- 
mastoid  muscle  on  its  inner  surface  from  one  to  two  inches  below  the  lobe  of 
the  ear,  and  after  leaving  the  muscle  at  its  outer  border  passes  to  the 
trapezius.  It  may  be  reached  by  an  incision  along  the  anterior  or  posterior 
borders  of  the  sterno-cleido-mastoid  muscle. 

Anterior  Operation.  An  incision  is  made  along  the  anterior  border  of 
the  muscle  from  the  lobule  of  the  ear  two  to  three  inches  downward.  The 
muscle  being  exposed  and  everted,  the  nerve  is  discovered  where  it  enters 
the  muscle  a  little  above  the  level  of  the  hyoid  bone.  In  a  stout  person  this 
depth  may  be  very  considerable. 

Posterior  Operation.  An  incision  two  to  three  inches  long  is  made  along 
the  posterior  border  of  the  muscle,  the  centre  of  the  incision  corresponding 
to  the  centre  of  the  muscle  lengthwise.  The  posterior  border  of  the  muscle  is 
then  turned  inward,  and  the  nerve  which  lies  a  little  above  the  centre  of 
the  wound  is  traced  to  its  point  of  emergency  from  the  muscle  and  exsected. 

Resection  of  the  Posterior  Cervical  Xeryes.  The  posterior  branches 
of  the  first  three  cervical  nerves  can  be  resected  for  spasmodic  wryneck,  in- 
volving not  only  the  sterno-cleido-mastoid  and  trapezius,  but  also  the  pos- 
terior cervical  muscles  by  a  method  which  I  described  in  1891  and  published 
in  the  Annals  of  Surgery  for  1891,  vol.  xiii.  p.  44.  The  first  case  in  which 
I  had  the  opportunity  of  doing  the  operation  (one  of  Dr.  Dercum's)  was 
May  3, 1889.     Since  then  I  have  performed  the  operation  in  three  additional 


SURGERY  OF  THE  BRAIN,  SPINAL  CORD,  AND  NERVES.     1001 

cases.  Xoble,  Smith,  Powers,  Gardner,  and  others  have  also  done  the  opera- 
tion several  times.  The  result  in  three  of  my  four  cases  has  been  very  good. 
The  nerves  to  be  divided  are  the  external  branches  of  the  posterior  divi- 
sions of  the  second  and  third  cervical  nerves  supplying  the  splenius  ;  the 
sub-occipital  from  the  first  cervical  supplying  the  rectus  capitis  posticus 
major,  and  a  branch  from  the  second  cervical  which,  with  the  sub-occipital, 
supplies  the  obliquus  inferior.  The  wound  is  always  a  deep  one,  especially 
in  a  patient  with  a  very  thick  neck,  and  the  operation  is  much  facilitated 
by  an  electric  forehead  lamp.     The  steps  of  the  operation  are  as  follows  : 

1.  After  the  usual  shaving  and  disinfection,  a  transverse  incision  2i  to  3 
inches  long  is  made,  half  an  inch  below  the  level  of  the  lobule  of  the  ear. 
This  incision  should  be  on  the  same  side  toward  which  the  chin  is  turned, 
since  the  posterior  muscles  draw  the  head  to  their  own  side,  in  marked  con- 
trast to  the  sterno-cleido  mastoid,  which  rotates  the  chin  to  the  opposite  side. 
If,  therefore,  the  right  spinal  accessory  nerve  has  been  divided  the  posterior 
nerves  of  the  left  side  should  be  divided,  and  vice  versa.  Xoble  Smith 
has  substituted,  he  thinks  with  advantage,  a  vertical  incision  for  this  trans- 
verse one. 

2.  The  trapezius  is  divided  in  line  with  the  first  transvere  incision. 

3.  The  trapezius  is  dissected  on  its  anterior  surface  in  order  to  find  the 
occipitalis  major  nerve  as  it  emerges  from  the  complexus  and  enters  the 
trapezius  at  a  point  between  the  intra-muscular  aponeurosis  of  the  complexus 
and  the  middle  line  about  half  an  inch  below  the  incision.  This  is  a  large 
nerve,  the  size  of  a  stout  piece  of  catgut,  and  is  readily  found. 

4.  The  complexus  is  divided  transversely  at  the  level  of  the  nerve  by 
repeated  small  cuts,  so  made  as  not  to  divide  the  nerve,  which  is  the  guide. 
The  nerve  can  then  be  dissected  down  to  the  point  where  it  arises  from 
the  posterior  division  of  the  second  cervical.  The  posterior  division  of  the 
second  cervical  is  then  exsected  at  a  point  on  the  spinal  side  of  the  origin  of 
the  occij^italis  major,  so  as  to  catch  also  the  filament  to  the  inferior  oblique 
muscle. 

5.  Dissect  upward  toward  the  occiput  and  find  the  sub-occipital  nerve,  a 
nerve  somewhat  larger  than  the  occipitalis  major.  The  nerve  passes  imme- 
diately below  the  border  of  the  inferior  oblique  muscle,  running  from  the 
spinous  process  of  the  axis  and  passing  almost  horizontally  outward,  to  be 
inserted  into  the  transverse  process  of  the  atlas. 

6.  Recognize  the  sub-occipital  triangle  formed  by  the  inferior  oblique, 
the  superior  oblique,  and  the  rectus  captis  posticus  major.  The  sub-occipital 
nerve  lies  in  this  triangle  close  to  the  occiput,  and  is  there  to  be  exsected. 
Should  there  be  any  difiiculty,  as  I  found  in  one  case,  from  the  fact  that  the 
triangle  was  completely  blocked  up  with  some  large  veins,  the  nerve  may  be 
drawn  out  at  the  lower  border  of  the  inferior  oblique  and  divided  there. 

7.  An  inch  lower  down  than  the  occipitalis  major,  and  under  the  com- 
plexus, is  the  external  branch  of  the  posterior  division  of  the  third  cervical, 
supplying  the  splenius.  This  is  a  much  smaller  nerve  than  the  other  two, 
and  is  sometimes  diflicult  to  find,  or  it  may  be  divided  by  careless  dissection. 

It  should  be  exsected  close  to  the  bifurcation  of  the  posterior  division. 

A  drainage-tube  is  to  be  inserted  in  the  wound,  and  the  Avound  closed  as 
usual  by  buried  and  superficial  sutures.  The  drainage  in  the  dorsal  position 
is  all  that  could  be  desired. 

Cervical  Plexus.  This  plexus  is  reached  by  an  incision  along  the 
middle  of  the  posterior  border  of  the  sterno-cleido-mastoid  muscle  in  the 
interval  between  it  and  the  trapezius.  An  incision  having  been  made  through 
the  skin,  superficial  and  deep  fascia,  the  nerves  are  found  by  a  blunt  dissec- 
tion, and  such  of  them  operated  upon  as  is  necessary.     It  should  be  remem- 


1002  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

bered  that  the  phrenic  nerve  arises  from  the  third  and  fourth  divisions,  with 
a  branch  from  the  fifth.  Stretching  of  these  particular  nerves,  therefore, 
should  be  done  with  care  ;  but  they  may  be  resected  beyond  the  origin  of  the 
phrenic  without  difficulty. 

Brachial  Plexus.  This  plexus  is  easily  exposed  just  above  the  clavicle 
by  a  horizontal  incision  parallel  to  the  clavicle  and  one  inch  above  it.  The 
skin,  superficial  and  deep  fascia  are  divided  when  a  blunt  dissection  will 
readily  expose  the  nerves.  If  it  is  desired  either  in  the  branchial  or  cervical 
plexus  to  differentiate  the  cords,  it  can  be  done  by  a  battery.  Care  should 
be  taken  in  operating  on  the  brachial  plexus  to  see  that  none  of  the  cords 
are  overlooked.  The  inner  cord  lies  immediately  external  to  the  subclavian 
artery,  and  can  be  identified  by  this  relation.  It  can  be  differentiated  from 
the  artery  by  the  effect  of  pressure  on  the  pulse. 

AuRicuLARis  Magnus  jSTerve.  The  auricularis  magnus  emerges  from 
behind  the  sterno-cleido-mastoid  at  the  middle  of  its  posterior  border.  An 
incision  along  the  posterior  border  at  its  middle  discloses  the  nerve  passing 
ujDward  toward  the  ear. 

OcciPiTALLS  MixOR  Kerve.  This  also  emerges  from  behind  the  posterior 
border  of  the  sterno-cleido-mastoid  a  little  above  the  middle  of  the  muscle. 
An  incision  along  the  posterior  border  of  the  muscle  somewhat  above  its 
middle,  followed  by  a  little  blunt  dissection,  will  show  the  nerve. 

OcciPiTALLS  Major  jS'erve.  This  emerges  from  the  trapezius  near  its 
outer  border  just  below  its  insertion  into  the  superior  curved  line  of  the 
occipital  bone.  The  hair  from  the  lower  occiput  should  be  shaved.  A  hori- 
zontal incision  made  near  the  centre  of  the  inner  border  of  the  attachment 
to  the  trapezius  muscle  and  just  below  the  superior  curved  line  will  disclose 
the  nerve.     The  occipital  artery  lies  very  near  it  externally. 

Ixtra-Spixal  Division  of  the  Posterior  or  Sensory  Nerve-Roots 
FOR  Inveterate  Keuralgia.  In  1889  and  again  in  1890  and  1895 
{Annals  of  Surgery,  Jan.,  1895)  Abbe  reported  three  cases  in  which  he  did 
this  operation  for  neuralgia  of  the  arm.  Bennett  in  1889  {Med.-Chir.  Trans., 
1889,  Ixxii.  p.  329)  reported  a  fourth  case.  Bennett's  case  seems  to  have  been 
relieved  of  his  pain,  but  died  suddenly  on  the  eleventh  day  from  cerebral 
apoplexy.  Horsley  {Brit.  Med.  Journ.,  1890,  ii.  p.  1289)  has  reported  two 
cases,  and  McCosh  (Annals  of  Surgery,  Jan.,  1895)  has  reported  a  seventh. 
All  of  the  cases  have  been  relieved,  but  apparently  not  absolutely  cured. 
The  operation,  if  done  at  all,  should,  I  think,  be  done  early  rather  than  after 
other  operations,  especially  amputation,  inasmuch  as  it  does  not  affect  the 
motor  roots  of  the  nerves,  and  therefore  if  it  relieves  the  pain  it  will  leave  a 
useful  extremity.  Often,  however,  patients  Avill  have  insisted  on  other  prior 
operations,  including  amputation.  The  operation  is  done  as  follows.  A  verti- 
cal incision  is  made  at  the  desired  point,  and  the  posterior  arches  of  the  se- 
lected cervical  or  other  vertebrse  are  removed,  thus  exposing  the  dura.  This 
is  then  divided  and  held  to  one  side  by  an  aneurism  needle  or  other  similar 
retractor.  The  posterior  nerve-roots  are  then  identified.  In  order  to  deter- 
mine which  roots  we  are  deabng  with,  it  is  always  well  to  mark  on  the  skin 
by  a  slight  incision  the  level  of  a  definite  spine,  for  instance,  that  of  the 
vertebra  j)rominens  or  other  vertebras.  This  will  enable  us  to  identify  exactly 
the  nerve  or  nerves  the  roots  of  which  are  to  be  removed.  The  posterior 
roots  having  been  exsected,  the  dura  is  sutured  and  the  wound  closed  and 
treated  as  usual.  The  operation,  of  course,  is  serious,  but  not  especially  dan- 
gerous.    None  of  the  seven  cases  have  died  from  the  operation. 

Median  Nerve.  This  nerve  can  be  reached  in  the  axilla,  the  arm,  the 
foreai'm,  or  the  hand. 

1.   The  Axillary  Operation.     A  two-inch  incision  is  made  at  the  junction 


SUBGEBY  OF  THE  BBAIN,  SPINAL  COBD,  AND  NEBVES.     1003 

of  the  anterior  and  middle  thirds  of  the  axilla,  dividing  the  skin,  superficial 
and  deep  fasciae.  The  axillary  nerves  and  arteiy  are  found  by  a  blunt  dis- 
section. The  median  nerve  is  easily  recognized  either  by  the  battery,  which 
will  cause  the  flexors  and  pronators  of  the  hand  to  contract,  or  by  the  fact 
that  it  arises  by  two  heads  astride  the  axillary  artery. 

2.  The  Operation  in  the  Ann.  An  incision  is  made  at  the  inner  border  of 
the  biceps  at  its  middle.  The  nerve  and  the  brachial  artery  are  found  just 
under  the  deep  fascia.  The  nerve  ordinarily  crosses  in  front  of  the  artery 
from  without  inward ;  occasionally,  however,  it  passes  behind  it.  The  bat- 
tery, if  need  be,  may  be  used  to  determine  whether  it  is  the  median  nerve. 

3.  Operation  of  the  Forearm.  The  nerve  can  readily  be  reached  just  above 
the  wrist-joint  by  an  incision  two  inches  long  at  the  inner  border  of  the  ten- 
don of  the  palmaris  longus.     It  lies  immediately  under  the  deep  fascia. 

4.  Operation  in  the  Hand.  The  branches  to  the  thumb,  fore-  and  middle- 
fingers  may  be  reached  by  an  incision  along  the  internal  border  of  the  thenar 
eminence.  The  skin  and  superficial  fascia  being  divided,  the  palmar  fascia 
is  disclosed.     The  nerve  lies  just  under  the  edge  of  this  latter  fascia. 

The  Ulnar  Nerve.  This  nerve  can  be  reached  in  the  axilla,  the  arm, 
or  the  forearm. 

1.  The  Axillary  Operation.  The  same  incision  as  that  for  the  median  nerve 
will  disclose  the  ulnar,  which  is  a  large  nerve  lying  to  the  inside  of  the 
median.  The  internal  cutaneous  usually  lies  between  the  median  and  the 
ulnar.  The  battery  will  differentiate  it  readily  from  the  cutaneous  nerve, 
and  will  cause  the  deep  ulnar  flexors  and  interosseous  muscles  to  contract, 
thus  flexing  the  fingers  at  the  knuckles  and  extending  them  beyond  the 
knuckles. 

2.  Operation  in  the  Arm.  A  two-inch  incision  is  made  at  the  inner  border 
of  the  biceps,  but  slightly  further  back  than  that  for  finding  the  median 
nerve.  The  nerve  lies  under  the  deep  fascia  posterior  to  the  artery  and  the 
median  nerve. 

The  ulnar  nerve  may  also  be  exposed  in  the  groove  between  the  external 
condyle  and  the  olecranon,  but  it  is  undesirable  to  cut  away  the  tense  fibres 
which  hold  the  nerve  to  its  groove.  A  few  of  the  upper  fibres  may  be 
divided  if  it  is  necessary,  as  I  have  had  to  do  in  one  instance. 

3.  Operation  in  the  Forearm.  Just  above  the  wrist  the  nerve  can  be  found 
by  ain  incision  on  the  radial  border  of  the  tendon  of  flexor  carpi  ulnaris.  The 
nerve  at  this  point,  it  should  be  remembered,  lies  under  a  second  layer  of 
the  deep  fascia  to  the  ulnar  side  of  the  ulnar  artery. 

MuscuLO-SPiRAL  Nerve.  This  is  best  found  by  a  nearly  vertical  incision 
three  inches  long  along  the  outer  border  of  the  arm,  beginning  a  little 
below  the  insertion  of  the  deltoid.  The  nerve  is  found  in  the  groove  be- 
tween the  brachialis  anticus  and  the  supinator  longus,  or  a  little  higher  up 
between  the  internal  and  external  heads  of  the  triceps  muscle.  The  deep 
fascia  having  been  incised,  the  appropriate  muscles  are  separated  and  the 
nerve  disclosed.  In  the  former  position  the  branch  to  the  supinator  longus 
may  first  be  encountered.  A  little  deeper  dissection  following  this  branch 
down  to  the  musculo-spiral  groove  of  the  bone  will  disclose  the  main  trunk 
in  the  muscular  interspace. 

The  Radial  Nerve.  This  is  a  branch  of  the  musculo-spiral,  and  is 
easily  found  by  a  longitudinal  incision  along  the  outer  border  of  the  fore- 
arm, three  inches  above  the  wrist-joint,  just  as  the  nerve  passes  under  the 
tendon  of  the  supinator  longus  to  the  posterior  surface  of  the  forearm.  The 
skin,  superficial  and  deep  fascia  are  divided,  disclosing  the  tendon  of  the 
supinator  longus,  which  is  the  guide  to  the  nerve. 

Anterior  Crural  Nerve.     The  anterior  crural  nerve  passes  from  the 


1004  I^EBVOUS  DISEASES  AND  THEIR  TREATMENT. 

abdomen  on  to  the  thigh,  underneath  Poupart's  ligament,  in  the  groove 
between  the  psoas  magnus  and  the  iliacus,  as  they  also  emerge  from  the 
pelvis  under  Poupart's  ligament.  It  lies  at  a  slight  distance  external  to 
the  femoral  artery.  An  incision  just  below  Poupart's  ligament,  and  parallel 
with  it,  the  centre  of  the  incision  being  a  little  external  to  the  artery,  will 
disclose  the  nerve  (by  a  blunt  dissection)  just  under  the  deep  fascia.  Of 
course,  care  should  be  taken  in  the  inner  part  of  the  incision  not  to  wound 
either  the  artery  or  the  vein. 

External  Cutaneous  IS^erve.  The  external  cutaneous  nerve  emerges 
from  the  abdomen,  under  Poupart's  ligament,  just  internal  to  the  anterior 
superior  spine.  An  incision  parallel  with  Poupart's  ligament  and  just  below 
it,  the  centre  of  which  is  slightly  internal  to  the  anterior  superior  spine, 
will  disclose  the  nerve  to  the  inner  side  of  the  tendon  of  origin  of  the  sar- 
torius  muscle  and  just  under  the  deep  fascia  of  the  thigh. 

The  Great  Sciatic  Nerve.  The  patient  is  placed  upon  the  abdomen  ; 
an  incision  is  made  from  three  to  four  inches  long  in  the  middle  line  of  the 
thigh,  beginning  at  the  gluteo-femoral  crease.  At  the  upper  part  of  the 
incision  the  lower  fibres  of  the  glutseus  maximus  muscle  will  be  found,  and 
may  be  recognized  by  their  almost  transverse  direction.  Just  below  these 
fibres  the  bellies  of  the  hamstring  muscles  run,  the  biceps  being  external. 
Tearing  through  the  connective  tissue  at  its  outer  border,  by  the  finger,  the 
great  sciatic  nerve  can  be  readily  found  at  a  depth  of  about  two  inches. 

The  Popliteal  Nerves.  The  popliteal  space  is  a  lozenge  formed  by 
two  long  arms  above,  the  semitendinosus  to  the  inside  and  the  biceps  to  the 
outside  and  by  two  short  arms  below,  the  two  bellies  of  the  gastrocnemius 
below.  Near  the  upper  angle  of  the  lozenge  the  great  sciatic  divides 
into  the  external  and  internal  popliteal  nerves.  The  internal  popliteal  runs 
in  the  axis  of  the  popliteal  space  from  the  upper  to  the  lower  angle.  It 
lies  immediately  below  the  deep  fascia.  Immediately  beneath  it  (in  the 
prone  position)  lies  the  popliteal  vein,  and  still  further  down,  next  the 
bone,  lies  the  artery.  The  external  popliteal  nerve  lies  along  the  inner 
border  of  the  biceps  tendon,  just  underneath  the  deep  fascia.  The  relation 
of  these  nerves  is  described,  not  so  much  because  they  are  frequently  oper- 
ated on,  but  because  in  tenotomy  of  the  hamstring  tendons  they  are  to  be 
carefully  avoided.  The  external  popliteal  lying  so  near  the  biceps  is  espe- 
cially liable  to  be  divided,  unless  the  surgeon  carefully  remembers  its  posi- 
tion.   Its  division  paralyzes  the  anterior  muscles  of  the  leg,  causing  foot-drop. 

The  Anterior  Tibial  Nerve.  An  incision  three  inches  long  is  made 
at  a  slight  angle  to  the  course  of  the  anterior  tibial  ai^tery,  which  is  in  a  line 
drawn  from  the  mid-point  between  the  external  borders^  of  the  tubercle  of 
the  tibia  and  the  head  of  the  fibula,  to  a  point  midway  between  the  two 
raalleoli.  The  deep  fascia  having  been  exposed,  the  white  line  between  the 
tibialis  anticus  and  the  extensor  communis  digitorium  is  found,  and  the  fascia 
divided  in  this  line.  The  connective  tissue  in  the  interspace  between  these 
two  muscles  is  then  loosened  by  the  finger  or  a  blunt  dissector.  Hidden 
toward  the  bottom  of  the  interspace  will  be  found  the  beginning  of  the  ex- 
tensor longus  poUicis.  The  anterior  tibial  nerve  lies  to  the  fibular  side  of 
its  artery,  deep  in  the  interspace,  between  the  anterior  tibial  and  extensor 
longus  pollicis  muscles. 

The  nerve  may  also  be  found  just  above  the  ankle  by  an  incision  in  the 
middle  line  of  the  leg ;  the  deep  fascia  having  been  divided,  the  tendon  of 
the  extensor  longus  pollicis  is  found.  The  nerve  lies  to  the  outer  border  of 
this  tendon,  between  it  and  the  tendons  of  the  extensor  longus  digitorum. 

Posterior  Tibial  Nerve.  By  an  incision  three  to  four  inches  long  at 
the  inner  border  of  the  tibia,  the  skin,  superficial  and  deep  fascia,  and  the 


SURQEBY  OF  THE  BRAIN,  SFINAL  COBI),  AND  NEBVES.     1005 

fibres  of  the  soleus  muscle  arising  from  the  tibia  are  divided.  A  second 
layer  of  the  deep  fascia  is  then  disclosed,  covering  in  the  tibialis  posticus 
muscle.  The  posterior  tibial  nerve  lies  underneath  this  fascia  to  the  fibular 
side  of  the  posterior  tibial  artery.  The  fascia  is  divided,  the  artery  found, 
and  by  it  as  a  guide  the  posterior  tibial  nerve. 

MuscuLO-cuTANEOUS  Neeve.  The  musculo-cutaneous  nerve  is  a  branch 
of  the  external  popliteal,  which  pierces  the  deep  fascia  from  one-half  to  two- 
thirds  of  the  way  down  from  the  knee  to  the  ankle.  An  incision  obliquely 
to  its  course  discloses  the  nerve  in  the  superficial  fascia. 

Internal  Saphenous  Nerve.  The  internal  saphenous  nerve  pierces 
the  deep  fascia  to  the  inside  of  the  knee  in  the  interval  between  the  tendons 
of  the  sartorius  and  gracillis,  and  then  descends  along  the  inner  side  of 
the  leg  just  behind  the  internal  border  of  the  tibia.  A  slightly  oblique  in- 
cision at  any  part  of  its  course  below  the  knee  will  disclose  the  nerve  in  the 
superficial  fascia. 

External  Saphenous  J^eeve.  This  is  a  branch  from  the  internal  pop- 
liteal nerve,  and  pierces  the  deep  fascia  at  the  upj^er  part  of  the  calf.  It 
then  descends  toward  the  outer  side  of  the  ankle-joint.  An  incision  some- 
what oblique  to  its  course  will  reveal  it  in  the  superficial  fascia. 

PuDic  Nerve.  The  pudic  nerve  accompanies  the  pudic  vessels  upward 
and  forward  along  the  outer  wall  of  the  ischio-rectal  fossa,  and  under  the 
protection  of  the  tuberosity  and  ramus  of  the  ischium.  It  lies  between  the 
two  layers  of  the  obturator  fascia.  An  incision  in  the  perineum  just  to  the 
inner  border  of  the  tuberosity  of  the  ischium,  and  a  blunt  dissection  toward 
the  obturator  fascia,  with  division  of  its  outer  layer,  will  disclose  the  vessels 
and  nerve  which  lie  about  one  and  a  quarter  inches  above  the  lower  border 
of  the  tuberosity. 

The  Digital  Nerves.  The  digital  nerves  of  the  fingers  and  toes  run  in 
a  line  corresponding  to  the  junction  of  the  palmar  and  lateral  aspects  upon 
each  side  of  the  fingers.  Those  to  the  thumb  emerge  from  the  palm  at  the 
border  of  the  thenar  eminence  near  the  base  of  the  first  phalanx.  All  of 
them  can  be  reached  best  by  a  lateral  flap. 


SURGICAL  TREATMENT  OP  CONTRACTURES. 

Most  of  these  cases  heretofore  have  been  left  untreated  surgically,  under 
the  mistaken  notion  that  no  good  could  be  done.  But  of  late  the  surgeon 
has  interfered,  to  the  great  advantage  and  often  to  the  entire  cure  of  the 
patient. 

In  cases  in  which  the  joints  have  become  immobilized  from  rheumatic, 
gouty,  or  other  forms  of  arthritis,  if  the  case  is  seen  early  enough,  the  adhe- 
sions should  be  broken  up  under  ether,  repeatedly,  if  necessary,  care  being 
taken,  of  course,  not  to  apply  such  a  degree  of  force  as  will  either  be  fol- 
lowed by  serious  inflammation  of  the  joint,  or  fracture  of  the  bone.  Sub- 
sequent massage,  Swedish  movements,  hot  and  cold  douches,  and  elec- 
tricity will  often  accomplish  a  great  deal.  If  seen  late,  when  firm  anchylosis 
is  established,  it  is  doubtful  whether  in  many  cases  any  permanent  good  will 
result  from  such  treatment,  and  I  have  seen  very  serious  results  follow,  even 
to  the  point  of  imperilling  life. 

It  is,  however,  in  the  muscular  contractures  proper  following  nervous 
lesions  that  I  have  been  able  to  accomplish  very  much  of  late.  Tenotomy 
with  forced  flexion  and  extension  and  persistent  suitable  after-ti'eatment 
will  sometimes  restore  even  almost  apparently  helpless  limbs  to  normal  or 
nearly  normal  use.     In  contractures  after  cerebral  lesions,  attended  with 


1006  NERVOUS  DISEASES  AND  THEIR  TREATMENl. 

athetoid  movements,  it  is  doubtfiil  whether  any  good  result  can  be  obtained, 
as,  even  if  the  limb  is  straightened,  there  is  no  such  control  of  it  as  to 
make  it  useful.  In  spastic  contractures  of  the  arms  or  legs  there  is  no 
such  voluntary  control  of  the  muscles  as  to  make  us  hopeful  of  benefit.  But 
in  hysterical  contractures  I  have  obtained  unexpectedly  good  results,  so  that 
I  am  greatly  encouraged,  even  in  the  most  severe  cases.  In  order  to  obtain 
the  best  results  this  tenotomy  will  generally  have  to  be  very  extensive  and 
thorough ;  all  the  contractured  parts,  whether  they  be  tendon,  contractured 
fascia  or  fibrous  tissue,  must  be  divided,  even  down  to  the  bone.  I  have 
entirely  given  up  for  several  years  any  attempt  to  treat  such  cases  by  subcu- 
taneous division.  Modern  surgery  enables  us  to  efiect  the  widest  division  of 
such  parts  by  open  wounds,  with  no  resulting  evils.  Eecently,  in  two  cases 
kindly  referred  to  me  by  Dr.  S.  Weir  Mitchell,  in  which  both  thighs  were 
flexed  at  a  right  angle  on  the  trunk  and  strongly  adducted  against  each 
other  and  both  knees  so  flexed  that  the  heels  touched  the  buttocks,  I 
divided  the  soft  parts  immediately  below  the  anterior  superior  spine  of  the 
ilium,  and  the  adductors  on  the  upper  inner  aspect  of  the  thigh,  both  down 
to  the  bone,  by  a  wide  open  incision,  and  in  the  ham  I  divided  the  ham- 
string tendons,  the  popliteal  fascia,  and  soft  tissues,  down  to  the  bone,  in  all 
three  places  being  watchfol  to  avoid  injury  to  the  important  nerves  and 
bloodvessels.  Forced  extension  at  the  hip  and  knee  enabled  me  to  overcome 
about  two-thirds  of  the  contracture,  in  doing  which,  of  course,  the  wounds 
gaped  open  very  widely.  They  were  closed  as  far  as  possible  by  suture,  and 
where  this  was  impossible  were  packed  with  iodoform  gauze.  No  reaction 
followed,  and  the  operative  gaps  were  gradually  filled  up  by  granulation 
tissue.  The  remaining  third  of  the  contracture  was  then  overcome  by  the 
persistent  use  of  splints  and  traction  by  means  of  weights  and  pulleys.  This 
later  use  of  splints,  weight  and  pulley,  with  massage,  electricity,  and  Swedish 
movements,  is  a  most  important  adjuvant  to  the  operative  treatment,  and 
must  never  be  neglected.  Several  weeks,  or  even  months,  may  be  necessary 
to  attain  the  end  in  view.  In  another,  even  more  remarkable  case,  in  which 
from  excessive  contracture  the  knee  had  been  bent  at  a  right  angle  for  a 
long  time,  the  patient  insisted  upon  either  a  straight  leg  or  amputation. 
After  extensive  tenotomy  of  all  the  structures  in  the  ham,  excepting  the  ves- 
sels and  nerves,  during  the  attempt  to  straighten  the  leg  the  posterior  liga- 
ments of  the  knee-joint  suddenly  gave  way  so  widely  that  I  could  thrust  three 
fingers  into  the  knee-joint.  I  debated  for  some  moments  whether  I  should 
not  amputate  at  once  above  the  knee,  but  my  confidence  in  modern  anti- 
septic methods  was  such  that  I  resolved  to  attempt  the  preservation  of  the 
leg.  The  wound  was  stuffed  with  iodoform  gauze  and  placed  upon  a  splint. 
The  man  got  well  without  the  slightest  reaction,  the  wound  filled  up  with 
granulation  tissue,  and  I  was  gratified  by  seeing  him  go  out  of  the  hospital 
with  a  usefi.ll  leg,  though  anchylosed  in  the  straight  position. 

In  some  cases,  instead  of  such  simple  tenotomy,  the  tendons  may  be 
lengthened  or  shortened  by  a  definite  amount,  as  I  have  described  in  a  paper 
in  the  Transactions  of  the  College  of  Physicians,  Phila.,  1891.  The  same 
prolonged  after-treatment  described  above  must  follow  the  operation  if  any 
good  is  to  be  obtained. 


CHAPTER    XXXIY. 

NEURO-ELECTROTHERAPEUTICS. 
By  GEORGE  W.  JACOBY,  M.D. 


Electrotherapy  designates  that  part  of  therapeutics  in  which  the  elec- 
tric current,  galvanic,  faradic,  or  static,  is  employed  in  the  treatment  of  dis- 
ease. Electrolysis  and  galvano-cautery,  although  properly  included  in  this 
definition,  will  not  be  referred  to  here,  and  this  chapter  will  be  still  further 
curtailed  by  limiting  it  to  a  consideration  of  the  use  of  electricity  in  diseases 
of  the  nervous  system.  For  this  and  other  reasons  the  following  chapter 
can  make  no  claim  to  completeness.  Much  that  may  be  looked  for  here 
will  not  be  found,  and  for  such  information,  as  well  as  for  the  literature  of 
the  subject,  the  reader  is  referred  to  any  of  the  large  number  of  special 
treatises  upon  medical  electricity  which  are  in  existence. 

History.  The  somewhat  mythical  stories  of  the  employment  by  the  an- 
cients of  natural  reservoirs  of  electricity,  as  bathing  patients  in  water  con- 
taining electric  eels,  can  interest  us  only  as  historical  curiosities.  With  the 
invention  of  the  friction  machine  by  von  Guericke  in  1663,  the  actual  thera- 
peutic employment  of  electricity  was  inaugurated,  and  for  more  than  a  cen- 
tury thereafter  static  electricity  was  alone  employed.  All  that  has  been 
transmitted  to  us  from  that  period  is  the  claim  of  various  electrotherapists 
of  the  eighteenth  century  (De  Haven,  Jallabert,  Mauduyt,  and  others),  that 
phenomenal  successes  had  been  attained  by  its  use.  The  end  of  that  century, 
bringing  with  it  as  it  did  the  discoveries  of  Galvani  and  Volta,  relegated  to 
obscurity  the  applications  of  static  electricity  with  their  vaunted  cures.  Gal- 
vanism, in  its  turn,  on  account  of  the  impractical  aj^paratus  which  at  that 
time  was  necessary  for  its  production,  and  on  account  of  its  exaltation  to  a 
general  panacea,  was  not  able  to  maintain  its  position  long.  It  was  really 
not  until  Oersted  discovered  the  force  of  magneto-electricity,  and  a  few 
years  later  (1832),  Faraday  made  his  fundamental  discovery  of  induced 
electricity,  that,  in  consequence  of  the  construction  of  the  first  induction  coil, 
electrotheraphy  escaped  from  the  contumely  with  which  it  had,  to  a  greater 
or  less  extent,  been  regarded.  As  the  foremost  representative  of  this  new 
era,  in  fact,  as  the  father  of  modern  electro-therapeutics,  we  must  regard 
Duchenne,  of  Boulogne.  He  it  was  who  developed  the  method  of  localized 
electrization,  and  through  his  painstaking  investigations  gave  a  sound 
basis  to  our  knowledge  of  electro-muscular  contractility  and  electro-cutane- 
ous sensation.  Upon  this  foundation  were  built  the  works  of  Remak,  Ziems- 
sen,  Brenner,  and  Erb.  In  1881,  at  the  International  Congress  in  Paris, 
another  impetus,  one  which  may  be  looked  upon  as  a  turning  point  in  its 
scientific  career,  was  given  to  electrotherapy.  This  was  the  introduction  of 
the  absolute  galvanometer.  By  this  means  it,  for  the  first  time,  became 
possible  to  regulate  the  dosage  of  the  current,  and  therefore  to  allow  a  cer- 
tain predetermined  amount  of  electricity  to  pass  through  a  given  part  of  the 
body. 


1008  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

Electrotherapy,  in  consequence  of  this  and  other  scientific  work,  then 
constituted  a  science,  per  se,  which  by  many  was  considered  as  finished  and 
complete.  Soon  thereafter  came  the  rejuvenation  of  static  electricity  in 
Paris.  Its  employment  there,  chiefly  upon  hysterical  patients,  coincided  in 
point  of  time  with  the  renewed  attention  bestowed  upon  hypnotism. 

The  instantaneous  results  obtained  with  both  of  these  measures  upon  this 
class  of  patients  could  not  fail  to  attract  attention,  and  from  this  to  the 
assumption  that  both  agents  acted  through  the  same  means,  namely,  by  sug- 
gestion, was  but  one  stej).  Furthermore,  unscientific  ultra-sanguinistic  ideas 
had  so  obtruded  themselves  in  the  treatment  of  disease  by  electricity  that  its 
use  was  being  advocated  in  nearly  every  disorder,  no  matter  how  slight,  to 
which  the  nervous  system  was  subject ;  many  of  its  advocates,  also,  not  only 
had  no  idea  as  to  the  mode  of  production  of  the  cures  supposed  to  have  been 
obtained  by  its  use,  but  were  not  even  interested  in  seeking  for  such  an 
explanation. 

It  may,  therefore,  be  easily  understood  why  observers  scientifically 
schooled  and  accustomed  to  search  for  explanations  of  their  observations  should 
have  generalized  the  deduction  derived  from  the  use  of  electricity  in  hys- 
teria, and  thus  become  ready  recipients  of  the  sweeping  assertions  which 
soon  followed. 

When,  then,  Moebius  expressed  the  opinion  that  our  knowledge  of  the 
nature  of  the  curative  action  is  nil,  and  that  at  least  four-fifths  of  all  elec- 
trical curative  properties  are  of  a  pyschic  character,  it  is  not  surprising  that 
he  soon  received  the  support  of  men  like  Schultze,  in  Bonn ;  Bruns,  in 
Hanover,  and  many  others.  The  nihilistic  tendencies  which  permeate  med- 
ical therapeutics  to  the  extent  even  that  surgical  operations  have  been  accused 
of  exerting  their  beneficial  effects  by  means  of  suggestion  have  thus  also  in- 
cluded the  action  of  electricity  in  their  grasp,  and  its  specific  curative  action 
has  become  the  subject  of  one  of  the  most  debated  questions  of  the  day. 

At  present  observers  are  divided  into  three  camps,  comprising  those  who 
admit  that  suggestion  bears  an  important  part  in  the  production  of  cures  by 
means  of  electricity,  but  who  claim  that  the  specific  electrical  action  is 
equally,  or,  perhaps,  more  important ;  those  who  claim  that  suggestion  as  a 
factor  does  not  enter  the  question  at  all ;  and  lastly,  those  who  claim  that 
all  that  is  achieved  is  done  by  means  of  suggestion,  electricity  itself  has  no 
more  specific  action  than  a  magnet  or  a  mustard  plaster,  and,  instead  of  using 
electricity,  you  may  just  as  well  employ  hypnotism  in  whatsoever  form. 

While  it  is  very  easy  to  make  sweeping  statements  of  this  nature,  it  is  an 
entirely  different  matter  to  disprove  them. 

It  may  as  well  be  admitted  here  that  our  knowledge  of  the  manner  in 
which  electricity  acts  upon  the  human  organism  is  very  elementary ;  that 
the  various  theories  as  to  its  electrolytic,  cataphoric,  and  catalytic  action  are 
none  of  them  proven,  and  that  the  therapeutic  action  of  electricity  may,  as 
Erb  has  suggested,  be  due  to  an  entirely  different  and  uninvestigated  series  of 
phenomena,  changes  in  assimilation  and  calorification,  elementary  affinities, 
osmotic  processes,  etc.  No  matter  how  indefinite  this  knowledge  may  be,  we 
certainly  have  not  yet  arrived  at  a  point  where  the  assertion  that  all  is  hypno- 
tism, all  is  suggestion,  should  be  allowed  to  confuse  and  befog  us.  At  the 
same  time,  the  electrotherapy  of  to-day  rests  only  upon  an  empirical  basis, 
and  until  experimental  investigations  shall  have  shown  us  how  electricity 
acts  upon  the  living  body,  so  long  will  we  have  to  admit  the  existence  of  a 
certain  strength  in  the  position  of  the  suggestionists.  That  suggestion  plays 
its  part  in  electro-therapeutics  cannot  be  denied.  Every  capable  physi- 
cian recognizes  the  value  of  suggestion  and  makes  use  of  it  in  some  form 
or  other.     If,  therefore,  in  electricity  we  possess  a  remedy  which,  in  addi- 


NEUBO-ELECTBO  THERAPEUTICS.  1009 

tion  to  specific  action,  is  a  potent  vehicle  for  the  employment  of  sugges- 
tion, all  the  more  reason  why  it  merits  a  prominent  place  in  our  thei'a- 
peutic  armamentarium.  At  the  same  time  we  must  not  deceive  ourselves, 
and  must  endeavor  to  form  in  our  mind  a  clear  idea  of  the  extent  of  this 
specific  action  and  of  the  actual  value  of  electricity  in  the  treatment  of  dis- 
ease. We  must  not  be  immoderate  in  our  exj^ectations,  nor  ask  the  impos- 
sible. That  destruction  of  substance,  degenerated  nerve-fibres  and  ganglia 
cannot  be_restored  by  means  of  electricity  should  be  very  evident ;  but  that 
we  do  possess  in  electricity  a  therapeutic  measure  which  in  many  disorders  of 
the  nervous  system  produces  as  positive  results  as  any  other  known  remedy, 
is  a  fact  which  no  unj^rejudiced  observer  can  deny. 

While  we  admit  that  our  knowledge  of  the  manner  in  which  electricity 
acts  as  a  remedial  agent  is  very  meagre,  we  must  insist  that  only  he  will  be 
able  to  obtain  the  best  possible  results  from  its  use  who  possesses,  in  addition 
to  thorough  anatomical  and  physiological  knowledge,  a  complete  understand- 
ing of  the  physics  and  of  the  methods  of  the  application  of  the  electric 
current. 

Three  kinds  of  current  are  used  for  therapeutic  purposes,  constant  or  gal- 
vanic, faradic  or  induced,  and  frictional  or  static  electricity.  The  ways  of  ap- 
plying the  constant  current  are  known  as  the  labile,  stabile,  and  intermittent 
methods.  In  the  stabile  method  the  current  is  allowed  to  flow  continuously 
and  steadily  ;  during  the  entire  application  the  electrodes  must  be  kept  firmly 
applied ;  in  the  second  method  one  electrode  is  fixed  to  a  certain  place, 
while  the  other  is  moved  over,  but  not  lifted  from  the  body.  The  circuit  is 
at  no  time  actually  broken,  but  the  current  strength  necessarily  changes  ac- 
cording to  the  varying  resistance  of  the  skin  and  the  pressure  applied  to  the 
electrodes.  The  marked  exciting  action  of  this  method  is  certainly  not  due 
to  these  variations  in  current  strength,  for  these  can  with  care  be  avoided, 
but  is  caused  by  the  fact  that  the  several  parts  are  being  successively  ex- 
posed to  the  influence  of  the  greatest  current  density,  and  thus  are  specially 
irritated. 

In  the  interrupted  method  one  pole  is  immovably  fixed,  while  with  the 
other  the  parts  to  be  acted  upon  are  rejDeatedly  touched,  or  both  electrodes 
are  kept  in  contact  with  the  body  while  interruptions  are  made  in  the 
metallic  part  of  the  circuit.  Occasionally  voltaic  alternatives  are  used. 
These  consist  in  the  production  of  a  reversal  of  the  current  in  the  fixed  elec- 
trodes by  making  a  pole  change  in  the  metallic  circuit.  Such  interruptions 
and  voltaic  alternatives  constitute  a  most  decided  method  of  nerve  or  mus- 
cle excitation,  one  which,  in  the  severe  forms  of  reaction  of  degeneration,  is 
alone  capable  of  producing  any  response  to  the  current. 

Two  special  methods  of  galvanization  which  are  much  employed  are  central 
galvanization  and  galvanization  of  the  sympathetic,  or,  to  employ  a  better  term, 
subaural  galvanization.  The  first  consists  in  j)lacing  a  large,  flat  electrode 
(kathode)  upon  the  epigastrium,  while  the  anode,  formed  by  a  large,  round 
sponge-electrode,  is  placed  upon  the  head  and  then  moved  along  the  sj^iual 
column.  First  the  forehead  is  stroked  from  side  to  side  with  less  than  one 
milliampere  of  current ;  then  the  top  of  the  head,  the  sides  of  the  neck,  and, 
finally,  the  spinal  column  are  treated  in  the  same  way,  except  that  over  the 
spine  a  stronger  current  may  be  used.  Thus,  the  entire  cerebro-spinal 
axis  is  subjected  to  the  action  of  the  current.  Subaural  galvanization  is  car- 
ried out  as  follows :  One  pole,  consisting  of  a  medium-sized  electrode,  is  ap- 
plied to  the  angle  of  the  lower  jaw  next  to  the  hyoid  bones  and  pressed  back- 
ward and  upward  toward  the  spinal  column.  The  other  pole,  a  large  electrode, 
is  placed  upon  the  opposite  side  of  the  neck  next  to  the  fifth,  sixth,  and  seventh 
cervical  spinous  processes.     Usually  the  kathode  is  placed  at  the  first-de- 

64 


1010  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

scribed  place.  Weak,  stabile  currents,  2  to  5  milliamperes,  should  be  used 
and  care  taken  not  to  cause  any  interruptions  of  the  current  or  variations  in 
its  density.  The  duration  of  each  application  should  also  be  short,  lasting 
from  one  to  three  minutes. 

Faradization  may  be  divided  into  two  categories,  according  to  whether  the 
skin  or  the  underlying  tissues  are  to  be  acted  upon. 

Faradization  of  the  skin  requires  the  use  of  a  secondary  coil  wound 
with  long,  thin  wire.  The  skin  must  be  thoroughly  dried  and  the  exciting 
electrode,  which  should  be  connected  with  the  negative  pole  of  the  secondary 
coil,  must  also  be  dry.  For  this  purpose  either  a  perfectly  dry  sponge-elec- 
trode or  a  wire  brush  should  be  employed.  The  positive  pole  is  connected 
with  a  moist  electrode  and  placed  upon  some  non-muscular  part  of  the  body, 
as  upon  the  sternum  or  nape  of  the  neck  ;  then,  Avith  the  other  dry  electrode, 
the  skin  over  the  entire  area  which  it  is  desired  to  excite  is  to  be  touched 
or  brushed,  thus  producing  a  passage  of  sparks  between  the  skin  and  the 
electrode. 

If  very  sensitive  parts  are  to  be  thus  treated  it  may  be  better  for  the 
operator  to  make  use  of  his  own  hand  as  an  exciting  electrode.  By  this 
means  the  painfullness  of  the  current  is  constantly  controlled  and  can  easily 
be  regulated  by  lessening  or  increasing  the  amount  of  contact  between  sub- 
ject and  operator.  In  this  method  the  moist  positive  electrode  is  again 
placed  upon  an  indifferent  point,  while  a  moist  negative  electrode  is  held 
tightly  in  one  hand  of  the  operator,  who,  with  the  back  of  the  other  hand, 
more  or  less  gently  strokes  the  parts  to  be  acted  upon. 

For  faradization  of  muscles  and  nerves  a  secondary  coil  wound  with  short, 
thick  wire  is  employed.  A  large,  well-moistened  electrode  is  placed  upon 
an  indifferent  point,  and  the  other  moist  but  smaller  electrode  is  passed 
over  the  body  of  the  muscle.  In  many  muscles  certain  points  will  be  found 
from  which  they  can  be  more  easily  excited  to  contraction.  These  are  the 
motor  points  and  correspond  to  the  entrance  of  the  nerves  into  the  muscles. 

If  not  only  a  single  muscle  is  to  be  acted  upon  but  an  entire  muscular 
group  made  to  contract,  then  faradization  of  the  nerve-triinks  is  employed. 
The  method  is  the  same  as  that  described  for  faradization  of  the  muscles ; 
the  small  electrode,  however,  being  placed  over  the  motor  point  of  the 
nerve. 

General  faradization  consists  in  passing  one  electrode  over  the  whole  or 
greater  part  of  the  body,  the  other  being  fastened  at  some  indifferent  part 
(sternum,  sacrum,  soles  of  the  feet).  Full  stimulation  and  good  contrac- 
tions of  the  muscles  are  to  be  produced  with  as  little  pain  as  possible. 

Oalvanofaradization  consists  in  uniting  the  secondary  coil  of  the  induc- 
tion apparatus  and  the  galvanic  current  into  one  circuit  and  applying  both 
currents  through  one  set  of  electrodes.  The  negative  pole  of  the  coil  is  con- 
nected with  the  positive  pole  of  the  galvanic  current,  and  the  electrodes  are 
attached  to  the  unconnected  poles.  A  good  rule  to  follow  in  the  regulation 
of  this  current  is  to  use  the  same  amount  of  galvanic  current  as  we  would 
were  we  using  this  current  alone,  and  then  to  regulate  the  faradic  current 
according  to  the  amount  of  skin  or  muscle  action  that  we  desire  to  produce. 
In  this  combined  current  we  have  a  summation  of  the  exciting  action  of  the 
galvanic  kathode  to  that  of  the  faradic  kathode,  and  thus  the  exciting  action 
of  certain  current  strengths  is  materially  increased. 

This  may  be  the  place  to  sj^eak  of  another  method  of  general  electriza- 
tion which  certainly  has  its  value  and  indications.  I  refer  to  the  hydro- 
electric bath.  According  to  which  current  is  used  we  speak  of  a  faradic,  a 
galvanic,  or  a  galvano-fai'adic  bath.  Two  forms  of  hydro-electric  baths  may 
be  used,  the  monopolar  and  the  dipolar.     In  the  monopolar  bath  the  tub  is 


NEURO-ELECTROTHERAPEUTICS.  1011 

connected  with  one  pole  of  the  battery  directly  if  made  of  metal,  indirectly 
by  means  of  the  water  if  of  wood,  while  the  other  pole  is  attached  to  a 
metal  rod  which  is  suspended  from  above  the  tub  ;  the  free  end  of  this  rod 
is  covered  by  a  sponge  or  other  material  for  the  patient  to  take  hold  of. 

If  the  tub  is  of  metal,  care  must  be  taken  by  means  of  a  net  or  other 
arrangement  to  prevent  direct  contact  between  the  body  of  the  patient  and 
the  tub.  This  form  of  bath  is  called  monopolar,  because  the  patient's  body 
is  surrounded  by  water  charged  with  electricity  from  a  single  pole. 

In  the  bipolar  bath,  both  poles  are  placed  in  the  tub,  the  simplest  manner 
being  to  cover  the  metallic  plates,  which  constitute  the  electrodes,  with  perfor- 
ated wood  or  hard  rubber,  and  then  to  place  them  in  the  water  at  the  ends  or 
at  the  sides  of  the  tub,  according  to  whether  it  is  desired  to  have  the  current 
traverse  the  body  longitudinally  or  transversely.  Very  complicated  and 
expensive  tubs  have  been  constructed  for  the  administration  of  electric 
baths,  but  the  simple  methods  here  described  will  answer  in  all  cases. 

Franklinization.  For  the  application  of  the  static  or  frictional  current, 
the  patient  is  placed  upon  an  isolating  platform  and  the  machine  then  set 
in  motion.  Knowing  which  is  the  positive  and  which  the  negative  pole  ot 
the  machine,  the  negative  terminal  is  to  be  connected  by  means  of  a  metallic 
conductor  with  the  isolating  platform,  and  the  positive  one  is  connected  by 
means  of  a  chain  with  an  insulated  electrode.  The  shape  of  this  electrode 
determines  the  form  of  the  current  obtained,  a  ball  electrode  giving  sj^arks, 
while  a  crown  or  pointed  electrode  produces  a  spray.  Now  the  terminals  of 
the  machine  which  have  thus  far  been  in  contact  are  Avidely  separated  so 
that  no  spark  passes  between  them,  and  then  the  insulated  electrode  held  by 
the  opei'ator  is  approached  to  the  body  of  the  patient,  whose  clothes  need  not 
have  been  removed. 

In  order  to  diminish  the  action  of  the  current  the  negative  pole,  instead  of 
being  connected  with  the  insulating  platform,  may  be  directly  connected  with 
the  earth  by  means  of  any  water  or  gas-pipe. 

Therapeutically  the  various  currents  may  be  applied  to  the  seat  of  disease 
if  it  is  desired  to  obtain  a  direct  influence,  and  at  some  distant  point  if  indi- 
rect or  reflex  action  is  desired.  This  desire  to  obtain  a  direct  or  an  indirect 
action  of  the  current  will  not  only  govern  our  choice  of  the  place  of  applica- 
tion of  the  electrodes,  but  will  also,  to  a  certain  extent,  determine  the  size  of 
the  electrodes  to  be  used.  Our  choice  of  electrodes  will,  however,  depend  to 
a  greater  extent  upon  the  dosage  (density)  of  the  current  desired.  As 
we  will  show  presently,  the  smaller  the  electrode  the  greater  is  the  den- 
sity of  a  given  current,  and  its  action  is  directly  proportionate  to  its 
density ;  therefore,  in  the  majority  of  instances  one  large  and  one  small 
electrode  are  chosen,  the  latter  being  placed  over  that  part  upon  which  it  is 
desired  to  concentrate  the  action  of  the  current ;  if  a  deeper  lying  organ  is 
to  be  reached  we  must  endeavor  to  include  the  organ  between  the  electrodes, 
both  of  which  should  be  of  large  size. 

Quite  as  important  as  the  determination  of  the  size  of  the  electrodes  and 
their  place  of  application  is  correct  current  dosage. 

As  regards  dosage,  galvanism  possesses  a  distinct  advantage  over  the  other 
forms  of  current,  since  we  are  able  by  means  of  the  absolute  galvanometer, 
and  by  attention  to  the  size  of  the  electrodes,  to  regulate  precisely  the  strength 
and  the  density  of  the  current.  The  regulation  of  both  strength  and  density 
of  current  is  the  fundamental  factor  of  the  dosage  of  electricity. 

The  size  of  the  electrode  determines  the  density  of  the  current ;  therefore, 
to  speak  of  current  strength  without  giving  the  size  of  the  electrodes  em- 
j)loyed  has  no  value  Avhatever,  as  a  current  of  10  milliamperes  strength 
passed  through  an  electrode  of  large  surface  is  a  weak  current,  whereas  the 


1012  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

same  strength  of  current  passed  through  a  small  electrode  may  be  very 
strong.  In  noting  the  strength  and  density  of  a  given  current  it  is  well  to 
make  use  of  some  practical  formula  which  may  be  universally  understood. 

As  current  density  is  equal  to  the  strength  of  the  current  divided  by  the 
diameter  of  the  electrodes,  we  can  describe  the  density  by  a  fraction  whose 
numerator  is  expressed  by  milliamperes  and  whose  denominator  gives  us  the 
size  of  the  exciting  electrode. 

If  round  electrodes  are  used  it  is  convenient  to  follow  the  advice  of  Stint- 
zing  and  note  their  diameter,  while  in  the  case  of  rectangular  electrodes  the 
two  side-lengths  are  to  be  mentioned.  If  then  we  desire  to  express  that  in 
a  given  case  a  current  of  6   milliamperes  has  been  applied  through  an  excit- 

ing;  electrode,  12x6  c.cm.  in  size,  the  formula  employed  would  be  D  = 

^  '  y    ^  12x6. 

If  to  this  the  length  of  application  is  added,  then  every  person  will  know 

precisely  how  much  current  the  patient  has  received. 

Being  able  to  accurately  determine  the  density  of  the  current  which  is 
being  administered,  it  might  properly  be  asked  what  current  density  should 
be  used  in  the  treatment  of  disease  ?  This  is  dependent  upon  so  many  vary- 
ing factors  that  no  definite  answer  can  be  given. 

For  general  use  a  density  of  -^-^  to  ^V  0-^  ^o  ^0  square  centimetres  of 
electrode  for  each  milliampere  of  current)  appears  to  be  about  correct,  but 
currents  of  less  or  more  density  may  naturally  be  indicated  in  individual 
cases.  In  galvanization  of  the  brain  the  density  should  not  be  more  than 
Y^^,  and  in  subaural  galvanization  not  more  than  -^^  to  ^-^. 

An  attempt  has  been  made  to  introduce  infinitesimal  doses  in  electrotherapy. 

as  ^-—  to  -^,  in  the  treatment  of  peripheral  paralysis,  but  proofs  of  such 

efficacy  are  totally  insufficient  to  convince  any  but  a  strongly  partisan  ob- 
server. 

The  dosage  of  the  current  should  be  regulated  in  every  galvanic  ap2:)li- 
cation. 

No  absolute  measure  exists  for  the  strength  of  the  faradic  current,  and  no 
practical  apj)aratus  for  measuring  it  has  yet  been  invented.  All  that  we 
can  do  is  to  give  the  distance  to  which  the  secondary  coil  has  been  drawn 
out,  and  even  then  the  results  obtained  from  each  coil  are  only  comparable 
among  themselves,  as  the  length  and  thickness  of  the  wire  with  which  the 
coils  are  wound  influence  the  action  of  current.  We  are  thus  enabled  to 
speak  of  the  strength  of  an  induced  current  only  in  very  vague  terms,  re- 
ferring to  it  as  weak,  medium,  or  strong. 

The  dosage  of  static  electricity  is  even  a  more  difficult  matter  than  that 
of  the  faradic,  for,  although  we  can  recognize  the  tension  of  a  current  from 
the  size  of  the  spark,  there  is  no  practical  way  of  estimating  its  strength 
(intensity.) 

Other  factors  besides  dosage  must,  of  course,  also  receive  consideration  in 
electrotherapy.  The  choice  of  the  proper  current,  the  number  of  applica- 
tions, as  well  as  their  duration,  are  important  questions,  which,  however,  can 
be  specifically  settled  only  for  each  individual  case. 

The  choice  of  the  proper  current  is  not  always  easy,  and  frequently  cannot 
be  determined.  In  such  case  the  selection  will,  to  a  great  extent,  have  to  be 
made  empirically. 

The  duration  of  each  application  has  been  shortened  with  the  introduc- 
tion of  the  galvanic  current  into  therapeutics  ;  formerly  applications  lasting 
from  a  half  to  one  hour  were  recommended,  but  to-day  the  consensus  of 
opinion  tends  toward  the  opposite  direction  ;  applications  "to  a  single  part  are 


NE  UR  0-ELECTR  0  THEBAPE  UTICS.        ^  1013 

to  occupy  from  one  to  ten  minutes,  while  generally  an  entire  treatment,  em- 
bracing the  ajDplication  to  various  parts,  should  not  exceed  fifteen  to  twenty 
minutes. 

The  frequency  of  applications  to  be  made  will  depend  upon  the  character 
of  the  disease  to  be  treated.  Chronic  cases  will  require  treatment  once  or 
twice  a  week,  while  acute  cases  should  be  treated  daily,  or  under  exceptional 
circumstances  even  twice  daily. 


PRACTICAL  POINTS   FOR  THE  APPLICATION  OF 
ELECTRICITY. 

In  addition  to  the  necessary  knowledge  of  the  technique  of  electrical  ap- 
plication, of  the  physics  of  electricity  and  of  the  anatomical  relationship  of 
the  underlying  parts  to  the  surface  of  the  body,  every  electrotherapist  should 
be  the  possessor  of  an  ample  instrumentarium,  and  should  always  be  sure 
that  this  apparatus  is  in  thoroughly  good  working  order.  The  necessary 
apparatus  consists  of: 

1.  An  induction  coil. 

2.  A  galvanic  battery  of  sufficient  electromotive  force  Cat  least  thirty 
cells),  which  is  supplied  with  (a)  a  selector  and  (6)  a  pole-changer. 

3.  A  rheostat. 

4.  A  milliamperemeter. 

5.  Electrodes  of  a  certain  known  surface. 

6.  Conducting  cords. 

7.  An  interrupting  handle. 

The  certainty  that  the  apparatus  to  be  used  is  in  good  condition  should  be 
the  first  rule  for  every  electro-therapeutical  application.  Everything  should 
be  carefully  inspected  each  time  it  is  used,  and  we  must  be  sure  that  the 
current  is  turned  off  before  the  electrodes  are  applied  to  the  body.  The 
causation  of  pain,  unnecessary  excitation,  current  interruptions,  or  voltaic 
alternatives  are  to  be  studiously  avoided.  The  electrodes  must  be  thoroughly 
moistened,  steadily  and  quickly  applied,  and  the  current  very  gradually 
introduced  and  removed.  It  is  best  to  increase  and  decrease  the  strength  of 
the  current  by  means  of  the  rheostat,  and  during  the  entire  application  the 
needle  of  the  milliamperemeter  should  be  carefully  watched.  The  electrodes 
should  be  applied  and  removed  only  when  the  needle  of  the  galvanometer 
indicates  the  absence  of  all  current ;  one  hand  of  the  operator  should  always 
be  upon  the  excitation  electrode  and  the  other  upon  the  rheostat,  the  indif- 
ferent electrode  having  been  given  to  the  patient  to  hold,  or,  better  still, 
fastened  by  means  of  any  mechanical  contrivance.  In  no  other  way  can 
changes  in  the  density  of  the  current,  especially  in  labile  applications,  where 
the  resistance  varies  in  the  different  parts  over  which  the  electrode  is  applied, 
be  controlled.  This  gradual  introcluction  and  removal  of  the  galvanic  cur- 
rent is  perhaps  the  most  important  point  in  the  technique  of  its  application, 
and  I  will  even  go  so  far  as  to  say  that  he  who  has  not  completely  mastered 
these  procedures  should  not  be  intrusted  with  the  application  of  galvanism. 
In  electrotherapy  every  success  depends  upon  the  method  and  the  manner  in 
which  the  current  is  employed,  and  attention  must  be  paid  to  a  great  many 
details  which  can  be  most  surely  and  quickly  mastered  by  personal  exj^e- 
rience.  Applications  to  one's  own  body  will  quickly  bring  to  light  any 
defects  which  may  exist  in  the  apparatus,  and  will  give  a  better  knowledge 
of  the  variations  of  sensibility  in  the  different  parts  of  the  body,  of  the 
situation  of  the  motor  points,  of  the  amount  of  moisture  and  pressure  to  be 


1014  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

used,  and  of  the  current  action  and  current  strength,  than  hours  spent  in 
the  study  of  these  questions. 

In  all  applications  it  should  never  be  forgotten  that  harm  may  be  done  by 
the  use  of  electricity.  Not  alone  that  its  employment  is  often  positively  con- 
traindicated,  or  that  dizziness,  flashes  of  light,  buzzing  in  the  ears,  cough, 
vomiting,  drowsiness,  and  other  occurrences  due  to  faulty  method,  may  be 
produced,  but  certain  persons  appear  to  have  an  idiosyncrasy  against  the  use 
of  electricity  in  whatsoever  form  it  may  be  applied.  Such  persons  react 
badly  to  even  a  minimum  amount  of  current ;  another  class  of  patients 
always  react  badly  when  the  negative  pole  is  applied  to  the  head.  This  fact 
may  be  noted,  not  only  in  the  use  of  the  galvanic  current,  but  also  in  appli- 
cations of  static  electricity.  Here  a  negative  charge  of  the  body  will  pro- 
duce restlessness  and  disagreeable  sensations,  while  a  positive  charge  will 
calm  and  soothe  them.  This  purely  clinical  experience  has  its  analogue  in 
the  action  of  the  constant  current  upon  certain  lower  animal  (electrotopism). 
Finally,  it  will  be  found  that  many  hypochondriacs,  neurasthenics,  tremors 
of  certain  kinds,  and  vertigoes  are  badly  influenced  by  electricity  in  any  form. 

A  certain  definite  plan  of  treatment  should  be  mapped  out  for  each  case 
and  given  a  fair  trial ;  if  the  results  are  unsatisfactory  other  methods  may 
be  employed,  but  a  certain  method  should  be  adhered  to  for  a  length  of  time 
at  least  sufficient  to  clearly  demonstrate  its  efficacy  or  uselessness. 


THE  THERAPEUTIC  USE  OP  ELECTRICITY  IN  DISEASES 
OF  THE  CENTRAL  NERVOUS  SYSTEM. 

There  can  be  no  doubt  that  we  are  able  to  reach  the  brain,  and  perhaps 
also  the  spinal  cord,  by  electric  currents,  notwithstanding  their  bony  capsules  ; 
but  whether  the  current  is  able  to  influence  processes  of  disease  in  these  parts 
is  a  question  which  is  open  to  considerable  discussion.  It  has  been  assumed 
that  nerve  elements  which  for  one  reason  or  another  were  in  a  process  of 
atrophy  could,  by  means  of  electric  excitation,  be  incited  to  regeneration,  or 
at  any  rate  arrested  in  their  further  degeneration,  and  that  excitation  of  the 
trophic  centres  would  here  produce  an  increased  development  and  thus  exert 
an  influence  over  those  parts  of  the  nervous  system  which  were  still  unaf- 
fected by  the  disease.  Also,  it  was  thought  that  the  galvanic  current  could 
produce  vasomotor  changes,  which,  in  their  turn,  would  promote  retrogression 
of  the  pathological  process  (absorption  of  exudations,  new  growths,  etc.). 

That  we  have  in  the  galvanic  current  a  means  by  which  changes  in  the 
circulation  of  the  blood  in  the  brain  can  be  affected  may  be  experimentally 
demonstrated  by  ophthalmoscopic  examination  of  the  retina. 

The  normal  functioning  of  the  central  nervous  system  depends  to  a  great 
degree  upon  a  well-regulated  circulation ;  disorder  of  the  circulation  will,  if 
temporary,  produce  functional  disturbances  ;  if  repeated  or  constant,  it  seems 
probable  that  permanent  changes,  degenerations,  may  result.  Under  these 
circumstances  it  cannot  be  denied  that,  possessing  in  electricity  a  remedy 
which  can  influence  the  circulation  in  the  central  nervous  system,  we  are 
warranted  in  making  use  of  this  agent  in  the  treatment  of  certain  diseases  of 
these  parts. 

It  is,  however,  improbable  that  any  direct  influence  can  be  exerted  upon 
the  ganglion  cells  by  means  of  ,the  electric  current,  and  thus  far  no  proof  of 
any  kind  has  been  furnished  that  such  a  specific  action  exists.  Under  these 
circumstances,  we  would  hardly  expect  to  obtain  any  beneficial  results  in  a 
large  number  of  diseases  of  the  brain  and  spinal  cord.     Clinically,  this  as- 


1 


NEUBO-ELECTROTHEBAPEUTICS.  1015 

sumption  is  fully  corroborated,  for  all  organic  diseases  of  the  nervous  system 
in  which  the  motor  cells  are  primarily  affected  can  in  no  way  be  permanently 
influenced  by  electrical  treatment.  At  the  same  time,  not  all  the  symptoms 
occurring  in  such  disease  are  due  to  the  organic  changes  in  the  ganglia. 
Symptoms  must  be  produced  by  the  functional  disturbances  which  precede 
the  organic  changes,  and  that  these  early  disorders  may  be  indirectly  in- 
fluenced and  beneficially  stimulated  by  acting  upon  their  blood-supply  can- 
not be  denied. 

In  electrization  of  the  brain  stabile  galvanization  is  used ;  medium-sized  or 
large  electrodes  should  be  employed,  and  so  placed  as  to  obtain  the  greatest 
density  of  current  over  the  diseased  focus.  The  currents  should  be  weak, 
from  one  to  five  miUiamperes,  and  the  duration  short,  two  to  five  minutes. 
If  the  brain  is  to  be  ti'aversed  by  the  current  longitudinally,  a  large  flexible 
electrode  is  to  placed  upon  the  forehead  and  a  smaller  one  on  the  occipital 
region ;  if  transverse  electrization  is  desired,  a  medium  or  large  electrode  is 
applied  to  each  mastoid  region. 

Considering  the  progress  made  by  neuropathologists  in  topical  brain  diag- 
nosis, it  would  not  seem  impracticable  to  endeavor  to  localize  the  action  of 
the  current  to  the  actual  seat  of  disease.  For  this  purpose  a  small  electrode 
is  to  placed  over  the  locus  morbi,  and  the  other  large  electrode  on  the  oppo- 
site side  of  the  head  or  neck.  It  is  as  yet  entirely  impossible  to  determine 
with  intact  skull  which  parts  of  the  brain  in  particular  are  traversed  by  the 
current,  so  that  this  method  should  still  be  received  with  a  certain  amount  of 
reserve. 

In  addition  to  the  direct  electrization  of  the  brain,  great  importance  has 
been  attached  in  the  treatment  of  diseases  of  this  organ  by  prominent  elec- 
trotherapists  to  subaural  galvanization ;  this  has  already  been  described. 

The  electrical  treatment  of  cerebral  hemorrhage  and  its  dependent  disorders 
consists  chiefly  of  galvanization  of  the  brain  and  faradization  or  galvano- 
faradization  of  the  paralyzed  muscles.  Considering  the  frequency  of  cere- 
bral hemorrhage  and  the  prolonged  disability  due  to  the  resultant  paralysis, 
it  is  important  to  know  when  to  begin  electrical  treatment,  and  to  appreciate 
how  far  any  result  may  be  expected  from  such  applications. 

It  shoukl  be  self-evident,  and  not  require  special  mention,  that  the  use  of 
electricity  during  the  apoplectic  attack  is  absolutely  contraindicated.  There 
seems  to  be  a  general  agreement  that  in  these  cases  electricity  should  not  be 
used  earlier  than  four  to  six  weeks  after  the  attack.  This  is  certainly  proper, 
for  nothing  is  to  be  gained  by  its  earlier  use,  and  harm  may  be  done.  The 
manner  of  applying  the  current  is  that  already  described ;  each  application 
should  be  short,  and  attention  should  be  called  before  the  treatment  is  begun 
to  the  possible  occurrence  of  dizziness,  nausea,  and  headache,  so  that  the 
patient  experience  no  alarm  should  they  occur.  The  treatment  is  to  be 
repeated  every  second  day,  and  continued  for  about  a  month.  If  any  ill 
effects  of  an  alarming  nature  are  observed,  the  direct  treatment  of  the  brain 
should  be  at  once  discontinued.  The  occurrence  of  late  rigidity,  of  oedema  of 
the  extremities,  of  glossy  skin,  or  joint  affections,  cannot  be  prevented,  nor 
once  present  can  they  be  benefited  by  the  use  of  electricity. 

Aphasia  may  be  treated  by  localized  galvanization,  the  anode  being  placed 
upon  the  previously  shaved  scalp  over  the  left  lower  frontal  or  first  temporal 
convolution,  and  the  kathode  on  the  nape  of  the  neck. 

The  treatment  of  the  jyaralyzed  limbs  must  not  be  neglected.  Labile  ap- 
plications of  the  kathode,  the  anode  being  placed  on  some  indifferent  point, 
or  faradization  of  the  nerves  and  muscles  are  here  indicated. 

In  abscesses  of  the  brain  valuable  time  may  be  lost  by  electrical  treatment, 
as  nothing  but  harm  can  result  from  its  use;  tumors,  inflammatory  brain  dis- 


1016  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

orders  not  ending  in  suppuration,  the  cerebral  loaldes  of  childhood,  the  athe- 
tosic  movements  resulting  therefrom,  hardly  deserve  to  be  considered  as  sub- 
jects for  electrical  treatment.  Also,  in  mental  diseases,  we  would  hardly  expect 
to  attain  beneficial  results  from  any  known  electro-therapeutic  procedure,  nor 
should  we  forget  that  fresh  delusions  may  easily  be  implanted  upon  such  a 
psychically  disordered  brain. 

In  certain  conditions  of  stujjor,  however,  energetic  use  of  the  faradic  brush, 
excitations  of  the  skin  by  the  static  spark,  often  by  their  reflex  modification 
of  the  cerebral  circulations,  produce  a  decided  improvement  in  the  mental 
condition  of  the  patient. 

The  spinal  cord  may  be  treated  electrically  in  a  direct  and  an  indirect 
manner.  For  direct  electrization  of  the  cord  the  galvanic  current  alone  is 
available,  and,  even  with  this,  it  is  a  question  whether  we  are  able  to  reach 
the  spinal  cord  through  its  bony  envelope ;  certainly  actual  proof  of  such 
a  possibility  does  not  exist ;  clinically,  however,  we  do  see  an  improvement 
in  certain  symptoms  follow  the  apiDlication  of  galvanism  to  the  cord,  so  that, 
inasmuch  as  no  harm  can  be  caused  by  such  treatment,  it  is  our  duty  to  make 
use  of  it  in  this  class  of  diseases  which  in  general  is  so  barren  of  therapeutic 
results. 

The  current  is  to  be  applied  with  large  electrodes,  and  the  labile  method 
used  if  the  entire  length  of  the  cord  is  to  be  influenced,  the  stabile  method 
if  it  is  desired  to  act  upon  any  particular  segment.  Under  all  circumstances, 
on  account  of  the  deep  situation  of  the  cord,  strong  currents  must  be  em- 
ployed. 

In  affections  of  the  conducting  tracts,  whether  primary  or  secondary,  one 
pole  may  be  placed  upon  the  sternum  and  the  other  successively  passed  over 
all  the  parts  of  the  spinal  column,  or  the  stabile  method  may  be  made  use  of 
by  placing  one  pole  on  the  cervical  and  the  other  on  the  lumbar  region. 

In  any  transverse  focal  affection  or  disorder  at  a  certain  level  of  the  cord 
we  should  attempt  to  directly  transverse  the  focus  with  the  current  by  placing 
a  large  electrode  on  the  spine  over  the  diseased  segment,  and  the  other  elec- 
trode upon  the  ventral  surface  of  the  body,  so  that  the  affected  part  lies  in 
a  direct  line  between  the  two  electrodes.  As  a  matter  of  general  agreement 
it  is  well  to  use  the  anode  only  in  irritable  conditions  and  the  kathode  in 
atonic  ones,  as  the  active  pole. 

Besides  this  direct  electrization  of  the  cord,  we  may  also  act  upon  it  in- 
directly by  means  of  peripheral  faradization.  Here  either  the  skin  over  the 
spinal  column  may  be  faradized  with  a  dry  electrode  or  with  a  wire  brush, 
or  the  skin  of  the  extremities  thus  treated  until  a  marked  reddening  of  the 
surface  takes  place. 

Hemorrhages  into  the  spinal  cord  are  of  so  little  practical  importance  on 
account  of  their  rare  occurrence  that  only  a  few  words  need  be  said  about 
their  electrical  treatment.  If  it  is  admitted  that  the  cord  can  be  reached  by 
the  current,  and  provided  that  we  can  locaHze  the  seat  of  the  hemorrhage, 
there  is  no  reason  why  resorption  of  the  clot  and  nutritional  changes  may 
not  be  effected  through  galvanization. 

As  inflammatory  processes  of  the  cord  those  disorders  are  here  to  be  con- 
sidered in  which  there  is  a  destruction  of  nerve  elements  and  a  secondary 
increase  of  connective  tissue,  involving  the  gray  as  well  as  the  white  sub- 
stance of  the  cord  and  not  confined  to  any  S5^stem  of  fibres.  They  may  be 
summed  up  under  the  generic  name  of  myelitis.  Only  in  the  chronic  forms 
is  any  hope  of  electrotherapeutical  success  warranted,  and  even  here  the 
prognosis  will  naturally  vary  according  to  the  special  characteristics  of  each 
iiidividual  case.  The  prime  indication  in  the  electrical  treatment  of  chronic 
myelitis  is  the  locaHzation  of  the  lesion  ;  this  having  been  accomplished,  the 


NEURO-ELECTBOTHERAPEUTICS.  1017 

cord  is  to  be  treated  iu  the  manner  already  described.  The  results  of  the 
cord  disease,  the  paralyses  of  the  extremities,  the  disturbances  of  bladder 
will  have  to  be  treated  symptomatically.  For  the  former  galvanization  of 
the  nerves  and  muscles  is  to  be  combined  with  the  galvanization  of  the 
lesion  ;  for  the  latter  affection  the  method  employed  is  to  apply  the  anode  to 
the  lumbar  enlargement,  the  kathode  over  the  bladder,  and  to  allow  a  current 
of  medium  strength  to  pass  for  several  minutes.  Voltaic  alternatives  may 
then  be  used,  and  if  necessary  intra- vesical  applications  or  excitations  of  the 
sphincter  of  the  bladder,  according  to  whether  the  condition  here  is  one  of 
spasm  or  of  paralysis.  If  intra-urethral  or  intra-vesical  applications  are  to 
be  made,  the  strictest  antiseptic  methods  must  be  employed.  Faradization 
may  also  be  used  either  externally  or  internally.  The  results  attained  by  the 
use  of  electricity  alone  are  usually  not  of  a  satisfactory  nature. 

In  poliomyelitis  anterior  acuta  the  treatment  should  be  directed  to  the  spinal 
cord  in  the  manner  described  according  to  the  seat  of  the  lesion  and  also  to  the 
degenerated  muscles.  The  latter  is  the  most  important,  and  should  be  care- 
fully and  energetically  carried  out  and  continued  for  a  year  or  even  more, 
from  the  onset  of  the  disease,  if  there  is  the  slightest  evidence  of  improve- 
ment. 

Even  later  it  is  of  advantage  to  institute  a  fresh  course  of  treatment  cover- 
ing a  period  of  from  eight  to  ten  weeks,  twice  or  three  times  a  year.  In 
cases  which  have  apparently  come  to  a  standstill,  an  improvement  will  fre- 
quently be  noted  after  each  course  of  treatment.  A  large  electrode  is  to  be 
applied  over  the  diseased  portion  of  the  cord,  and  with  a  medium-sized  ex- 
citing electrode  all  the  affected  muscles  are  to  be  made  to  contract.  The 
skin  is  to  be  markedly  irritated  during  this  procedure,  as  we  thus  obtain  a 
reflex  action  upon  the  cord.  The  galvano-faradic  current  here  merits  the 
preference,  but  the  induced  current  alone  may  be  employed.  A  thorough 
electro-massage  of  the  muscles  is  also  of  advantage.  Daily  applications  of 
from  five  to  ten  minutes'  duration  are  indicated  ;  electricity  should  here  not 
be  used  to  the  exclusion  of  other  methods,  as  a  great  deal  can  be  done  for 
these  children  in  other  ways  with  energy  and  perseverance. 

Subacute  and  chronic  poliomyelitis,  whether  occurring  in  children  or  in 
adults,  should  be  treated  upon  the  same  principles.  Here  it  is  again  neces- 
sary to  emphasize  the  fact  that  improvements  and  recoveries  of  the  lost  func- 
tions may  occur  after  the  lapse  of  a  very  long  period  of  time,  so  that  it  is 
essential  to  keep  up  the  nutrition  of  the  muscles  and  to  persevere  in  the 
electrical  treatment  for  many  months.  The  treatment  should  be  begun  as 
early  as  possible,  but  of  course  not  until  all  general  symptoms  have  passed 
away. 

In  progressive  muscular  atrophy  the  treatment  is  to  be  carried  out  in  much 
the  same  manner  as  in  poliomyelitis,  galvanization  of  the  cord  and  strong 
galvanic  faradization  of  the  affected  muscles ;  the  results  of  electrical  appli- 
cations are  decidedly  unsatisfactory  in  this  affection,  and,  while  it  will  rarely 
be  possible  to  forego  the  use  of  this  remedy  at  some  period  of  the  disease,  it  is 
well  to  be  perfectly  frank  with  ourselves  and  to  acknowledge  the  futility  of 
such  treatment. 

The  same  may  be  said  of  other  more  systematized  diseases  of  the  sjDinal 
cord.  In  sjxistic  sjniial paralysis,  ataxic  pajxiplegia,  and  amyotrophic  lateral 
sclerosis,  electricity  can  only  serve  as  a  means  for  keeping  up  the  hopes  of 
the  patient. 

In  the  treatment  of  locomotor  ataxia  (tabes  dorsalis)  electricity  still  oc- 
cupies an  important  position  in  the  oj^iniou  of  many  prominent  neurologists. 
Undoubtedly  a  large  number  of  the  indisputable  improvements  in  some  of 
the  symptoms  which  occur  soon  after  the  beginning  of  electrical  treatment 


1018  NERVOUS  DISEASES  AXn  THEIR  TREATMENT. 

in  cases  of  tabes  are  dependent  upon  psychic  influences,  but  the  fact  that 
certain  other  symptoms  are  always  improved  in  the  same  sequence  goes  far 
to  sustain  the  supposition  that  electricity  possesses  a  specific  influence  upon 
them.  If  ■vve  consider  that  the  anatomical  changes  in  tabes  are  not  Hmited 
to  the  spinal  cord,  but  that  the  j^erijDheral  sensory  nerves  are  usually  invaded 
by  the  degenerative  process,  and  in  many  cases  are  the  primary  seat  of  dis- 
ease, it  is  evident  that  taken  very  early  such  cases  must  be  susceptible  of 
cure  or  of  arrest. 

It  is  all  a  question  of  early  diagnosis,  and  how  early  the  diagnosis  of  tabes 
can  be  made  with  certainty  is  a  point  which  can  hardly  be  decided.  That 
the  tabic  process  cannot  be  influenced  by  electricity  after  the  gross  anatomi- 
cal changes,  which  we  are  accustomed  to  find  in  the  cord,  have  taken  place, 
is  certain,  and  it  seems  probable  that  all  improvements  which  may  occur 
after  the  eaidiest  initial  stage  has  passed  occur  in  the  natural  course  of  the 
disease,  and  are  not  due  to  any  remedy  which  may  have  been  employed. 
Unfortunately  tabic  patients  are  subjected  to  electrical  treatment  only  after 
a  great  deal  of  valuable  time  has  been  lost  by  attempts  to  influence  the 
disease  through  internal  medication.  Electricity  should  be  used  in  the 
very  early  stages  and  not  as  a  last  resort ;  then  and  then  only  can  its 
proper  remedial  position  in  this  disease  be  ascertained.  It  is  my  personal 
opinion,  gained  of  course  only  by  clinical  observation,  that  cases  show- 
ing sensory  disturbances,  transitory  attacks  of  diplopia,  which  on  this  ac- 
count were  diagnosticated  as  tabes  incipiens,  have  been  prevented  fi'om 
growing  worse  through  systematic  and  prolonged  courses  of  electrical  treat- 
ment. 

The  treatment  in  the  early  stages  should  be  directed  to  the  peripheral 
parts.  General  galvano-faradization  of  the  skin,  muscles,  and  nerves  of  the 
entire  body,  with  the  exception  of  neck,  head,  and  face,  is  here  indicated. 
Such  daily  apjjlications,  covering  a  period  of  four  to  six  weeks,  are  often 
followed  by  the  most  satisfactory  results.  Should  this  not  be  the  case,  or 
should  the  patients  be  first  seen  after  symptoms  of  anatomical  cord  changes 
have  presented  thenxselves,  then  the  direct  galvanization  of  the  cord  is  to  be 
employed  in  addition  to  general  farado-cutaneous  brushing.  In  the  fully 
developed  stage  of  the  disease  electricity  in  an}'  form  is  useless. 

There  can  only  be  one  opinion  concerning  the  action  of  electricity  upon 
diseases  of  the  jyeripheral  nerves,  motor  as  well  as  sensory,  and  that  is  that 
such  treatment  is  frequently  followed  by  good  rasults.  This  statement  can 
hardly  be  disputed  by  the  most  intense  suggestionist,  as  it  allows  amply  for, 
the  natural  tendency  to  recovery  as  well  as  for  any  effect  which  the  patients 
psychic  state  may  have  upon  the  acceleration  of  siich  recovery. 

Disorders  of  the  motor  nerves  may  be  divided  into  two  kinds,  the  paralytic 
and  the  spasmodic.  While  practically  the  benefits  derived  from  the  use  of 
electricity  in  the  paralytic  form  of  the  motor  nerve  disorder  have  been 
demonstrated  in  manifold  instances,  we  are  theoretically  far  from  under- 
standing the  manner  in  which  these  results  are  brought  about.  It  is  obvi- 
ous that  where  complete  and  irreparable  destruction  of  the  nerve-tissue 
exist,  electricity  as  well  as  every  other  method  will  fail  to  re-establish  con- 
duction. On  the  other  hand, 'it  should  be  clear  that  the  remarkable  im- 
provements ^yhich  are  frequently  observed  to  follow  upon  a  single  applica- 
tion of  electricity  are  entirely  dependent  upon  suggestion,  and  not  due  to  any 
specific  action  of  the  current.  At  the  same  time,  if  we  are  able,  through 
causing  a  functionally  disordered,  group  of  muscles  to  contract  energeticalfy, 
to  produce  upon  the  centres  which  preside  over  this  group  a  perception  of 
motion  corresponding  to  this  muscular  contraction,  we  certainlv  convev  to 
these  centres  the  suggestion  that  the  muscles  can  be  freelv  used.     That  Ave 


NEUR  0-ELECTR  0  THERAPE  UTICS. 


1019 


do  possess  in  electricity  an  unequalled  and  incomparable  method  of  produc- 
ing such  a  suggestion  is  manifest.  The  fact,  therefore,  that  in  certain  cases  of 
paralysis  the  action  of  electricity  is  a  psychic  one  does  not  in  the  least  invali- 
date its  curative  properties ;  in  addition  to  this  psychic  action  it  must  also  be 
admitted  that  the  electrical  excitation  to  contraction  of  those  muscular  fibres, 
which  still  react  mechanically,  aids  in  producing  a  better  nutrition,  and 
thus  an  increased  gro^yth  of  these  fibres. 


Fig. 


A  diagram  of  the  motor  points  of  the  face,  showing  the  position  of  the  electrodes  during 
electrization  of  special  muscles  and  nerves.  The  anode  is  supposed  to  be  placed  in  the 
mastoid   fossa,  and   the  kathode  in  the  part   indicated  upon  the  diagram.      (From   Von 

ZlEJISSEN.) 

1.  Occipito-frontalis  (ant.  belly).  2.  Corrugator  supercilii.  3.  Occipito-fron talis  (post,  belly). 
4.  Orbicularis  palpebrarum.  5.  Retrahens  et  attollens  aurem.  6.  Pyramidalis  nasi.  7.  Facial 
nerve.  8.  Lev.  lab.  sup.  et  alse  nasi.  9.  Deep  posterior  auricular  branch  of  facial  nerve. 
10.  Lev.  lab.  sup.  propr.  11.  Stylo-hyoid.  12.  Dilator  naris  ant.  13.  Digastric.  14.  Dilator 
naris  ptost.  15.  Buccal  branches  of  facial  nerve.  16.  Zygomat.  minor.  17.  Subcutaneous 
branch  of  inferior  maxillary  nerve.  18.  Zygomat.  major.  19.  Splenius  capitis.  20.  Orbicu- 
laris oris.  21.  External  branch  of  spinal  accessory  nerve.  22.  Branch  of  levator  menti  and 
dep.  ang.  oris.  23.  Sterno-mastoid.  24.  Levator  menti.  25.  Sterno-mastoid.  26.  Dep.  lab. 
infer.  27.  Levator  anguli  scapulae.  28.  Dep.  ang.  oris  29.  Phrenic  nerve.  30.  Subcutaneous 
nerves  of  neck.  31.  Posterior  thoracic  nerve  to  rhomboid  muscles.  32.  Stemo-hyoid.  33.  Cir- 
cumflex nerve.  34.  Omo-hyoid.  35.  Posterior  thoracic  nerve  to  serratus  magnus.  36.  Sterno- 
thyroid. 37.  Branch  of  brachial  plexus.  38.  Branch  for  platysma.  40.  Sterno-hyoid.  42.  Omo- 
hyoid.   44,  46.  Nerves  to  pectoral  muscles. 

Whether  electricity  has  any  action  whatsoever  upon  the  arrest  of  degenera- 
tion or  promotion  of  the  regeneration  in  a  diseased  nerve  is  an  undecided 
question.  The  treatment  must  here,  as  in  other  affections,  be  divided  into  a 
peripheral  and  a  central  one,  the  peripheral  treatment  consi.sting  in  electri- 
zation of  the  muscles  and  the  central  one  in  treating  the  diseased  nerve  above 
or  at  the  seat  of  lesion. 


1020 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


In  direct  excitation  of  the  muscles  the  faradic  current  is  to  be  used  ;  if  the 
excitability  to  the  faradic  current  is  lost,  labile  and  interrupted  galvanic 
currents  should  be  employed,  and  only  if  the  galvanic  excitability  is  mark- 
edly reduced  are  voltaic  alternatives  indicated.  In  excitation  of  a  muscle 
from  the  nerve  either  the  faradic  or  galvanic  current  may  be  employed. 

As  regards  the  curative  action  of  static  electricity  upon  paralysis  we  still 
possess  very  few  data.  That  the  action  of  the  static  and  faradic  current  is 
not  absolutely  identical  is  shown  by  cases  of  peripheral  paralysis  in  which 
the  muscles  fail  to  respond  to  the  faradic  current,  but  react  well  to  static 
excitation. 

In  the  treatment  of  peripheral  paralysis  we  should  not  fail  to  classify  the 
cases  according  to  the  severity  of  the  nerve  affection,  as  determined  by  elec- 
trical examination. 

Fig.  333.     ■ 


Eectiis  abdominis. 
Intercostal  nerves. 


Serratus  magnus. 
Latissimus  dorsi. 


— /  Intercostal  nerves. 


Transversus 
abdominis. 


Motor  points  of  the  trunk.    (From  Von  Ziemssen.) 

In  light  cases,  which  get  well  in  from  four  to  six  weeks,  it  must  have  be- 
come apparent  to  every  observer  that  a  slight  increase  in  voluntary  control 
is  produced  after  each  application  of  electricity.  In  medium  cases,  which 
improve  up  to  a  certain  point  and  then  seem  to  remain  stationary,  rapid 
progress  toward  complete  recovery  may  be  inaugurated  by  the  use  of  elec- 
tricity. The  severe  cases,  with  well-marked  reaction  of  degeneration,  run 
their  usual  course,  entirely  uninfluenced  by  electrical  treatment. 

The  paralysis  due  to  peripheral  nerve  disorder  to  which  electrical  treat- 
ment may  be  directed  are : 

Paralysis  of  the  motor  nerves  of  the  ocular  muscles.  In  paralysis  of  the  third, 
fourth,  and  sixth  pair  of  cerebral,  nerves  the  direct  treatment  of  the  muscles 
is,  on  account  of  their  situation,  impracticable.  Nevertheless  an  attempt 
should  be  made  to  produce  indirect  kathodic  excitation  of  these  paralyzed 
muscles,  by  applying  the  small  kathode  to  the  closed  lids  over  the  insertion 


NE  UR  0-ELECTB  0  THERAPE  UTICS. 


1021 


of  the  muscle  to  be  acted  upon,  the  eye  at  the  same  time  being  turned  in  the 
opposite  direction.  Whether  any  decided  excitation  of  the  muscle  is  thus 
produced  is  questionable,  although  the  possibility  of  such  production  cannot 
be  denied.  The  faradic  current  applied  through  the  closed  lids  is  certainly 
entirely  useless. 

The  insertions  of  the  paralyzed  muscles  in  the  conjunctiva  may  be  directly 
excited,  the  pain  being  lessened  by  an  application  of  cocaine.  A  galvanic 
current  sufficiently  strong  to  stimulate  the  muscles  is,  on  account  of  the  close 
proximity  of  the  retina  and  the  delicate  structure  of  the  conjunctiva, 
scarcely  safe. 

The  indirect  method  recommended  by  Benedikt  consists  in  placing  one 
pole  (anode)  upon  the  forehead,  the  other  (kathode)  on  the  margin  of  the 
orbit,  near  the  affected  muscle.  Either  the  faradic  or  the  stabile  or  labile 
galvanic  current  may  be  thus  used.  All  in  all,  it  is  questionable  whether, 
besides  an  increase  of  power  observed  after  the  current  has  been  applied  for 
a  few  minutes  and  which  is  quickly  lost,  we  are  able  to  accomplish  anything 
by  the  electrical  treatment  of  these  nerves. 

Facial  paralysis,  if  of  peripheral  origin,  whether  due  to  a  lesion  of  the 
nerve  after  its  exit  from  the  stylo-mastoid  foramen,  or  whether  the  lesion 


Fig.  334. 
1  3 


Motor  points  of  the  arm,  under  side.    (From  Von  Ziemssen.) 
1.  Musculo-cutaneous  nerve.    2.  JMusculo-cutaneous  nerve.    3.  Biceps.    4.  Internal  nerve  of 
triceps.     6.  Median  nerve,     8.  Brachialis  anticus.     10.  Ulnar  nerve.    12.  Branch  of  median 
nerve  to  the  pronator  teres. 

affects  the  nerve  in  its  course  from  the  pons  to  the  Fallopian  canal,  may  be 
beneficially  influenced  by  electrical  treatment.  The  action  of  electricity  in 
the  first  instance,  however,  is  a  direct  one,  while  in  the  second  case  a  cen- 
tripetal excitation  of  the  facial  trunk  is  produced  reflexly  through  the  tri- 
geminus. The  lighter  cases,  as  determined  by  the  electrical  reactions,  may 
be  treated  with  the  faradic  current  alone  or  in  conjunction  with  a  labile  gal- 
vanization of  the  muscles  supplied  by  the  nerve,  the  indifferent  electrode 
(anode)  being  well  pressed  in  behind  and  below  the  ear  upon  the  point  of 
emergence  of  the  nerves. 

In  severe  cases,  first  the  kathode  and  then  the  anode  should  be  used 
in  the  same  manner;  then  a  series  of  closure  and  opening  contractions 
should  be  obtained ;  and,  finally,  galvano-faradization  of  the  entire  territory 
carried  out.  The  seat  of  the  lesion  can,  of  course,  not  be  reached  directly. 
Each  application  should  last  about  five  minutes  and  be  repeated  three  to 
four  times  a  week.     The  duration  of  such  treatment  will  depend  entirely 


1022 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


upon  the  severity  of  the  affection,  but  averages  from  three  weeks  to  six 
months.  If,  after  six  months,  no  marked  improvement  has  taken  place,  the 
treatment  should  be  determined.  It  is,  however,  well  in  all  cases  of  old, 
long-standing  facial  paralysis  to  renew  the  electrical  treatment  from  time  to 
time,  as  fresh  improvements  may  thus  be  produced. 


Moror  points  of  the  arm,  outer  side.    (From  Von  Ziemssen.) 
1.  External  head  of  triceps.    2.  Musculo-spiral  nerve.    3.  Brachialis  anticus.    4.  Supinator 
longns.    5.  Extensor  carpi  radialis  longior.    6.  Extensor  carpi  radiahs  brevier. 

Pareses  of  the  muscles  of  the  larynx  frequently  necessitate  the  application 
of  electricity.  Intra-laryngeal  electrization  is,  on  account  of  its  difficulty  and 
unpleasantness,  to  be  avoided,  particularly  as  it  presents  no  advantages  over 
the  extra-laryngeal  method.  A  large  electrode  is  to  be  fastened  over  the 
nape  of  the  neck,  and  labile  galvanization  of  the  skin  over  the  larynx  and 
trachea  carried  out.  Voltaic  alternatives  and  galvano-faradization  are  often 
of  benefit. 

Electrization  of  the  jyhrenic  nerves  is  chiefly  made  use  of  in  23aresis  of  the 
diaphragm,  if  artificial  repiration  is  to  be  produced.  The  best  plan  is  to 
press  a  very  small  round  electrode  well  in  at  the  posterior  border  of  the 
sterno-mastoid  above  the  lower  end  of  the  scalenus  anticus.  A  strong  faradic 
current  is  to  be  used,  and  is  to  be  applied  until  respiration  is  re-established. 
With  the  first  sign  of  returning  respiration  the  current  is  to  be  discontinued. 

The  paralyses  affecting  the  nerves  of  the  arm  and  leg  are  to  be  treated  elec- 
trically upon  the  general  j)rinciples  already  set  down  ;  labile  galvanization 
and  galvano-faradization  of  the  entire  territory  innervated  by  the  affected 
nerve,  the  kathode  and  anode  being  used  successively,  and  the  other  pole 
being  placed  over  the  seat  of  lesion  or  at  some  indifferent  point. 

For  the  treatment  of  spasmodie  affections  of  motor  nerves  only  general 
rules  can  be  given,  and  these  must  be  modified  to  meet  the  exigencies  of  the 
various  forms  and  localizations. 

The  main  indication  in  the  treatment  of  spasms  will  be  to  discover  and 
remove  their  cause  and  to  modify  the  functional  or  molecular  disorder, 
which  probably  exists  in  the  motor  nerves  and  their  centres.  Whether  the 
latter  indications  can  be  met  by  the  use  of  electricity,  can  be  decided  only 
empirically,  and  it  seems  that  some  cases  and  forms  of  spasm  are  benefited 
by  its  use. 

In  the  electrical  treatment  galvanism  alone  is  indicated,  and,  inasmuch  as 
it  is  always  a  question  of  reducing  the  irritability  of  the  motor  apparatus, 
the  anode  will  be  employed  ;  it  is  also  assumed  that  through  the  modifying 
and  catalytic  effects  of  the  current  pathological  irritations  in  the  vicinity 
of  the  nerves  may  be  removed ; '  if  this  is  so,  we  also  have  in  galvanism  a 
remedy  Avhich  will  act  upon  the  cavise  of  the  spasm  in  some  cases.  The  sin- 
gle forms  of  spasm  to  which  galvanism  is  specially  applicable  are  facial 


NEUBO-ELECTROTHEBAPEUTICS. 


1023 


spasm,  -with  its  ofispring,  blepharospasm,  torticollis  tonic  and  clonic,  and 
the  various  spasms  or  cramps  occurring  in  the  muscles  of  the  hand  and  arm 
in  consequence  of  overexertion. 


Fig  336 


Fig.  337. 


8^ 
I 

10 
12 
14 


=1/ 

/ 


20  -^    2- 


Motor  points  of  forearm,  inner  surface.  Motor  points  of  forearm,  outer  surface. 

(From  Von  Ziemssen.) 

Fig.  336.— 1.  Flexor  carpi  radialis.  2.  Branch  of  the  median  nerve  for  the  pronator  teres.  3. 
Flexor  profundus  digitorum.  4.  Palmaris  longus.  5.  Flexor  sublimis  digitorum.  6.  Flexor 
carpi  ulnaris.  7.  Flexor  longus  pollicis.  8.  Flexor  sublimis  digitorum  (middle  and  ring 
fingers).  9.  Median  nerve.  10.  Ulnar  nerve.  11.  Abductor  pollicis.  12.  Flexor  sublimis  digi- 
torum (index  and  little  finger).  13.  Opponens  pollicis.  14.  Deep  branch  of  ulnar  nerve.  15. 
Flexor  brevis  pollicis.  16.  Palmaris  brevis.  17.  Adductor  pollicis.  18.  Adductor  minimi 
digiti.  19.  Lumbri calls  (first).  20.  Flexor  brevis  minimi  digiti.  22.  Opponens  minimi  digiti. 
24.  Lumbricales  (second,  third,  and  fourth). 

Fig.  337.— Extensor  carpi  ulnaris.  2.  Supinator  longus.  3.  Extensor  minimi  digiti.  4.  Ex- 
tensor carpi  radialis  longior.  5.  Extensor  indicis.  6.  Extensor  carpi  radialis  brevior.  7.  Ex- 
tensor secundi  internodii  pollicis.  8.  Extensor  communis  digitorum.  9.  Abductor  minimi 
digiti.  10.  Extensor  indicis.  11.  Dorsal  interosseus  (fourth).  12.  Extensor  indicis  and  extensor 
ossis  metacarpi  polUcis.  14.  Extensor  ossis  metacarpi  pollicis.  16.  Extensor  primi  internodii 
pollicis.    18.  Flexor  longus  pollicis.    20.  Dorsal  interossei. 

Of  the  disordered  conditions  to  which  the  -sensory  nerves  are  subject,  anses- 
thesia  and  pain  are  the  two  which  chiefly  call  for  electrical  treatment. 


1024 


NERVOUS  DISEASES  AND  THEIR  TREATMENT. 


Parcesthesias  and  other  sensory  disturbances  very  rarely,  pe?'  se,  require 
treatment  of  any  kind,  as  they  are  usually  simply  concomitants  of  other 
more  serious  troubles. 

Anc&sthesia  will  have  to  be  treated  upon  the  same  general  principles  as 
paralysis,  directing-  the  treatment  to  the  seat  of  the  disease,  when  this  can 


Fig.  33 S. 


Fig.  339. 


Motor  points  of  thigh,  anterior  surface.  Motor  points  of  thigh,  posterior  surface. 

(From  Von  Ziemssen.) 
Fig.  338.— 1.  Tensor  vaginse  femoris  (branch  of  superior  gluteal  nerve).  2.  Anterior  crural 
nerve.  3.  Tensor  vaginae  femoris  (hranch  of  crural  nerve).  4.  Obturator  nerve  5.  Rectus 
femoris.  6.  Sartorius.  7.  Vastus  externus.  8.  Adductor  longus.  9.  Vastus  externus.  10. 
Branch  of  crural  nerve  to  quadriceps  extensor  cruris.  12.  Crureus.  14.  Branch  of  crural  nerve 
to  vastus  externus. 

Fig.  339.— 1.  Adductor  magnus.  2.  Inferior  gluteal  nerve  for  gluteus  maximus.  3.  Seml- 
tendinosus.  4.  Great  sciatic  nerve.  5.  Semi-membranosus.  6.  Long  head  of  biceps.  7.  Gas- 
trocnemius (internal  head).  8.  Short  head  of  biceps.  10.  Posterior  tibial  nerve.  12.  Peroneal 
nerve.    14.  Gastrocnemius  (external  head).    16.  Soleus. 

be  localized,  as  well  as  to  the  seat  of  the  symptoms.  Anaesthesia  due  to  cen- 
tral disorder  must  be  carefully  differentiated  from  that  due  to  peripheral 
causes,  for  in  the  former  the  good  results  of  electrical  treatment  will  be 
sought  for  in  vain,  while  in  the  latter  thorough  faradization  with  a  dry  elec- 
trode or  with  a  faradic  brush  will  be  found  to  exert  a  beneficial  influence  in 
very  many  cases. 

In  the  treatment  of  neuralgkis  the  specific  curative  action  of  electricity 
has  been  generally  acknowledged  ;  but  whether  this  action  is  dependent 
upon  the  production  of  a  change  in  the  excitation  or  nutrition  of  the  hyper- 
sesthetic  nerve,  or  whether  direct  ausesthesia  is  produced  by  means  of  strong 


NE  UR  0-ELECTR  0  THEE  APE  UTICS. 


1025 


counter-irritation,  or  whether  the  action  is  not  a  purely  mechanical  one,  pro- 
ducing a  molecular  change  in  the  nerve  itself,  cannot  be  stated. 

This  much  is  certain,  that  whatever  may  be  the  cause  of  the  beneficial 
influence,  idiopathic  neuralgias  offer  a  more  fruitful  field  for  electrical  treat- 
ment than  do  any  other  affections  of  the  nervous  system.     In  accordance 


Fig.  340. 


Fig.  341. 


Motor  points  of  the  leg,  outer  side.  Motor  points  of  the  leg,  inner  side. 

(From  VoN  Ziemssen.) 
Fig.  340.— 1,  Peroneal  nerve.  2.  Peroneus  longus.  3.  Gastrocnemius  (external  head).  4. 
Tibialis  anticus.  5.  Soleus.  6.  Extensor  longus  pollicis.  7.  Extensor  communis  digitorum 
longiis.  8.  Branch  of  peroneal  nerve  for  extensor  brevis  digitorum.  9.  Peroneal  brevis.  10. 
Dorsal  interossei.  11.  Soleus.  13.  Flexor  longus  pollicis.  15.  Extensor  brevis  digitorum.  17. 
Abductor  minimi  digiti. 

Fig.  341. — 1.  Gastrocnemius  (internal  head).     2,  Soleus.     3.  Flexor  communis  digitorum 
longus.    4.  Posterior  tibial  nerve.    5.  Abductor  pollicis. 


herewith,  the  differentiation  between  the  idiopathic  and  symptomatic  neural- 
gias is  of  prime  importance  ;  if  the  neuralgia  is  found  to  be  a  symptom  of  some 
local  or  general  affection,  other  remedies  than  electricity  will  have  to  be  em- 
ployed for  the  removal  of  this  cause,  but  aid  may  be  sought  in  the  use  of 
general  faradization  or  galvano-faradization.     If,  on  the  other  hand,  the 

65 


1026  NERVOUS  DISEASES  AND  THEIB  TREATMENT. 

neuralgia  is  as  far  as  can  be  determined  not  dej)endent  upon  any  such  local 
or  general  disease,  then,  as  stated,  great  service  may  be  expected  from  the 
direct  use  of  electricity.  In  this  direct  treatment  all  three  currents  may  be 
employed,  but  it  is  well  always  to  begin  with  the  galvanic  anode  on  account 
of  its  analgesic  action.  The  method  of  application  is  usually  a  stabile  one, 
the  kathode  being  placed  at  some  indifferent  point  and  the  anode  upon  the 
place  of  exit  of  the  nerve  or  upon  a  particularly  painfiil  point.  The  size  of 
the  electrode  to  be  used  will  be  governed  here,  not  only  by  the  general  prin- 
ciples already  laid  down,  but  by  the  extent  of  the  pain.  A  difluse  pain 
would  indicate  the  employment  of  a  broad  electrode,  while  a  circumscribed 
pain  requires  the  use  of  a  small  one.  During  this  application  variations  in 
the  current  density  are  to  be  carefully  guarded  against,  and  interruptions 
under  all  circumstances  to  be  avoided. 

If  we  have  satisfied  ourselves  that  the  galvanic  current  gives  no  relief, 
the  faradic  current  may  be  employed,  either  for  its  direct  or  for  its  indirect 
action.  If  the  former  is  desired,  a  weak  current  is  passed  directly  through 
the  nerve  ;  if  this  current  is  well  borne,  it  may  be  slowly  and  carefully  in- 
creased, and  then  again  decreased.  Indirectly  the  faradic  current  acts 
purely  as  a  counter-irritant,  and  nothing  can  serve  the  purpose  of  such  ap- 
plication better  than  the  metallic  brush.  An  increased  counter-irritant 
action  can,  if  desired,  be  obtained  by  attaching  the  brush  to  the  galvanic 
kathode ;  after  application  of  the  electric  brush  remarkable  and  continued 
improvements  are  often  noted,  so  that  this  mode  of  procedure  should  always 
be  tried  if  the  stabile  application  of  galvanism  has  failed. 

In  some  cases  in  which  both  the  galvanic  and  faradic  current  have  failed 
to  produce  good  results  static  electricity  seems  to  give  evidences  of  analgesic 
properties. 

All  depends  here  upon  the  method  of  apjolication  and  the  carefully  gradu- 
ated discharge  of  the  current,  so  as  to  avoid  giving  shocks  to  the  patient. 
It  would  almost  seem  as  though,  in  consequence  of  the  enormous  tension  of 
this  current  and  of  the  great  deviations  which  take  place  during  every  dis- 
charge, that  molecular  alterations  must  be  produced  in  the  nerves. 

A  matter  of  general  experience  in  the  electrotherapy  of  neuralgias  is  that 
certain  nerves  are  more  easily  and  more  quickly  influenced  by  this  agent 
than  by  others ;  this  difference  is  also  noted  among  various  branches  of  the 
same  nerve. 

The  neuralgias  which  we  are  most  frequently  called  upon  to  treat  are 
those  of  the  trigeminus  and  of  the  sciatic  nerves.  As  regards  the  method 
of  treatment  of  trigeminal  neuralgias,  there  is  not  much  more  to  be  said 
than  that  which  has  already  been  stated  in  the  general  remarks ;  the 
painful  points,  the  supra-orbital,  infra-orbital,  and  that  of  the  chin,  will  be 
treated  anodally,  according  to  which  branch  is  particularly  affected.  The 
current  should  be  gradually  increased  up  to  the  desired  point,  and  then 
again  equally  gradually  decreased.  Each  application  should  last  from  three 
to  five  minutes,  and  in  acute  cases  one  or  two  daily  applications  are  indi- 
cated. Great  care  must  be  exercised  in  the  electrical  treatment  of  the  afiec- 
tions  of  this  nerve,  as  not  infrequently  exacerbations  of  the  pain  occur  as  a 
direct  result  of  such  treatment.  Purely  symptomatically,  the  use  of  medicinal 
cataphoresis  will  temporarily  serve  to  alleviate  the  sufferings  of  the  patient. 
In  the  treatment  of  sciatica  by  electricity  a  great  diversity  of  opinion 
exists  as  to  the  methods  to  be  employed,  as  well  as  to  the  results  which  may 
be  attained.  This  is  certainly  due  to  the  fact  that  we  do  not  exercise  suflS- 
cient  care  in  properly  differentiating  the  various  cases  and  separating  the 
neuritic  sciaticas  from  the  neuralgic  ones.  The  first  form — and  to  this  the 
majority  of  cases  belong — are  certainly  but  little  helped  by  the  use  of  elec- 


NEUBO-ELECTROTHEBAPEUTICS.  1027 

tricity,  while  in  the  second  categoiy  we  very  often  attain  good  results.  It  is 
essential  in  this  form  to  subject  the  entire  nerve  to  the  action  of  the  current. 
For  this  purpose  a  large  plate  electrode  is  placed  over  the  sacrum  or  over 
the  sciatic  notch,  while  the  other  electrode  is  passed  over  the  entire  course  of 
the  nerves.  Strong  currents  may  be  used,  and  each  application  be  made  to 
last  from  ten  to  fifteen  minutes.  Galvano-faradization  of  the  entire  limb 
and  faradic  brushing  of  the  skin  are  also  occasionally  of  benefit. 

Of  other  neuralgias,  the  cervico-occipital  and  those  of  the  radial  and  ulnar 
territories  are  frequently  quickly  and  permanently  relieved  by  a  few  appli- 
cations of  electricity. 

Of  intercostal  neuralgias  the  same  may  be  said  as  of  sciatic  :that  they  are 
often  due  to  inflammatory  disorders  of  the  nerve,  and  are  then  hardly  sus- 
ceptible of  improvement  by  means  of  electricity.  In  idiopathic  intercostal 
neuralgias  relief  is  obtained  by  the  usual  methods.  These  remarks  apply  in 
their  entirety  to  the  form  known  as  mastodynia  and  to  the  "functional  neu- 
roses," from  the  fact  that  disorders  of  the  nervous  system,  without  known  path- 
ological basis,  may  produce  local  as  well  as  general  symptoms.  We  can  under- 
stand that  their  electrical  treatment  may  similarly  be  divided  into  a  local  and 
a  general  one.  According  to  the  nature  of  the  case,  the  relief  of  simple  symp- 
toms and  the  restoration  of  the  disturbed  nervous  parts  to  their  normal  con- 
dition will  be  the  results  aimed  at.  The  first  of  these  indications  may  often 
be  met  by  local  electrical  treatment  alone,  but  in  the  second  it  is  always 
necessary  to  subject  the  entire  central  nervous  system  to  the  modifying  treat- 
ment, and  here  electricity  should  be  regarded  simply  as  an  adjuvant,  a  very 
valuable  one,  it  is  true,  to  other  remedies. 

Among  the  functional  neuroses,  in  the  treatment  of  which  electricity  has 
been  at  various  times  highly  recommended,  is  chorea  minor.  The  failure  of 
all  the  usual  remedies  occasionally  makes  it  necessary  that  electricity  should 
be  tried  in  this  aflfection. 

The  only  current  which  could  possibly  have  any  influence  upon  this  dis- 
order is  the  galvanic,  and  galvanization  of  the  spine  or  of  the  brain  has  been 
recommended,  according  to  whether  the  advocate  was  an  adherent  of  the 
spinal  or  cerebral  theory  of  its  causation.  Temporary  results  are  occasionally 
obtained  by  either  method,  but  I  have  never  seen  any  evidence  of  permanent 
benefit ;  on  the  other  hand,  I  have  repeatedly  seen  the  choreic  movements 
decidedly  increased  through  unskilled  electrical  applications.  Everything 
which  excites  or  frightens  the  patient  is  to  be  strenuously  avoided  in  the 
treatment  of  chorea ;  hence  the  use  of  the  faradic  current,  of  the  electric 
brush,  of  strong  galvanic  currents,  as  has  been  advocated,  cannot  be  too 
strongly  discountenanced. 

Cerebral  galvanization  has  also  been  recommended  in  epilepsy,  notwith- 
standing that  neither  our  knowledge  of  the  pathogeny  of  this  obscure  disease 
nor  clinical  experience  furnishes  a  single  argument  in  its  favor.  The  current 
recommended  has  naturally  been  galvanic,  and  the  methods  those  of  central 
and  subaural  galvanization.  If  made  use  of  at  all,  extraordinary  care 
should  be  exercised  in  these  applications,  for  the  occurrence  of  an  epileptic 
attack  during  the  passage  of  the  current  would  certainly  be  attributed  to 
this  procedure. 

All  in  all,  even  the  reports  of  the  advocates  of  the  use  of  electricity  in  the 
treatment  of  epilepsy  are  not  such  as  to  warrant  us  in  expecting  as  good 
results  from  it  as  we  do  from  the  administration  of  certain  internal  remedies. 

Paralysis  Agitans.  The  electrical  treatment  of  this  disease,  galvanic  or 
static,  occupies  the  same  place  as  treatment  of  other  nature.  Various 
writers  have  recommended  this  or  that  electrical  method  as  palliative  of  cer- 
tain symptoms,  or  even  as  curative  of  the  disease,  but  every  conscientious 


1028  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

observer  who  follows  these  recommendations  must  arrive  at  the  conclusion 
that  all  forms  and  methods  of  electrical  treatment  are  worse  than  useless  in 
this  affection. 

Exophthalmic  goitre  is  one  of  the  "neuroses"  in  which  galvanism  is  un- 
doubtedly of  a  great  deal  of  benefit.  That  the  affection  is  ever  arrested  in 
its  course,  or  entirely  cured  by  the  use  of  electricity  alone,  is  improbable, 
but  that  single  symptoms  often  disappear,  and  that  the  entire  condition  of 
the  patient  is  improved  by  its  use,  is  quite  generally  acknowledged. 

The  method  which  is  usually  advocated  is  that  of  subaural  galvanization. 
In  many  instances  a  lowering  of  the  pulse- rate  of  from  15  to  20  beats  per  min- 
ute may  be  obtained  by  each  application,  and  exceptionally  even  a  decrease 
in  the  size  of  the  thyroid  may  be  noted.  Unfortunately  this  effect  is  usually 
transient,  but  repeated  aj)plications  may  produce  permanent  effects.  A 
large  number  of  other  methods,  including  general  faradization  and  galvani- 
zation of  the  brain,  have  also  been  recommended,  and  it  is  certainly  diffi- 
cult from  the  various  descriptions  to  decide  upon  the  best  method  of  treat- 
ing this  disease. 

In  my  experience  two  principles  should  form  the  basis  of  every  treatment, 
viz.,  the  use  of  weak  currents  and  their  very  frequent  applications.  The 
frequency  of  the  applications  (several  times  a  day)  necessitates  self-adminis- 
tration by  the  patient,  and  the  plan  recommended  by  Cardero  answers  all 
requirements.  The  galvanic  current  alone  is  to  be  used,  the  current  strength 
not  to  exceed  two  milliamperes,  and  each  application  to  last  from  five  to  ten 
minutes.  "  The  anode  is  to  be  placed  on  the  nape  of  the  neck,  the  centre  of 
its  lower  border  corresponding  to  the  seventh  cervical  spinous  process,  and 
be  firmly  held  in  that  position  during  the  application.  The  electrode  should 
be  moved  up  and  down  the  side  of  the  neck  from  the  mastoid  j)i'ocess  along 
the  course  of  the  great  occipital  nerve." 

A  battery  containing  a  sufficient  number  of  dry  or  wet  cells — i.  e.,  of  suffi- 
cient voltage  to  give  the  desired  current  (the  resistance  of  the  skin  or  elec- 
trodes, of  course,  being  considered) — together  with  electrodes  of  a  fixed  diam- 
eter, may  be  given  to  the  patient  with  the  necessary  instructions.  No 
selector,  rheostat,  nor  galvanometer  is  necessary,  as  the  current  cannot 
exceed  the  desired  amount,  and,  with  attention  to  details  (wetting  the  elec- 
trodes, etc. ),  can  fall  but  little  below  it.  According  to  the  voltage  of  the 
cell  used,  and  assuming  the  resistance  of  the  parts  to  which  the  current  is  to 
be  applied,  when  thoroughly  moistened,  to  be  from  2000  to  3000  ohms,  from 
three  to  six  cells  will  be  required.  The  battery  should  be  inspected  at 
regular  intervals,  so  as  to  be  sure  that  everything  is  in  working  order. 

The  local  treatment  of  the  struma  or  exophthalmus  either  by  galvanic  or 
static  currents  is  irrational  and  not  productive  of  favorable  results.  Every- 
thing should  be  done  to  improve  the  general  nutrition  of  the  patient,  and 
with  this  in  view  general  faradization  or  galvano-faradization  is  often  of 
value. 

A  number  of  cases  of  exophthalmic  goitre  will  be  encountered  with  unde- 
veloped or  not  well-defined  symptoms.  Such  cases,  showing  only  one  of  the 
classical  triad  of  symptoms,  with  or  without  some  of  the  other  less  important 
phenomena,  such  as  tremor,  etc.,  are  frequently  indistinguishable  from  cases 
of  neurasthenia.  They  will  do  well  if  treated  according  to  the  authority  laid 
down  in  the  following  paragraphs. 

Neurasthenia.  If  there  is  any  affection  of  the  nervous  system  in  which 
physical  methods  alone  deserve  prime  consideration,  it  is  the  disorder  known 
as  neurasthenia.  Among  these  physical  methods  no  remedy  plays  a  more 
important  part  than  electricity.  Electricity  may  here  form  part  and  parcel 
of  other  treatment — drugs,  rest,  nutrition,  massage,  hydrotherapy — or  may 


NEURO-ELECTBOTHEBAPEUTICS,  1029 

be  used  alone.  In  eithei*  case  general  faradization  or  galvanization  may  be 
used.  It  is  my  opinion  that  strong  currents  are  to  be  avoided,  and  that  a 
moderate  excitation  of  the  peripheral  nerves  is  all  that  is  necessary.  Neur- 
asthenics require  very  circumspect  treatment,  and  the  symptoms  of  cerebral 
or  spinal  irritation  are  very  often  increased  by  the  use  of  strong  currents ; 
each  application  should  also  be  short — five  to  ten  minutes — at  any  rate  at 
first,  and  later  the  time  may  be  increased. 

The  results  of  general  electrization  are  often  directly  apparent  in  the  relief 
of  pain,  fatigue,  and  regulation  of  the  pulse. 

Besides  general  electrization,  central  galvanization  is  of  benefit  in  the 
treatment  of  neurasthenics  whose  general  nutrition  seems  to  be  good. 

Also  in  the  treatment  of  single  symptoms  the  use  of  electricity  is  of  value. 
Thus  headache,  sleeplessness,  paljjitation,  etc.,  may  often  be  relieved  by 
cerebral  galvanization.  Particularly  against  the  insomnia  of  neurasthenia 
has  galvanization  of  the  brain  and  the  static  head-douche  been  recommended. 
Personally,  I  have  often  found  the  use  of  the  positive  static  charge  of  very 
great  benefit  in  combating  this  symptom,  having  been  able  to  produce  sleep 
by  this  means  after  all  other  physical  methods  had  failed  and  a  resort  to  the 
use  of  drugs  being  undesirable.  In  many  cases  of  neurasthenia,  as  already 
stated,  electricity  in  any  form  does  harm  instead  of  good ;  it  is  not  possible 
to  determine  without  a  trial  which  cases  will  be  benefited  and  which  ones 
made  worse  by  the  use  of  electricity.  If  patients  after  each  application 
complain  of  being  excited,  of  tremor,  dizziness,  headache,  tendency  to  faint, 
and  sleeplessness,  there  is  either  something  wrong  in  the  method  of  applica- 
tion or  the  use  of  electricity  is  contraindicated. 

Hysteria.  All  doubts  which  have  been  expressed  concerning  the  specific 
curative  action  of  electricity  in  organic  diseases  of  the  nervous  system  deserve 
to  be  much  more  strongly  emphasized  in  considering  the  treatment  of  hysteria. 
Many  of  the  symptoms  met  with  in  this  affection  are  the  result  of  auto- 
suggestion, and  these  same  symptoms  can  often  be  made  to  disappear  by  an 
allo-suggestion  transmitted  through  the  porper  channels.  Whatever  vehicle 
may  have  been  employed  for  this  transmission,  we  should  be  clear  upon  the 
point  that  it  is  the  suggestion  and  not  the  vehicle  which  has  aifected  the 
cure.  In  the  great  majority  of  cases  when  electricity  is  of  service  in  dispel- 
ling certain  predominant  symptoms  of  hysteria  it  is  as  a  vehicle  for  carrying 
suggestion  that  its  action  must  be  sought ;  and  as  such  a  psychic  remedy  its 
value  in  the  treatment  of  hysterical  symptoms  is  very  great.  The  firmest 
believer  in  the  actual  therapeutic  value  of  electricity  will  hardly  contend 
that  the  disease  "  hysteria "  can  be  cured  by  this  remedy.  The  removal 
of  certain  symptoms  is  an  important  part  of  the  treatment  of  this  disease, 
and  any  remedy  which  will  aid  us  in  effecting  such  a  result,  immaterial  in 
what  way,  must  be  considered  a  valuable  acquisition. 

In  every  case  a  certain  plan  of  treatment  must  be  laid  out  and  followed, 
but  not  blindly  ;  changes  and  modifications  will  be  necessitated  by  the  course 
and  character  of  the  symptoms  in  different  patients,  and  nowhere  is  it  more 
important  than  here  to  remember  that  we  are  treating  individuals  and  not 
diseases. 

As  part  and  parcel  of  the  "Weir  Mitchell  treatment,  or  whenever  it  is 
deemed  necessary  to  increase  nutrition  and  to  promote  assimilation,  general 
electrization  will  be  found  of  value. 

Local  symptoms,  paralysis,  contractures,  neuralgias,  hypersesthesias,  and 
anaesthesias  should  be  treated  upon  the  principles  already  laid  down  for  the 
application  of  electricity  in  these  disorders. 

Diseases  op  the  Muscles.  Certain  diseases  of  the  muscles,  in  the  treat- 
ment of  which  the  use  of  electricity  is  of  value,  must  be  referred  to  before 


1030  NERVOUS  DISEASES  AND  THEIR  TREATMENT. 

closing  this  chapter ;  these  are  muscular  rheumatism,  arthritic  atrophy,  and 
the  primary  myopathies.  The  affection  known  as  muscular  rheumatism, 
notwithstanding  our  indefinite  knowledge  as  to  its  actual  character,  is  fre- 
quently very  much  benefited  by  the  use  of  electricity.  The  localization  of 
the  affection  has  more  influence  upon  the  amount  of  benefit  to  be  expected 
than  the  intensity,  and  the  most  striking  results  may  be  obtained  in  severe 
torticollis  or  lumbago,  while  myalgia  of  the  pectoral  muscles  or  of  those  in 
the  vicinity  of  joints  is  often  but  slightly  influenced.  The  treatment  should 
consist  in  the  j)i'oduction  of  thorough  contractions  of  the  affected  muscles 
and  excitation  of  the  overlying  skin.  At  best  this  treatment  is  very  painful, 
but  milder  measures,  as  the  use  of  the  stabile  galvanic  current,  are  of  avail 
only  in  such  cases  in  which  a  superficial  massage  would  bring  about  quicker 
results.  Faradization,  galvano-faradization,  the  use  of  the  faradic  brush  or 
of  the  static  spark  are  here  the  sovereign  remedies. 

Fresh  cases  may  thus  often  be  cured  by  a  few  applications,  while  chronic 
cases  will  require  several  weeks  of  daily  treatment. 

In  the  treatment  of  the  muscular  atrophy  occurring  in  consequence  of 
joint-lesions  electricity  is  an  important  agent.  By  means  of  galvanic  and 
faradic  excitation  the  nutrition  of  the  muscles  is  to  be  bettered,  and  thus  an 
increase  in  their  volume  attained.  The  use  of  continuous  weak  galvanic  cur- 
rents is  said  to  be  of  value,  particularly  in  the  treatment  of  these  atrophies. 
The  results  of  all  treatment  here  will  depend  upon  the  condition  of  the  joint ; 
until  the  primary  joint-lesion  is  cured  little  is  to  be  expected  from  any  treat- 
ment directed  to  the  muscles  themselves. 

In  the  treatment  of  the  primary  myop)atliies  as  little  has  been  attained  by 
the  use  of  electricity  as  by  any  other  means ;  at  the  same  time  the  systematic 
employment  of  this  remedy  in  the  shape  of  galvano-faradization  of  the 
muscles  and  of  the  motor  points  may  aid  in  promoting  the  nutrition  of  the 
parts,  and  thus  be  instrumental  in  delaying  their  involvement  by  the  atrophic 
process. 


INDEX. 


ABDUCENS  nerve,  diseases  of,  773 
anatomy  of,  775 
paralysis,  40,  789 
Abscess  of  brain,  374,  971.    See  Brain  Abscess. 
Acoustic  paralysis,  806 
Acromegaly,  891 

dift'erential  diagnosis,  897 
etiology,  891 
history,  891 
pathology,  897 

changes  in  pituitary  gland,  897 
changes  in  the  bones,  897 
symptoms,  894 
features,  894 
feet,  895 
hands,  895 
mental,  896 
posture,  894 

sensory  phenomena,  896 
spinal  column,  895 
visceral,  896 
theories  of  origin,  892 

rule  of  the  pituitary  gland,  894 
treatment,  898 
Acropareesthesia,  721 
Acute  ascending  paralysis,  583 
course  of,  585 
diagnosis  of,  586 
sphincters  in,  585 
etiology  of,  583 
mortality  in,  585 
order  of  onset,  584 
pathology  of,  585 
prognosis  of,  586 
reflexes  in,  584 
sensory  phenomena  in,  584 
symptoms  of,  584 
toxic  origin  of,  586 
treatmen  t  of,  586 
atrophic  paralysis,  620 
circumscribed  oedema,  885 
ophthalmoplegia,  785 

causes,  785 
softening  of  brain,  areas  involved,  468 
cranial  nerve  palsies  in,  467 
etiology,  467 
pathology,  469 
prognosis,  468 
symptoms,  467 
treatment,  468 
Adiposis  dolorosa,  893 
diagnosis,  900 
symptoms,  898 
treatment,  900 
Affections  of  smell,  804 
taste,  805 

the  auditory  nerve,  806 
the  phrenic  nerve,  836 
African  sleeping-sickness,  956 
Ageusia,  805 
Agraphia,  435,  496 
Agoraphobia,  65 
Alcoholic  neuritis,  727 
diagnosis,  "30 
duration,  729 
prognosis,  730 
symptoms,  728 
brain,  729 
contractures,  729 
electrical  reaction,  729 
foot-drop,  728 
gait,  729 


Alcoholic  neuritis,  symptoms,  hypersesthesia,  728 
inco-ordination,  729 
pain, 728 
temperature,  728 
tenderness,  728 
wrist-drop,  728 
Alcoholism,  190 

epilepsy  from,  192 
etiology,  190 
insanity  from,  191 
neuritis  from,  192 
pachymeningitis  from,  191 
pathology,  190 
prognosis,  193 
spinal  diseases  from,  192 
symptoms,  191 
treatment  of.  193 
Alexia,  439 
AUocheiria,  34 
Amaurosis,  43 
Amblyopia,  43 
toxic,  761 
Arayelia,  522 
Amimia,  436 
Amnesia  literarum,  440 
Amusia,  437 

Amyotrophic  lateral  sclerosis,  630 
diagnosis,  632 
etiology,  631 
pathology  and  pathological  anatomy, 

632 
prognosis,  632 
symptomatology,  631 
treatment,  632 
Anaemia  of  the  brain,  370 
Anaesthesia,  34 

segmental,  35 
Analgesia,  35 
Anatomy  of  the  cerebral  cortex,  381,  395 

convolutions,  381 
AnClC,  38 

Andriezen  on  the  cortex,  398 
Anencephalia,  316,  317 

causes  of,  317 
Aneurisms,  iutra-cranial,  479 
Angioneurotic  cedema,  885 
diagnosis,  889 
etiologv,  886 
pathology,  889 
prognosis,  889 
symptoms,  887 
treatment,  890 
Angular  gyrus  and  vision,  420,  421 
Ankle-clonus,  30,  619 

method  of  eliciting,  30 
AnOC,  38 

Anorexia  nervosa,  125 
Anosmia,  804 

Anterior  crural  nerve,  paralysis  of,  849 
surgery  of,  1003 
tibial  nerve,  surgery  of,  1004 
Anthropophobia,  66 
Ape-like  fissures,  325 
Aphasia,  432,  493 
ataxic,  435 
auditory,  437 
combined,  442 
conceptual,  433 
conduction,  433,  440 
elementary  forms  of,  433 
emissive,  433 
how  to  study  cases  of,  443 


1032 


INDEX 


Aphasia,  mixed,  442 
motor,  433,  434,  496 
receptive,  433,  437 
recovery  in,  434 
scheme  of,  441 
sensory,  433,  437 
suhcortical  infra-pictorial  motor,  440 

sensory,  440 
systematic  examination  of,  443 
total,  442 
transcortical  supra-pictorial  motor,  440 

sensory,  440 
visual,  437 
Aphemia,  433,  434 
Aphthongia,  275 
Apoplectic  attaclj,  symptoms  of,  451 

treatment  of,  465 
Apoplectiform  attacks  in  paresis,  685 
myelitis,  559 
onset  of,  561 
Apoplexy,  444 

and  hemiplegia,  444 
meningeal,  362 
diagnosis  of,  463 

differential  diagnosis  betvreen  cerebral  hem- 
orrhage and  emboUsm  and  thrombosis,  464 
Apraxia,  437,  439 
Arachnoid  cyst,  351 
Argyll-Robertson  symptom,  43,  800 
Arhinencephalia,  342 
Arrested  cerebral  development,  315 
causes  of,  315 
craniectomy  for,  337 
maternal  impressions  in,  316,  834 
symptoms  of,  322 
syphilis  and,  319,  334 
training  in,  336 
treatment,  335 
Arsenical  neuritis,  731 
symptoms,  731 
poisoning,  200 

cerebral  symptoms,  200 
diagnosis,  201 
etiology,  200 
pathology,  200 

peripheral  aifections  from,  200 
prognosis,  201 . 
sensory  disturbances  in,  200 
spinal  affections  from,  200 
symptoms,  200 
treatment,  201 
Arteries,  anterior  cerebral,  445,  448 
bulbar,  448 
central,  445 
cerebral,  diameters  of,  449 

pressure  in,  449 
of  cortex,  blood-pressure  in,  448 
cortical,  447 
hind-brain,  448 
inferior  cerebellar,  445,  448 
lenticular,  445 
lenticulo-striate,  445 
medullary,  448 
middle  cerebral,  445,  448 
of  brain,  445 
postero-lateral  central,  446 

mesial  central,  446 
posterior  cerebral,  445,  448 

meningeal,  448 
spinal,  448 
vertebral,  445 
Artery,  basilar,  445 

of  cerebral  hemorrhage,  446 

Arthritic  muscular  atrophy,  877 

diagnosis,  878 

pathology,  877 

prognosis,  878 

symptoms,  877 

treatment,  879 

Articulative  amnesia,  440 

ataxia,  435 

paresis,  435 

Astasia-abasia,  124 

Asynergia  verbalis,  435 

^sthesiometer,  33 

Astrophobia,  66 

Atavism,  327,  334 


Ataxic  gait,  23 

oscillations  of  the  foot  in,  23,  24 

paraplegia,  648 
Atelomyelia,  522 
Athetosis,  264 

bilateral,  266 

diagnosis,  267 

pathology,  267 

prognosis,  268 

symptoms,  265 

treatment,  268 
Atrophia  musculorum  lipomatosus,  864 
Atrophy  of  the  optic  nerve,  762 
Auditory  dyssesthesia,  808 

hypersesthesia,  808 

causes  of,  808 

localization,  423 

nerve,  afiections  of,  806 

tract,  course  of,  438 
Aurae,  297 

vertigo,  945 
Auricularis  magnus  nerve,  surgery  of,  1002 
Auriculo-temporal  nerve,  surgery  of,  1000 


BASEDOW'S  disease,  920 
Basilar  paralysis  of  the  sixth  nerve,  789 
Bell's  palsy,  822 

Benedict  on  frontal  lobes  of  criminal  brains,  389 
Beri-beri,  733 
causes  of,  734 
symptoms  of,  734 
types  of,  734 
Bevan  Lewis  on  the  cortex,  396 
Bilateral  cerebral  softening   simulating  bulbar 

palsy,  657 
Bird-claw  hand,  846 
Blepharospasm,  271 
Blood-pressure  in  brain  arteries,  449 

in  the  cortex,  448 
Blood-supply  of  brain,  445 
Body-sense,  hallucinations  of,  684 
Brachial  monoplegia,  27 
neuralgia,  841 
neuritis,  83ii 

diagnosis,  837 
etiology,  837 
pathology,  836 
prognosis,  838 
symptoms,  837 
treatment,  838 
drugs,  838 
electricity,  839 
immobility,  838 
massage,  839 
plexus,  diseases  of,  836 
palsies,  839 
surgery  of,  1002 
Brain  abscess,  374 

and  extra-dural  abscess.  379 
cerebellar,  377 

symptoms  of,  377 
classification  of,  375 
complications  of,  379 
course  of,  378 
diagnosis,  379 

differential  cranial  percussion  note,  379 
diagnosis  from  meningitis,  379 
from  tumor,  379 
etiology,  374 
encapsulation  of,  378 
of  frontal  lobe,  377 

symptoms,  377 
leptomeningitis  in,  379 
localizing  symptoms  of,  375-378 
multiple,  379 
otitic  and  allied,  376 

symptoms,  377 
pathology.  378 
in  pons,  377 

symptoms,  377 
prognosis,  380 
pyjemic  and  infecting,  376 
symptoms,  376 
rupture  of,  378 
sinus  thrombosis  in,  379 
spheno-temporal,  377 


INDEX. 


1033 


Brain  abscesss,  spheno-temporal,  symptoms  of, 
377 
statistics  of,  374 
symptoms  of.  374 
general,  374 
special,  375 
termination  of,  378 
treatment,  380,  971 
traumatic,  375 

symptoms  of,  376 
compression  of,  988 
concussion  of,  988 
syphilis,  702 
tumor,  470 

absence  of  symptoms  in,  481 
angioma,  479 
aphasia  in,  493 
appearance  of  brain  in,  479 
carcinoma,  477 
cholesteatoma,  479 
course  of,  502 
cystic,  478 
diagnosis,  500 

differential  diagnosis  from  abscess,  oOl 
chronic  hydrocephalus,  501 
tubercular  meningitis,  501 
double  optic  neuritis  in,  483 
duration  of,  502 
etiology,  470 
fibroma,  479 
focal  symptoms,  485 

of  base,  485,  498 
of  cortex,  485 
direct,  485 
indirect,  485 
Jacksonian  epilepsy,  489 
general  symptoms,  481 
glioma,  476 
glio-sarcoma,  476 
gumma,  478 
hemianopsia  in,  492 
Intra-cranial  aneurisms,  479 
lipoma,  479 
myxoma,  479 
osteoma,  479 
pathology,  471 
percentage  removable,  471 
prognosis,  503 
psammoma,  479 
sarcoma,  474 
symptoms,  480 
tables  of,  471 
teratoma,  479 
treatment,  503 
medical,  503 
surgical,  504,  976 
tubercular,  471 
diagnosis,  473 
operation  for,  473 
varieties,  471 
wounds  of,  986 
Bronchial  crises,  640 
Brow  ague,  815 

Brown-Sequard's  paralysis,  619 
Buchanan's  cyrtometer,  958 
Bulbar  palsy,  657 
acute,  660 
atrophic  form,  659 
chronic,  etiology,  657 
course  of,  658 
diagnosis,  659 

from  the  acute  form,  659 
from  bulbar  tumors,  659 
from  multiple  sclerosis,  659 
from  pseudo-bulbar  paralysis,  659 
nuclei  involved  in,  659,  657 
paralytic  form,  659 
pathology  and  morbid  anatomy,  658 
prognosis  of,  659 
symptomatology,  658 
treatment,  659 


CACHEXIA  strumapriva,  916 
CaClC,  38 
Caisson  disease,  575 

apoplectiform  cases  of,  576 


Caisson  disease,  autopsies  in,  579 

chronic  myelitis  following,  579 

course  of,  .576 

degeneration  of  columns  of  spinal  cord 

from,  580,  581,  582 
etiology  of,  577 
gaseous  theory  of,  577 
morbid  anatomy  of,  581 
pathology,  577 
symptoms,  575 
theory  of  congestion,  578 
treatment  of,  582 

bandaging  of  limbs,  583 
by  the  pneumatic  cabinet,  583 
Cbllingswood's  rule,  582 
ergot,  583 
prophylaxis,  582 
CaOC,  38 

Cardiac  crises,  640 
Cardio-vascular  vertigo,  947 
Catalepsy,  105 
Catoptric  test,  45 
Cauda  equina,  652 

functions  of,  653 
relations  to  the  spinal  canal,  652 
Cavernous  sinus,  arterio-venous  aneurism  of,  790 
thrombosis  of,  368,  790 
causes,  368 
diagnosis,  369 
symptoms  of,  368,  790 
Central  arteries  of  the  brain,  445 
galvanization,  1009 
hemorrhage,  445 
vision,  46 
Centres  for  accommodation,  795 
for  angle  of  mouth,  409 
for  associated  eye  movements,  406 
for  common  sensation,  416,  419 
for  concept,  427 

for  contraction  of  the  pupil,  796 
for  convergence,  795 
for  dilatation  of  the  pupil,  797.; 
for  elevation  of  upper  eyeUds,  408 
for  face  movements,  409,  410 
for  hearing,  423 
for  idea,  427 

for  laryngeal  movements,  408 
for  lips  and  tongue,  409 
for  macular  region,  420 
for  movements  of  elbow,  411 
of  head  and  eyes,  405 
of  hip  and  thigh,  411 
of  jaw,  409 
of  lower  limb,  411 
of  the  platysma,  410 
of  shoulder,  411 
of  thumb,  411 
of  trunk,  41:-! 
of  the  upper  limb,  411 
of  wrist,  411 
for  naming,  427 
for  proposilionizing,  434 
for  psychical  phenomena,  432 
for  Quadrant  and  half-vision,  422 
for  retraction  of  angle  of  mouth,  410 
for  smell,  430 
for  sphincters,  651 
for  sphincter  of  iris,  795 
for  taste,  431 
for  upper  face,  409 
for  utterance,  434 
for  vision,  420 
maps  of,  414,  515 
motor,  for  writing,  436 
orolingual,  409 
overlapping  of,  414 
Cephalsea,  927 
Cephalalgia.  927 

Cerebellar  abscess,  surgical  treatment  of,  497 
Cerebellum,  abscess  of,  338 

defective  development  of,  338 
microgyria  in,  338 
Cerebral  anaimia,  370 

and  neurasthenia,  371 
causes  of,  371 

relation  to  other  affections,  371 
symptomatology,  371 


1034 


INDEX. 


Cerebral  anaemia,  treatment,  372 
anatomy,  381 
deafness,  424 
hemispheres,  383 
hemorrhage,  444 
diagnosis,  463 
differential  diagnosis  from  embolism  and 

thrombosis,  464 
etiology,  449 
formation  of  cyst  in,  462 
frequency  of  parts  affected,  455 
into  basal  ganglia,  454 
into  cerebellum,  455 
into  cortex,  454 
into  frontal  lobe,  453 
into  medulla,  454 
into  pons,  454 
ingravescent,  454 
ligation  of  carotid  artery  for,  981 
location  of,  453 
occipital  lobe,  453 
parietal  lobe,  453 

pathology  and  pathological  anatomy,  460 
prognosis,  463 

relation  to  other  affections,  371 
reparatory  changes,  462 
secondary  degeneration,  457,  462 
shocli  in,  464 
symptoms.  451 

of  attack,  451 

of  fatal  termination,  453 

premonitory,  451 
treatment,  465 

during  attack,  465 

subsequent  to  attack,  466 
hypersemia,  370 
active,  371 
causes  of,  371 
passive,  371 
treatment  of,  371,  373 
hyperplasia.  339 
inflammation,  372 

acute  interstitial,  diagnosis,  372 

treatment,  373 
forms  of,  372 
interstitial.  372 

acute,  372 

causes  of.  372 

chronic,  372 

morbid  anatomy,  373 

symptoms  of,  373 
parenchymatous,  372 
Cerebral  localization,  399 
motor,  399 
theories  of.  400-403 
palsies  of  childhood,  506 

acquired  afterbirth,  572 

athetosis  in.  264,  573 

chorea  in,  513 

diagnosis.  518 

due  to  trauma  during  birth,  507,  511, 
512 

diplegia  in,  510,  515 

epilepsy  in,  .513 

etiology  and  pathology,  506 

from  brain  hemorrhage,  507 

gradually  acquired,  507 

hemiplegia,  509.  513 

inflammatory  disturbances  in,  506 

massage  in,  520 

maternal  impressions  in,  506 

mental  defects  in,  512 

meningeal  hemorrhage  in,  508 

paraplegia,  511,  517 

passive  movements  in,  520 

from  polioencephalitis,  509 

prenatal.  511 
causes  of,  506 
trauma  in,  506 
prognosis,  518 

secondary  degeneration  in,  509 
to  infectious  diseases.  508 

spasms  in,  513 

surgical  treatment  of,  978   ' 

symptoms,  551 

traumatic  (after  birth),  .509 

treatment  of,  519 


Cerebral  palsies  of  childhood,  treatment  preven- 
tive of,  519 
of  the  convulsion,  519 
by  electricity  in,  520 
by  gymnastics  in,  520 
by  training  in,  335,  520 
tremor  in,  513 

vascular  disturbances  in.  506 
sclerosis,  373 
syphilis,  702 

general  symptoms,  702 
special  symptoms,  702 

in  diffuse  syphilis  of  the   cortex, 

syphilitic  dementia,  707 
in  syphilis  of  the  base,  703 
in  syphihs  of  the  convexity  ,  706 
Cerebritis,  372 

Cerebro-spinal  meningitis,  203 
abortive  type,  207 
anomaloiis  form  of,  206 
chronic  type,  207 
complications  of,  207 
course  of,  206 
diagnosis,  208 
etiology,  203 
intermittent  type,  207 
ordinary  form  of,  205 
palholog}',  204 
prognosis,  209 
fulminant  form  of,  205 
sequeke  of,  207 
symptomatology,  205 
treatment,  209    " 
Cervical  plexus,  surgery  of,  1001 
Cervico-brachial  neuralgia,  841 
occipital  neuralgia,  835 
symptoms,  835 
prognosis,  835 
treatment,  835 
Charcot  joints,  592,  639 
Gheirospasmus,  276 
Cheyne-Stokes  respiration,  829 
Chiasm,  753 
Chiene's  method  of  determining  the  fissure  of 

Rolando,  958 
Chisels  used  in  brain  operations,  960 
Chloralism,  195 
Choked  disk.  46,  735 
Chorea,  27,  227 
chronic  252 
electrical,  260" 
gravidarum,  233 
habit,  258 
hereditary,  252 
insaniens,  250 
pathology,  251 

treatment,  251 
intention,  27 
major,  258 
passive,  27 
post-hemiplegic,  263 

paralytic,  263 
senile,  257 
spastica,  573 
Sydenham's,  226 

convulsive  attacks  in,  239 
cutaneous  affections  in,  241 
diagnosis,  245 
duration,  242 
echolaia  in,  236 
electrical  reactions  in,  237 
endocarditis  in,  239 
etiologv,  227 
face  in,  236 
handwriting  in,  235 
heart  murmurs  in,  238 
mental  state  in,  2:38.  2:59 
morbid  anatomy,  243 
movements  in,  235 
pathology,  243 
pericarditis  in,  239 
prognosis,  245 
recurrence,  242 
sensibility  in,  238 
speech  in,  236 
strength  in,  237 
symptoms,  235 


INDEX. 


1035 


Chorea,  Sydeaham's,  temperature  in,  23S 
tendon  reflexes  in,  240 
treatment,  246 
trophic  changes  in,  240 
urine  in,  239 

voluntary  movements  in,  237 
Chorionitis,  901 
Choroid  ring,  754 
Chronic  bulbar  palsy,  657 
chorea,  252 

hydrocephalus.  343,  511,  531 
myelitis,  570.    See  Myelitis, 
ophthalmoplegia,  786 
causes,  786 
pathology  of,  787 
spinal  muscular  atrophy,  625 
etiology,  625 
diagnosis,  628 
pathology      and       pathological 

anatomy,  627 
prognosis,  628 
symptomatology,  625 
termination,  627 
treatment,  628 
Ciliary  muscle,  nerve  supply  of,  795 
paralysis  of,  801 

structure  and  function  of,  795,  801 
Cilio-spinal  centre,  795 
Circle  of  WilUs,  445,  448 
Circumflex  nerve,  paralysis  of,  842 
Claustroph'ibia,  65 
Clavus.  99 
Claw-Uke  hand,  846 
Clonic  spasm.  27 
Cocainism,  195 
etiology,  195 
pathology,  195 
prognosis,  196 
symptoms,  196 
treatment,  196 
Colliculi,  385 

Coensesthesis,  hallucinations  of  the,  684 
Combined  paralysis  of  the  brachial  nerves,  839 
etiology,  839 
symptoms,  839 
sclerosis,  648 

diagnosis,  650 

from  cerebellar  heredo-ataxia,  65C 
from  cerebellar  tumor,  650 
from  Friedreich's  ataxia,  650 
from  myelitis,  650 
from  tabes,  650 
etiology  of  648 

pathology  and  pathological  anatomy,  649 
prognosis,  650 
symptomatology,  649 
treatment,  650 
Complete  conjugate  paralysis,  788 
Compression  of  brain,  988 

Cauda  equina,  6.53 
Concept  centre,  427 
Concepts,  494 
Concussion  of  brain,  987 

and  encephalitis,  373 
Conduction  aphasia,  440 
Congestion  of  the  optic  nerve,  753 
Conjugate  deviation,  787 
centre  for.  787 
from  cerebral  lesions,  788 

from  cerebral  destructive  lesions,  788 
from  cerebral  irritative  lesions,  788 
in  hemiplegia,  787,  788 
from  p.)ntine  lesions,  788 

from  destructive  pontine  lesions,  788 
from  irritative  pontine  lesions,  788 
lateral  paralysis,  787 

in  hemiplegia,  787,  788 
paralysis  of  upward  or  downward  movement, 
786 
Consecutive  atrophy  of  the  optic  nerve,  762 

etiology,  764 
Consensual  reflex  contraction,  796 
Contraction  of  the  pupil,  796 

reflex  conserved  in,  796 
Contracturas.  surgical  treatment  of,  1005 
Conus  medullaris,  651 
terminalis,  651 


Convergent  strabismus,  792 
Convolution,  angular,  395 

ascending  frontal,  391 

dentate,  393 

fusiform,  393 

hippocampal,  393 

inferior  occipital,  383 

infra-marginal,  395 

Ungual,  .393 

medifrontal,  391 

meditemporal,  393 

middle  occipital,  393 

precentral,  391 

retro-insular,  386 

subtemporal,  393 

super-frontal,  391 

superior  occipital,  393 

super-temporal,  393,  423 

supra-marginal,  395 

temporo-parietal,  of  insula,  386 

transverse,  of  Heschl,  386 

uncinate,  393 
Convolutions  of  the  brain,  381 
Convulsions  of  children,  519 
treatment,  .519 
symptoms  of,  .509,  512 

preceding  cerebral  palsy,  512 
Convulsive  centre,  301 

tremor,  268 
Cortex,  381 

division  of,  383,  384 

extent  of  382 

layers  of  the,  396 

minute  anatomv  of,  395 
in  old  age,  382 

pyramidal  cells  of,  396 

surface  of,  382 

thickness  of,  381 

tyi)es  of  cells  in,  397,  398 
Cortical  hemorrhage,  445 

reflex  of  the  pupil,  803 
Cranio-rachischisis,  340 
Cranioschisis,  340 
Cremasteric  reflex,  36 
Cretinism,  917 

etiology,  917 

morbid  anatomy,  919 

symptoms,  917 

brachycephalia,  917 
features,  918 

gait  and  movements,  917 
growth,  917 
limbs,  917 

mental  condition,  919 
muscles,  919 
skin,  919 
treatment,  920 
Crises  of  locomotor  ataxia,  640 
Crossed  diplopia,  7S1 

lateral  hypertrophy,  912 
Crural  monoplegia,  27 

neuralgia,  854 
Crver's  drill,  961 
Cuneus,  390,  394 
Cutaneous  reflexes,  36 
Cycloplegia,  40,  801 

with  mydriasis,  802 
Cyclopia,  342 


D 


EAD  finger,  880,  881 
Deafness,  bilateral,  807 

from  bilateral  disease  of  the  labyrinth, 


from  bilateral  disease  of  temporo-sphe- 

noidal  lobes,  808 
from  symmetrical  disease  of  the  audi- 
tory "nerves,  808 
of  nervous  origin,  806 

electrical  reactions,  807 
etiology,  806 
svmptoms,  807 
treatment,  808 
Defect  of  cerebellum,  developmental,  338 

of  speech. 433 
Deforcement,  29 
Descending  neuritis,  755 


1036 


INDEX. 


Diabetic  neuritis,  733 
Diaplomyelia,  522 
Diastemato-myelia,  522 
Diathesis,  183 
Diathetic  affections,  183 
Digital  nerves,  surgery  of,  1005 
Digiti  mortui,  881 
Dilatation  of  the  pupil,  797 
mechanism  of,  797 
Dilator  iridis,  794 
Diphtheritic  neuritis,  731 
diagnosis,  732 
symptoms,  731 
paralysis,  222 
diagnosis,  225 
general,  225 
local,  224 

morbid  anatomy  of,  223 
poison  of,  222 
prognosis,  225 
symptoms,  223 
treatment,  225 
Diplegia  of  childhood,  510,  515 
Diplopia,  40,  777 
lateral,  780 

homonymous,  780 
crossed,  780 
monocular,  114 

from  paralysis  of  external  rectus,  778 
inferior  oblique,  779 
inferior  rectus.  779 
internal  rectus,  778 
oculomotor  nerve,  780 
superior  oblique,  780 
superior  rectus,  779 
varieties  of,  777 
vertical,  781 
crossed,  781 
homonymous,  781 
Direct  method  of  ophthalmoscopy,  45 

reflex  contraction  of  pupil,  796 
Disease  of  abducens  nerve,  773 
of  auditory  nerve,  806 
of  brachial  plexus.  836 
of  brain.  315,  348,  444,  506 
of  cervical  nerves,  835 
of  cranial  nerves,  752 
of  conus  medullaris,  651 
of  dorsal  nerves,  847 
of  fifth  nerve,  811 
of  glosso-pharyngeal  nerve,  827 
of  hypoglossal  nerve,  832 
of  lumbar  and  sacral  plexuses,  848 
of  medulla  oblongata,  657 
of  muscles,  857 
of  nerves,  720,  752,  804,  835 
acroparaesthesia,  720 
hypersemia,  720 
causes,  720 
symptoms,  720 
of  ocular  nerves,  773 
of  oculomotor  nerves,  773 
of  olfactory  nerves,  804 
optic  nerves,  752 

hypersemia,  753 
etiology,  753 

ophthalmoscopic  appearances,  754 
prognosis,  755 
symptomatology,  755 
treatment,  755 
of  pathetic  nerve,  773 
of  phrenic  nerve,  836 
of  pneumogastric  nerve,  832 
causes  of,  828 
diagnosis,  832 
lesions  producing,  828 
symptoms,  829 

general  symptoms,  829 
special  symptoms,  829 

auEcsthesia  of  larynx,  830 
cardiac  symptoms,  831 
gastric  symptoms,  831 
laryngeal  paralysis,  8?9 

spasm,  830 
oesophageal  symptoms,  831 
pharyngeal  paralysis,  829 
spasm,  829 


Diseases  of  pneumogastric    nerve,    pulmonary 
symptoms,  830 
treatment,  832 
of  spinal  accessory  nerve,  828 

of  its  spinal  portion,  832 
of  spinal  cord,  521,  556,  612 
of  trigeminal  nerve,  811 
of  vagus,  828 
Dislocations  of  spine,  546,  992 
Disorders  of  sleep,  953 

treatment  of,  956 
of  smell,  804 
of  taste,  805 
Disseminated  neuritis,  726 

sclerosis,  661 
Diver's  paralysis,  575 
Dizziness,  943 

Dorsal  nerves,  diseases  of,  847 
Dorso-intercostal  neuralgia,  847 
Double  hemiplegia,  27 

homonymous  hemianopsia,  773 
Dreams,  953 

Dropsy  of  the  brain ,  343 
Dubini's  disease,  260 

Dura  mater,  afl'ections  of  inner  layer  of,  350 
of  outer  layer  of,  348 
hsematoma  of,  351 
inflammation  of,  348 
layers  of,  348 
sinuses  of,  365 
Dysacusis,  808 
Dynamometer,  26 
foot,  26 
hand,  26 
Dyslexia,  440 


EBERSTALLER  on  the  convolutions,  387,  394 
on  the  insula,  386 
Echolalia,  236,  441 

Ecker  on  the  convolutions,  385,  389  et  seq. 
Ecstasy.  104 
Elbow-jerk,  28 
Electric  baths,  1010 
Electrical  chorea,  260 
examinations,  37 
re-enforcement,  29 
Electrotherapeutics,  1007 
apparatus  required,  1013 
choice  of  current,  1012 
current  dosage,  1011 
duration  of  the  application,  1012 
history  of,  1007 
in  anaesthesia,  1024 
In  arthritic  muscular  atrophy,  1030 
in  brachial  neuralgias,  1027 
in  cervico-occipital  neuralgia,  1027 
in  chorea  minor,  1027 
in  diseases  of  the  muscles,  1030 
in  diseases  of  the  peripheral  nerves,  1018 
in  epilepsy,  1027 
in  exophthalmic  goitre,  1028 
in  facial  paralysis,  1021 
in  functional  neurosis,  1027 
in  hysteria,  1029 
in  intercostal  neuralgia,  1027 
in  laryngeal  paralysis,  1022 
in  locomotor  ataxia,  1017 
in  mastodynia,  1027 
method  of  making  applications,  1013 

in  abscess  of  the  brain,  tumors,  etc., 

1015 
in  the  affections  of  the  conducting 

tracts,  1016 
in  amyotrophic  lateral  sclerosis,  1017 
in  aphasia,  1015 
in  ataxic  paraplegia,  1017 
in  cerebral  hemorrhage    and  hemi- 
plegia, 1015 
in  diseases  of  the  brain,  1015 

of  the  spinal  cord,  1016 
in  inflammatory  processes,  1016 
in  mental  diseases,  1016 
in  poliomyelitis  acuta,  1017 
in  poliomyelitis  chronica,  1017 
in     progressive    muscular    atrophy, 
1017 


INDEX. 


1037 


Electrotherapeutics,  method  of  making  applica- 
tions in  spastic  paraplegia,  1017 
in  spinal  hemorrhage,  1016 
in  transveree  focal  aifections  of  cord, 
1016 
in  motor  nerves,  1018 
in  nerves  of  the  arms  and  legs,  1022 
in  neuralgia,  1024 
in  neurasthenia,  1028 
in  ocular  nerves,  1020 
In  paraesthesias,  1024 
In  paralysis  agitans,  1027 

of  the  phrenic  nerves,  1022 
in  primary  myopathies,  1030 
in  sciatica,  1026 
in  sensory  nerves,  1023 
in  spasmodic  affections,  1022 
role  of  suggestion  in,  1008 
three  kinds  of  current  used,  1009 
in  trigeminal  neuralgia,  1026 
Embolism  of  brain.  467.    See  Acute  Softening  of 

Brain. 
Emprosthotonos,  212 
Encephalitis,  318,  372 
Encephalocele,  310 
diagnosis  of,  342 
etiology  of,  341 
locations  of,  341 
maternal  impressions  in,  341 
sex  in,  341 
symptoms  of.  342 
Endemic  neuritis,  733 
Ependymitis,  318,  344 
Epilepsy,  296 

and  spastic  hemiplegia,  513 
bromides  in,  312 
convulsive  centre  in,  301 
definition,  296 
diagnosis,  302 
etiology,  299 
grand  mal,  297 
hysteria  and,  302 
Idiopathic,  298 
lesions  in,  301 
medical  treatment,  303 
migraine  and,  298 
operations  for,  304-311,  965 
organic,  299 
pathology,  299 
peripheral  irritation  in,  312 
petit  mal,  297 
procursive,  298 
prognosis,  303 
simulation  and,  302 
surgical  treatment  of,  965 
symptoms,  296 
Epileptiform  attacks  in  paresis,  685 
Erb's  form  of  spinal  syphilis,  709 

juvenile  form  of  muscular  atrophy,  866 
BT^Id' paralysis,  840 
Erect  or  upright  image,  45 
Erythromelalgia,  738 
diagnosis,  739 
pathology,  739 
symptoms,  738 
treatment,  739 
Essential  paralysis  of  children,  620 
Examination  of  the  eye,  39 

of  special  senses,  36 
Excentric  vision,  46 
Exophthalmic  goitre,  920 
complications,  923 

cranial  nerve  palsies,  923 
functional  nervous  disorders,  923 
insanity,  923 

spinal  cord  symptoms,  923 
trophic  changes,  923 
course,  924 
diagnosis,  924 
etiology,  920 
history,  920 
morbid  anatomy,  924 
prognosis,  924 
symptoms,  920 
theories  of  the  disease,  925 
treatment,  926 
drugs,  926 


Exophthalmic  goitre,  treatment  of,  electricity, 
926 
hydrotherapy,  926 
ice,  926 
rest,  926 

surgical  measures,  926 
Experimental  tetanus,  211 
External  cutaneous  nerve,  smrgery  of,  1004 
paralysis  of,  843 
popliteal  nerve,  paralysis  of,  853 
plantar  nerve,  paralysis  of,  854 
saphenous  nerve,  surgery  of,  1005 
Extra-dural  abscess,  surgical  treatment  of,  973 
hemorrhage,  363,  981 

symptoms  of,  364,  981 
treatment  of,  365,  981 
Eyeball,  trophic  changes  in,  49 
Eyes,  primary  position  of,  776 
secondary  positions  of,  776 


FAMILY  ataxia,  646 
history,  17 
Facial  hemiatrophy,  904 
course,  906 
diagnosis,  908 
etiology,  905 
pathology,  907 
symptoms,  905 
treatment,  908 
hemihypertrophy,  908 
nerve,  surgery  of,  1000 
paralysis,  821 
central,  821 
diagnosis,  825 

differentiation    of    peripheral     from 

central  form,  825 
of  seat  of  peripheral  lesion,  825 
double,  823 
etiology,  822 
infra-nuclear,  821 
nuclear,  821,  825 
peripheral,  821 
prognosis,  826 
supra-nuclear,  821 
symptoms,  823 
treatment,  826 

counter-irritation,  826 
drugs,  826 
electricity,  829 
spasm,  270 

diagnosis,  271 
etiology,  270 
prognosis,  271 
symptoms,  270 
treatment,  271 
tropho-neurosis,  904 
Facio-scapulo-humeral  form  of  muscular  atrophy, 

867 
Faradic  extinction,  37 
Faradization.  1010 
Fasciola  cinerea,  393 
Fascia  dentata,  393 
Fibres  of  Gratiolet,  753 

of  Wernicke,  753 
Field  of  vision,  47 

methods  of  determining,  47 
Fifth  nerve,  diseases  of,  811 
neuralgia  of,  814 
paralysis  of,  811,    See  Paralysis, 
resection  of  second  and  third  divisions, 
999 
Fissures,  385 

amygdaline,  389 
anterior  occipital,  393 
ape,  .390,  325 
basirhinal,  389 
calcarine,  390 

ental  correlative  of,  390 

and  hippocampal,  junction  of,  890 
callosal,  388,  390 
calloso-marginal,  390 
central,  390 
collateral,  393 
diagonal  opercular,  387 
ental  correlatives  of,  385 
exoccipital,  389 


1038 


INDEX. 


Fissures,  external  perpendicular,  390 
first  frontal,  391 
occipital,  393 
temporal,  392 
fourth  temporal,  392 
tronto-marginal,  388 
hippocampal,  393 

inferior  longitudinal  occipital,  388 
inflected,  3SS 
interparietal,  392 
median,  337 

frontal,  387 
occalcarine,  390 
occipital,  390,  393 
of  Sylvius,  390 
outer  perpendicular,  387 
paroccipital,  392,  394 
parietal,  392 
parieto-occipital,  390 
partial,  385 
precentral,  387,  391 
precuneal,  388 

of  Rolando,  390 
radiating  frontal,  388 
retrocentral,  387 
second  frontal,  391 
subfrontal,  391 
subtemporal,  389,  393 
supercallosal,  390 
supercentral,  387,  391 
superfrontal,  390 
superior  occipital,  393 

precentral,  387 
supertemporal,  393 
temporal,  292 
third  temporal,  392 
total,  385 

transverse  occipital,  388,  393 
vertical  frontal,  391 
Wernicke's,  390 
Flahrer's  aluminium  probe,  987 
Focal  illumination,  45 
Fourth  nerve,  diseases  of,  773 

paralysis  of,  709 
Fractures  and  dislocations  of  the  spine,  546 
surgical  treatment  of,  550,  992 
of  skull,  984 
of  base,  985 

treatment  of,  986 
of  vault,  984 

treatment  of,  984 
Franklinization,  1011 
Friedreich's  ataxia,  646 
diagnosis,  648 

from  ataxic  paraplegia,  648 
from  cerebellar  heredo-ataxia,  648 
from  cerebellar  tumor,  648 
from  locomotor  ataxia,  648 
etiology,  646 

pathology  and  jjathological  anatomy,  647 
prognosis,  648 
symptomatology,  646 
gait,  646 
knee-jerks,  646 
nystagmus,  647 
pupils,  647 
speech,  647 
station,  646 
treatment,  648 
disease,  646 
Frontal  lobe,  391 
Functional  spasms,  270 
tremors,  280 

cUnical  history  of,  280 
rates  of,  281 
Functions  of  spinal  cord,  612 
Fundus  oculi,  754 
arteries,  754 
choroid  ring,  754 
physiological  cup,  754 
scleral  ring,  754 
veins,  754 

GAIT,  19,  20 
ataxic,  21 

of  simple  weakness,  25 
spastic,  21 


Galvanic  extinction,  37 
Galvanization,  central,  1009 

subaural.  1009 
Galvano-faradization,  1010 
Gasserian  ganglion,  removal  of,  978 
Gastric  crises,  640 
Gastro-intestinal  neurasthenia,  67 
General  faradization,  1010 

palsy,  27 

paresis,  667 

paralysis  of  the  insane,  667 
Generic  ataxia,  646 
Giant  swelling,  885 
Giddiness,  943 

Gilles  de  la  Tourette's  disease,  261 
Girdle  pain,  561 

seat  of,  561 
Gliosis,  587.    See  Syringomyelia. 
Globus  hystericus,  99 
Glosso-pharyngeal  nerve,  diseases  of,  827 
Golgi  on  the  cortex,  397 
Gout,  mental  disease  from,  186 

nervous  afl'ections  from,  185 
etiology  ot,  185 
pathology  of,  185 
prognosis  in,  188 
symptoms  of,  186 
treatment  of,  188 

neuralgia  from,  188 

neurasthenia  from,  187 

neuritis  from,  187 

spinal  diseases  from,  187 
Grand  hysteria,  98 
Grand  mal,  297 
Graphospasm,  276 
Graves's  disease,  920 
Gray  matter,  specific  weight  of,  382 

of  brain  in  relation  to  sex,  382 

oil,  719 

hypodermatic  injections  of,  719 
Gunshot-wounds  of  the  brain,  986 
Gustatory  locaUzation,  481 
Gyres.    See  Convolutions. 
Gyri  operti,  385 
Gyrus  angularis,  394 

cunei,  327 

dentatus,  393 

fornicatus,  419 

fornicis,  384 

hippocampal,  393 

infra-callosus,  384 

super-callosal,  384 

uncinate,  393 


HABIT  chorea,  258 
blepharospasm  in,  259 
causes  of,  2-59 
movements  of,  259 
treatment  of,  260 
Hsematoma  auris.  689 

of  the  dura,  351 
Hammer  palsy,  279 
Hartley's  operation  for  removal  of  the  Gasserian 

ganglion,  979 
Headache,  927 

from  abscess,  923 
in  acute  febrile  disease,  931 
from  anajmia,  930 

associated  with  sexual  disorders,  936 
from  caries  of  the  bones  of  the  skull,  934 
from  cerebro-spinal  meningitis,  931 
classification  of,  928 
clinical  considerations,  929 
character  of  pain,  929 
from  coarse  intra-cranial  lesions,  933 
congestive,  930 
course  and  duration,  930 
diagnosis,  936 

difl'erential,  between  functional  and  or- 
ganic headaches,  937 
diathetic,  932 

from  disease  of  frontal  sinuses,  931 
from  drugs,  932 
in  epilepsy,  934 
from  errors  of  refraction,  935 
etiology,  927 


INDEX. 


1039 


Headache,  etiology  of,  ages  when  most  commoii, 
927 
city  life,  927 
climate,  927 
education,  927 
season,  927 
sex,  927 
from  glaucoma,  935 
from  hyperemia,  930 
from  intoxication,  932 
from  intra-cranial  aneurisms,  934 
from  malaria,  932 
from  meningitis,  930 
from  nasal  and  pharyngeal  disease,  935 
from  pachymeningitis,  348,  931 
interna  hemorrhagica,  933 
from  poisons  in  the  blood,  931 
from  reflex  irritation,  935 
from  tubercular  meningitis,  931 
from  tumor.  933 
functional,  929 
in  fever,  931 
in  hysteria,  934,  935 
in  influenza,  931 
in  neurasthenia,  934,  935 
in  relapsing  fever,  931 
in  smallpox,  931 
in  syphilis,  931 
in  typhus  fever,  931 
pathological  considerations,  928 
nerves  involved,  929 
seat  of  pain,  928 
reflex,  930 

symptoms  associated  with,  936 
traumatic,  930 
treatment,  937 
causal,  938 
surgical,  939,  977 
symptomatic,  937 
Head-tetanus,  212 
Hematomyelia,  541 
Hemianopsia,  48,  769 
binasal.  49,  770 
bitemporal,  49 

peripheral,  769 
heteronymous,  49 
homonymous,  48,  49,  770 
causes  of,  771 
left,  770 
right,  770 
horizontal  or  altitudinal,  769 
lateral  homonymous,  49 
vertical,  769 
Hemiatrophy  of  the  face,  904 
Hemicrania,  939 
Hemifacial  atrophy,  904 
hypertrophy,  908 
Hemihypertrophy,  910 
of  the  face,  908 
course  of,  910 
pathology,  910 
symptoms,  908 
Hemiopic  pupillary  inaction,  44,  802 
as  a  distant  symptom,  802 
in  basal  disease,  802 
lesions  producing  it,  802,  803 
method  of  determining,  802 
persistent,  802 
significance  of,  802 
transient,  802 
Hemiplegia,  27,  455 

alternate  or  crossed,  459 

aphasia  in,  458 

arm  type  of,  459 

associated  movements  in,  459 

athetosis  in,  459 

atrophy  in,  458 

choreic  movements  in,  459 

chronic  stage  of,  455 

contractures  in,  457 

double,  29 

electrical  irritability  of  muscles  in,  459 

fait  in,  457 
lemiataxia — aphasic  type  of,  459 
inco-ordination  of  movement  in,  458 
leg,  sensory  type  of,  459 
mental  condition  in,  458 


Hemiplegia,  mirror- writing  in,  459 
spasmodic  movements  in,  458 
tendon-reflexes  in,  457 
tremor  in,  458 
types  of,  459 

visceral  functions  in,  458 
Hemorrhage  into  the  cauda  equina,  653,  654 
from  the  sinuses  of  the  dura  mater,  362, 5 
surgical  treatment  of,  983 
Hemorrhagic  encephalitis,  373 
Hereditary  ataxia,  646 
chorea,  252 
gait  in,  254 
deglutition  in,  255 
melancholia  in,  256 
mental  disorder  in,  255 
movements  of,  254 
pathology,  256 
prognosis,  257 
speech  in,  255 
symptoms,  253 
treatment,  257 
tremor,  283 
Herpes  zoster,  848 

Heschl's  transverse  convolutions,  386 
Heterotopia  of  gray  matter  of  brain,  338 
Hippus,  44,  803 
Horsley's  cyrtometer,  958 

dural  separator,  962 
Homonymous  diplopia,  781 
hemiachromatopsia,  772 
hemianopsia,  double,  773 
lateral  hemianopsia,  771 
absolute,  771 
causes  of,  771 
complete,  771 
incomplete,  771 
Hutchinson's  pupil,  364 
Hydrencephalocele,  341 
Hydrocephaloid,  359 
Hydrocephalus,  etiology,  344 
congenitus,  343 
course,  347 
duration,  347 
internus,  343,  511,  531 
in  the  adult,  347 
pathological  anatomy  of,  346 
prognosis,  347 
surgery  of,  968 
symptoms  of,  346 
treatment,  347,  968 
Hydro-electric  bath,  1010 
Hydromyelocele,  527 
Hydrophobia,  215 
diagnosis,  217 
incubation,  215 
morbid  anatomy  of,  217 
preventive  inoculation,  218 
symptoms,  216 
treatment,  218 
Hyperemesis,  808 
Hypersemia  of  the  brain,  370 

of  the  optic  nerve,  753 
Hypersesthesia,  34 
Hyperageusia,  806 
Hyperosmia,  805 

Hypoglossal  nerve,  diseases  of,  832 
Hypertrophy  of  the  brain,  339 
Hypnoid  state,  129 
Hysteria,  87 

achromatopsia  in,  113 

amaurosis  in,  111 

amblyopia  in,  112 

ansesthesia  in,  107 

and  the  traumatic  neuroses,  131 

anuria  in,  127 

aphonia  in,  127 

astasia-abasia  in,  124 

cardiac  symptoms  in,  126 

catalepsy  in,  105 

color  fields  in.  ii3 

contractures  in,  116, 117, 122 

cough  in,  127 

deafness  in.  111 

diagnosis  of,  1 29 

double  consciousness  in,  129 

dreams  in,  128 


1040 


INDEX. 


Hysteria,  drugs  in,  133 

dyschromatopsia  in,  113 

ecstasy  in,  104 

electricity  in,  133 

etiology  of,  90 

geometric  ansesthesia  in,  108 

hemiansesthesia  in,  108 

hemianopsia  in.  112 

hemiplegia  in,  117 

hydrotherapy  in,  132 

hypergesthesla  in,  110 

hyperalgesia  in,  110 

hysterogenous  zones  in,  110 

interparoxysmal,  107 

lethargy  in,  105 

loss  of  smell  in,  115 

major,  104 

massage  in,  133 

minor,  104 

monocular  diplopia  in,  114 

motor  symptoms  in,  115 

neuromimesis  in.  111 

nightmares  in,  128 

nutrition  in,  107 

paralysis  in,  115, 116 

paraplegia  in,  117,  118 

the  paroxysm  of,  97 

pathology  of,  131 

phantom  tumor  in,  127 

prodromes  of,  98 

psychical  symptoms  of,  128 

pyrexia  in,  127 

respiration  in,  126 

segmental  anaesthesia  in,  108 

sensory  symptoms  of,  107 

somnambulism  in,  1U5 

symptoms  of,  97 

taste  in,  115 

trance  in,  106 

treatment  of,  132 

tremor  in,  122,  123 

vascular  symptoms  in,  126 

vasomotor  symptoms  in,  126 

visual  field  i'n,  112, 118 

visceral  symptoms  in,  125 

vomiting  in,  125 

yawning  in,  127 
Hysterical  abducens  palsy,  793 

amaurosis.  111 

blepharospasm,  793 

convulsions,  98 

consciousness  in,  100 
delirium  in,  100,  103 
epileptoid  period,  99,  100 
grand  movements  in,  99,  100 
passionate  attitudes  in,  99,  101 
periods  of,  99,  103 
prodromes  of,  98,  99 
sensory  stigmata  in,  102 
tableaux  in,  102 

convergent  strabismus,  793 

diplopia,  793 

fit,  aura  of,  39 
insanity,  128 
joints.  111 
ptosis,  793 
sleep,  106 
Hystero-epilepsy,  97,  297 
Hysterogenous  zones,  99,  101 


TDEA  centre,  427 
1     Idiocy,  322,  323 

education  in,  336 

pathology  of,  323-335 

symptoms,  322 

treatment,  335 
Idiopathic  epilepsy,  298 
Idiots  and  ape-like  fissures,  327 
Incisure  preovalarie,  388 
Inco-ordination  of  arms,  27 

in  brain  tumor,  498 
Indirect  method  of  ophthalmoscopy,  45 
Infantile  spinal  paralysis,  620 
Infectious  diseases,  203 
Inferior  dental  nerve,  surgery  of,  999 
Inflammation  of  brain,  372 


Inflammation  of  duia  mater,   348.    See  Pachy- 
meningitis, 
of  ependyma,  344 
of  muscles,  857 
of  nerves,  721 

pia  mater,  353.    See  Leptomeningitis. 
Infra-orbital  nerve,  surgery  of,  998 
Ingravescent  apoplexy,  454 
Injuries  of  nerves,  741 
causes  of,  741 

changes  in,  after  complete  division,  743 
degeneration,  743 
in  proximal  end,  743 
neuroma,  743 
regeneration  and  union,  744 

time  necessary  for,  744 
in  the  skin  and  its  appendages, 
742 
gunshot-wounds,  742 
Incised  wounds  of,  741 
treatment,  745 
electrical,  746 
medical,  745 
surgical,  745,  996 

nerve-grafting,  746,  997 
primary  suture,  745,  996 
secondary  suture,  745,  996 
median  nerve,  747 

ansBSthesia  from,  747 
paralysis  from,  747 
symptoms  of  747 
of  musculo-spiral  nerve,  748 
paralysis  from,  749 
wrist-drop,  749 
primary  symptoms  of,  742 
punctured  wounds,  742 
of  radial  nerve,  748 

anaesthesia  from,  748 
of  sciatic  nerve,  749 

aneesthesia  from,  749 
paralysis  from,  749 
secondary  eifects  of,  742 
to  spinal  cord  from  fractures  and  dislocations 
of  the  spine,  546 
analysis  of  symptoms  of, 

519 
etiology,  546 
symptoms,  546 
treatment,  550 
of  ulnar  nerve,  748 

ansesthesia  from,  748 
paralysis  from,  748 
Insanity  from  alcohol,  191 
from  gout,  185 
from  lead-poisoning,  197 
from  rheumatism,  183 
surgical  treatment  of,  978 
in  syphilitic  subjects,  708 
Insomnia,  66,  949 
etiology  of,  951 
functional,  950 
symptomatic,  950 
symptomatology  of,  951 
treatment  of,  951 

by  hypnotic  drugs,  952 
general,  952 

of  the  underlying  disease,  953 
Insula,  385 

anterior  portion,  385 
caudal  portion,  385 
central  fissure  of,  385 
cephalic  portion,  385 
pars  parieto-falciformis  of,  386 
pars  temporo-parietalis  of,  386 
posterior  portion,  385 
Insular  fissures,  385 

sclerosis,  661 
Intention  chorea,  27 

tremor,  27 
Intercostal  neuralgia,  847 
Internal  plantar  nerve,  paralysis  of,  854 
popliteal  nerve,  paralysis  of,  853 
saphenous  nerve,  surgery  of,  1005 
Intestinal  crises,  640 
Intra-cranial  aneurisms,  479 
symptoms  of,  479 
murmur  in,  479 


INDEX. 


1041 


Intra-crauial  hemorrhage,  spontaneous,  surgical 
treatment  of,  981 
traumatic,  surgical  treatment  of,  981,  983 
spinal  division  of  the  posterior  nerve  roots, 
1002 
Inverted  image.  45 
Iridoplegia,  40,  798 
reflex,  SCO 

unilateral,  800 
total,  798,  802 
Iris,  cilio-spinal  centre  of  Budge,  795 

dUatoriridis,  794 
Iris-innervation  sign,  44 
Iris,  nerve  supply  of  794 

oculomotor  lierve  supply  of,  794 
reflex  to  accommodation,  43 

to  convergence,  44 
response  to  light  stimulus,  43 
sympathetic  reflex,  44 
sphincter  iridis,  794 
structure  and  functions  of,  794 
sympathetic  nerve  supply  of,  795 
vascular  supply  of,  794 
Island  of  Reil.  385 " 


TACKSONIAN  epilepsy,  489 
O     Jaw-jerk,  2-8 
Jendrassik's  method,  28 
Jumpers,  261 


KAK-KE,  733 
Klumpke's  paralysis,  840 
Knee-jerk,  28 
metre,  30 

Lombard's,  30 
Weir  Mitchell's,  30 
physiology  of,  618 
reflex  arc  "and  inhibitory  fibre,  619 
variations  of,  31,  32 


T  ABYRIXTHIXE  disease,  deafness  from,  806 
Li    Laceration  of  the  brain,  987 
Lagophthalmos.  42 

Landouzy-Dejerine  type  of  muscular  atrophy,  867 
Landry's  paralysis,  583 
Lamination  of  cortex,  396 
Laminectomy,  after  treatment  in,  995 
for  spinal  caries,  553,  990 
technique  of,  993 
Laryngeal  crises,  640 

Vertigo.  298 
Latah,  261 
Latent  anisocoria,  801 

regions  of  cortex,  432 
Lateral  diplopia,  780 
crossed,  780 
homonymous,  780 
illumination,  45 
sclerosis,  629 

diagnosis  of.  630 

etiology  in,  629 

pathologv  and  pathological  anatomy  of, 

630 
prognosis  of,  630 
symptomatology  of,  630 
treatment,  630 
electricity,  630 
hydrotherapy,  630 
massage,  630 
sinus,  thrombosis  of,  366 

Bennetts  point,  367,  369 
causes  of,  366 
diagnosis.  369 
Gerhardt's  symptom,  368 
symptoms  of,  367 
ventricles,  puncture  of,  968 
Laura  Bridgeman.  381 
Lead-en  cephalopathy,  197 
-poisoning.  196 

acute  mania  from,  197 
cerebral  aflfections  in,  197 
diagnosis  of  198 
etiology.  196 
hallucinations  from,  197 


Lead-pMDisoning,  hemiplegia  from,  197 
insanitv  from.  197 
pathology  of  198 
peripheral  palsies  from,  198 
prognosis  of,  198 
spinal  diseases  from,  198 
symptoms  of,  197 
treatment  of,  198 
Lenticulo-striate  arteries,  445 
Leprous  neuritis,  735 
Leptomeningitis,  353 
alcoholic,  356 
diagnosis  of.  358 
diiferential  diagnosis  of,  359 
from  secondary  infection,  357 
infantum.  343 
of  base,  354 
of  vertex,  355 

pathology  and  morbid  anatomy,  356 
prognosis  in,  361 
purulent,  353 

rigidity  of  the  neck  in,  354 
secondary,  356 
serous,  355 
simple,  356 
spinal,  539,  533 
causes  of,  539 
symptoms  in,  539 
symp'tomatology  of,  353 
syphilitic,  355 
treatment  of.  361 
antipyrin  in,  361 
bromides  in,  361 
cold  in,  361 
iodides  in.  362 
mercurials  in,  363 
wet  cups  in,  361 
tuberculous,  355 
varieties  of  353 
Lesions  of  cauda  equina,  652 
compression,  653 
differentiation    from  lesions   due  to 

fractures  and  dislocations,  653,  654 
hemorrhage,  653,  654 
localization  of  lesions  in,  653 
neoplasms  of,  653,  654 
of  sacral  part  of  cord  653 
symptoms  of,  653 
table  of  symptoms,  655 
treatment,  656 
electrical,  656 
hydriatric,  656 
massage,  656 
surgical,  656 
of  conns  meduUaris,  651 

symptoms,  651 
producing  Wernicke's  symptom,  802,  803 
Lethargy,  105 
Lenticular  arteries,  445 
Light  reflex,  43 

Lingual  nerve,  surgery  of,  1000 
Lobe,  falciform.  384 

frontal,  boundaries  of,  391 

convolutions  of,  391 
limbic,  384 
occipital,  384 

parietal,  superior  portion  of.  392,  395 
inferior  portion  of,  392,  394 
Lobes  of  hemispheres,  384 
frontal,  384 
parietal.  384 
Lobulus  fusiformis,  393 
lingualis,  393 
marginalis.  384.  395 
paracentralis,  384,  395 
Local  asphyxia,  880 
hypertrophies,  912 
palsy,  27 
spasms,  270 
Localization  of  function  in  the  spinal  cord,  612- 
617 
visual,  120 
Locomotor  ataxia,  6;53 

ataxic  movements  of  arms  in,  635 
changes  in  posterior  columns,  641 
complications,  640 
course  and  termination  of,  640 


66 


1042 


INDEX. 


Locomotor  ataxia,  diagnosis,  643 

from  alcoholic  pseudo-tabes,  644 
from  ataxic  paraplegia,  644 
from  cerebellar  ataxia,  644 
from  post-diphtheritic  paralysis,  644 
from  rheumatism,  sciatica,  644 
etiology.  633 
gait  in.  21,  635,  636 
motor  symptoms,  634 
ocular  s'ymptoms,  637 

Argyll-Robertson  pupil,  637 
blindness,  63/ 
cilio-spinal  reflex,  637 
external  muscle  palsies,  637 
myosis,  637 
optic  atrophy,  637 
pathology    and    pathological   anatomy, 

640 
primary  lesions  in  the  ganglia  of  the  pos- 
terior roots,  641 
prognosis,  644 
reflex  symptoms,  637 
abdominal,  637 
bladder,  837 
cremasteric,  637 
gluteal,  637 
knee-jerk,  637 
sexual,  637 
Romberg  symptom,  634 
allocheiria,  637 
girdle  sensation,  635 
pains,  635 
parsesthesiae,  635 
polyaesthesia,  637 
retardation,  637 
sensory  symptoms  of,  636 
stages  of,  634 
symptomatology,  634 
tabetic  swaying,  634 
table  of  symptoms,  634 
treatment,  644 

antisyphilitic,  645 
arsenic,  645 

Bonnuzzi's  method,  645 
drugs,  644 
electricity,  644 
hydrotherapy,  644 
nitrate  of  silver,  645 
suspension,  645 
types  of,  633 

vasomotor  and  trophic  symptoms,  637 
arthropathies,  639 
Charcot  joints,  639 
dystrophies  of  joints,  639 
fragility  of  bones,  640 
muscular  atrophy,  637 
perforating  ulcers,  637 
visceral  symptoms,  640 
crises,  640 
Lombard's  knee-jerk  metre,  30 
Long  ciUary  nerves,  795,  797 
Longitudinal  fissure,  383 
sinus,  thrombosis  of,  368 
diagnosis  of,  370 
marantic  origin  of,  368 
symptoms  of,  368 
Loss  of  power  of  internal  recti  for  convergence, 
788 
of  sense  of  taste,  805.    See  Ageusia. 
Lumbago,  traumatic,  146 
Lumbar  plexus,  diseases  of,  848 

puncture,  969 
Lyssa,  215 


MACEWEN'S    differential    cranial    percussion 
note,  379 
Macrencephalia,  339 
etiology  of,  340 
fontaneUes  in,  340 
gyri  in,  340 
skull  in,  340 
symptoms  of,  340 
Main  en  griffe,  846  , 

Malarial  neuritis,  732 
symptoms,  732 
Malformations  of  brain,  315 


Malformations  of  brain,  artificially  produced,  318 
from  ependymitis,  318 
of  spinal  cord,  521 
Mammary  neuralgia,  847 
Maniacal  chorea,  250 
Mannkopf's  symptom,  147 
Masticatory  spasm,  272 
Mastodynia,  847 

Mastoid  abscess,  surgical  treatment  of,  972 
Maternal  impressions,  341,  507 
Measurements  of  head  in  children,  967 
Mechanical  injuries  ot  nerves,  741 

vertigo,  948 
Meckel's  ganglion,  removal  of,  999 
Mendel's  dog  experiments,  142 
Median  nerve,  paralysis  of,  844 

surgery  of,  1002 
Megrim,  939 
Meniere's  disease,  945 

etiology  and  symptoms,  946 
theories  of,  946 
Meningeal  apoplexy,  362 
symptoms  of,  363 
treatment  of,  363 
hemorrhage,  362 
causes  of,  362 
location  of,  362 
spinal,  544 
spontaneous,  362 

treatment  of,  363 
traumatic,  363 

diagnosis  of,  364 
Hutchinson's  pupil,  364 
prognosis,  365 
treatment,  365,  981,  983 
Meningitis,  348,  353.  See  Pachymeningitis,  Lepto- 
meningitis, 
spinal,  533 

surgical  treatment  of,  970 
Meningocele,  341.  525 

from  spina  bifida,  surgical  treatment  of,  989 
Meningo-bncephalocele,  341 
-ependymitis,  343 
-myelocele,  525 

from  spina  bifida,  surgical  treatment  of, 
989 
Memory  of  names  or  nouns,  427 
Mercurial  poisoning,  201 

amblyopia  from,  202 
diagnosis,  202 
etiology,  201 
pathology,  201 
prognosis,  202 

sensory  disturbances  in,  202 
symptoms,  201 
treatment,  202 
tremor  in,  202 
Metatarsal  neuralgia,  854 
Method  of  testing  pupillary  reactions,  795 
Meynert  on  the  cortex,  396 
Meynerl's  fibres,  796,  798 
Micrencephalia,  316,  323 

absence  of  callosum  in,  329 

aDsence  of  lobes  in,  333 

alcoholism  in,  334 

ape-like  fissures  in,  325 

asymmetry  in,  328 

atavism  in,  334 

atypical  gyri  in,  328 

brain  weight  in,  325 

cleft  palate  in,  333 

club-foot  in,  334 

cortex  in,  333 

external  perpendicular,  fissure  in,  326 

extremities  in,  333 

fissural  anomalies  in,  325 

harelip  in,  333 

heredity  in,  334 

island  of  Reil  in,  327 

junction  of  crura  in,  331 

junction  of  hemispheres  in,  333 

life  history  in,  334 

pathology  of,  325 

pons  in,  330 

sulci  and  gyri  in,  325 

Sylvian  fissure  in,  327 

transition  gyri  in,  326 


INDEX. 


1043 


Mierenccphalia,  treatment,  332 
Micrencephalia,  Zwickelwindung  in,  327 
Microcephalia,  323 

cranial  capacity  in,  32-1 
cranial  measurements  in,  325 
cranial  sutures  in,  32-1 
skull  in,  324 

surgical  treatment  of,  967 
Microgyria,  331 

cortex  in,  331 
Migraine,  937 
diagnosis,  942 
etiology,  939 
pathology,  940 
prognosis,  942 
symptomatology,  940 
treatment,  942 

constitutional,  943 
electrical,  943 
of  attack,  943 
Mimic  spasm,  270 
Mind-blindness,  437,  439 
Miryachit,  261 
Mirror  writing.  459 
Mogigraphia,  276 
Monocular  diplopia,  114 
Monophobia,  65 
Monoplegia,  27 
brachial,  27 
crural,  27 
Morbid  sleep,  955 
Morphinism,  193 
diagnosis.  194 
etiology,  193 
pathology,  193 
prognosis,  194 
symptoms,  193 
treatment,  194 
Morphcea,  902 

symptoms  and  distribution,  902 
Morphology,  relation  to  nervous  diseases,  17 
Morton's  affection  of  the  foot,  854 

fluid,  9S8 
Morvan's  disease,  597 
course  of,  598 
pathology  of,  598 

peripheral  neuritis,  598 
prognosis  of,  599 
symptoms  of,  597 

atrophy  of  muscles,  597 

dissociation  of  cutaneous  sensation, 

597 
electrical  contractility,  598 
neuralgic  pains,  597 
painless  felon,  597 
reflexes,  598 
sphincters,  598 
ulceration,  598 
treatment  of,  599 
Motor  aphasia,  433.  434,  496 
area,  its  boundaries,  403 
its  divisions,  403 
functions  of,  400 
centres,  400 
re-enforcement,  28 
Movements,  19 

Multiple  cerebro-spinal  sclerosis,  661 
atypical  forms  of,  663 
course  and  duration,  665 
diagnosis,  666 
etiology,  661 
forms  of,  661 
pathologj',  663 
prognosis,  666 

sjTnptomatology  and  course,  661 
treatment,  666 
neuritis,  726 
course  of,  727 
diabetic,  733 
diagnosis,  731,  736 

from  anterior  poliomyelitis,  736 
from  ascending  myelitis,  736 
from  locomotor  ataxia,  736 
endemic,  733 
etiology  of,  726 
following  diphtheria,  731 
following  typhoid  fever,  732 


Multiple  neuritis,  from  alcohol,  727 
from  arsenic,  731 
from  carbonic  oxide,  730 
from  lead,  730 
from  malaria,  732 
from  rheumatism,  733 
from  syphilis,  733 
history.  726 
idiopathic,  726 
of  old  age,  733 
pathology,  735 
prognosis,  736 
septiceemic,  733 
symptoms  of.  198,  727,  730,  731 
treatment,  737 
arsenic,  738 

coal-tar  derivatives,  737 
electricity,  738 
massage,  738 
potassium  iodide,  738 
rest,  737 
salicylates,  737 
supporting  measures,  737 
tubercular,  733 
types  of,  731 
palsy,  27 
Muscle-jerk,  33 

method  of  eliciting,  33 
Muscles,  disease  of,  857 

inflammation  of,  857 
Muscular  atrophy,  arthritic,  877 
Erb's  juvenile  form  of,  866 
facio-scapulo-humeral  form  of,  867 
Landouzy-Dejerine  form  of,  867 
scapulo-humeral  form  of,  866 
dystrophies,  864 
sense,  35 

methods  of  testing,  35,  36 
insuiflciency,  ocular,  41 

methods  of  determining,  41,  42 
Mnsculo-cutaneous  nerve,  paralysis  of,  843 
surgery  of,  1005 
-spiral  nerve,  paralysis  of,  843 
surgery  of,  1003 
Music-deafness,  437 
Mydriasis,  798 
causes  of,  798 
irritation,  798 
paralytic,  798 
Mydriatic  nerves,  797 
Myelitis,  556 
acute,  559 

transverse,  556 

alkalinity  ot  urine  in,  563 
anatomical  changes,  557 
ascending  degeneration,  564 
atrophy,  558,  562 
cellulitis  in,  564 
constipation  in,  563 
contractures  and  spasms  in,  564 
course  of,  564 
cystitis  in,  .i)64 
death  from,  564 

descending  degeneration  in,  564 
diagnosis,  566 

from  central  myelitis,  567 
from  disseminated  myelitis,  567 
from  hysterical  paralysis,  567 
from  Landry's  paralysis,  567 
from  poliomyelitis,  567 
from  multiple  neuritis,  567 
from  spinal  meningitis,  567 
disease  of  kidneys  in,  563 
dribbling  of  urine  in,  563 
electrical  reactions  in,  552 

resistance  in,  564 
etiology,  556 
girdle-pain  in,  561 
Joint  disease  in,  564 
level  of  anaesthesia  in,  561 
localization  of,  564 
loss  or  diminution  of,  561 
motor  nerves  in,  558 
nerve  roots  in,  558 
cedema  in,  564 
optic  neuritis.  564 
overflow  incontinence,  563 


1044 


INDEX. 


Myelitis,  acute  transverse,  pain  and  touch  in,  561 
pathology  of,  557 
priapism  in,  564 
prognosis  of,  567 
pupils  in,  562 
red  softening  in,  559 
reflexes  in,  562 
seat  of  bedsores  in,  564 
secondary  degeneration  in,  558 
sensation  in,  561 
sensibility  in,  561 
spastic  paraplegia  in,  562 
sphincters  in,  563 
symptoms,  558 

ansesthesia,  558,  559,  561 

anorexia,  560 

bedsores,  558,  560 

bladder  and  bowels  in,  560,  563 

bladder  symptoms,  559 

bullse,  558 

chills,  559 

convulsions,  559 

degree  of  paralysis,  560 

electrical  reactions,  558 

feeling  in  legs,  559 

fever,  559,  560 

girdle  sensation,  559 

grouping  of  symptoms,  559 

headache,  559,  560 

heaviness  of  legs,  559 

incontinence  in,  560,  563 

intellect  in,  560 

malaise.  559 

numbness,  559 

order  of  development,  559,  560 

pains  in  limbs,  559,  560 

paralysis,  558,  559,  562 
of  arms  in,  660 

premonitory  symptoms,  559 

rapidity  of  onset  in,  559 

reaction  of  degeneration,  560 

reflexes,  deep  and  superficial,  560 

respiration,  560 

retention  of  urine,  560 

temperature,  560 

variations  in  symptoms,  559 

vyasting  of  muscles,  558,  660 

vs^eakness  of  legs,  559 
table  of  symptoms  in  lumbar,  dorsal, 

and  cervical  myelitis,  566 
temperature  of  the  skin,  564 
termination  of,  564 
treatment  of,  567 

care  of  the  bladder,  569 

cold  to  the  spine,  569 

derivation  by  way  of  the  legs,  569 

electricity,  570 

ergor,  568 

massage,  570 

of  bedsores,  569 

potassium  iodide,  569 

strychnine,  569 

warm  baths,  568 

wet  cups,  568 
total  loss  of  reflexes  in,  663 
trophic  disturbances,  564 
white  softening  in,  557 
zone  of  hypersesthesia  in,  561 
apoplectiform.  559 
chronic,  570 

anatomical  peculiarities  of,  570 
a  sequel  of  acute  myelitis,  570 
course  and  termination  of,  572 
diagnosis  of,  573 

from  chronic  poliomyelitis,  573 
from  compression  myelitis,  573 
from  progressive  muscular  atrophy, 

573 
from  spastic  paraplegia,  573 
from  tumor,  574 
etiology  of,  570 
alcoholism,  570 
exposure,  570 
secondary  to  ascending  neuritis,  570 

to  meningitis,  570 
traumatism,  570 
pathological  anatomy  of,  570 


Myelitis,  primary,  570 
acute,  prognosis  of,  573 
symptoms  of,  571 
ansesthesia,  571 
atrophy,  571 
bladder  and  bowels,  571 
gait,  571,  572 

heaviness  and  weakness  of  legs,  571 
pains,  571 
reflexes,  571 

resemblance  to  spastic  paraplegia,  572 
sensory  disturbances,  572 
treatment  of,  574 

counter-irritation,  574 
electricity,  574 
iodides,  574 
of  bedsores,  575 
rest,  574 

warm  baths,  574 
climate,  574 
forms  of.  556 
subacute,  559 
course  of.  561 
symptoms,  561 

absence  of  special  symptoms,  561 
ansesthesia,  561 
paralysis,  561 
Myelocele,  527 
Myoclonus  multiplex,  268 
prognosis  of,  269 
treatment  of,  269 
Myopathies,  864 
Mysophobia,  66 
Myosis,  798 

causes  of,  798 
irritation,  799 
of  cerebral  origin,  798 
of  spinal  origin,  799 
paralytic,  799 
Myotonia  congenita,  873 
diagnosis  of,  876 
etiology  of,  873 
history  of.  873 
pathology  of,  876 
prognosis  of,  877 
symptomatology  of,  874 
treatment  of,  877 
Myotonic  reaction.  My  R,  874 
Myxoedema,  913 

diflferential  diagnosis  of,  915 
from  acromegaly,  915 
from  adiposis  dolorosa,  915 
from  elephantiasis,  915 
from  obesity,  915 
etiology  of,  913 

morbid  anatomy  and  pathology  of,  916 
prognosis  of,  915 
symptoms  of,  913 
features,  913 
mental  changes,  914 
onset,  913 
skin,  914 

subnormal  temperature,  915 
treatment  of,  917 

NAMING  centre,  427,  429 
Narcolepsy,  955 
Negative  re-enforcement,  29 
Nelavan,  956 

Nerve  cells,  functions  of,  402 
injuries,  741 
-grafting,  997 
-stretching,  997 
suture,  996 

primary,  996 
secondary,  996 
Nervous  deafness,  806 

diseases  from  infection,  203 

relation  to  general  medicine,  17 
dyspepsia,  67,  68 
pathology  in  general,  17 
syphilis,  699 
Neuralgia,  750 
brachial,  841 
causes  of,  750 
cervico-brachial,  841 
cervico-occipital,  835 


INDEX. 


1045 


Neuralgia,  character  of  paiu  in,  751 
crural,  854 
degenerative,  817 
diagnosis,  751 
epileptiform,  S16 
of  fifth  nerve,  814 

degenerative,  817 

diagnosis,  817 

epileptiform,  816 

etiology,  814 

herpetic,  816 

prognosis,  817 

reflex,  816 

removal  of  Gasserian  ganglion  for,  978 

symptoms,  815 

of  first  or  ophthalmic  division,  815 

migratory  pains,  816 

radiation  of  pain,  816 

of  second  or  superior  maxillary 

division,  816 
tender  points,  815,  816 
of  third  or  inferior  maxillary  divi- 
sion, 816 
tic  convulsif,  816 
trophic  disturbances,  816 
vasomotor  disturbances,  816 
treatment,  817 
electricity,  819 
local  measures,  819 
medicinal,  817 
surgical  measures,  820 
herpetic,  816 
idiopathic,  750 
intercostal,  847 
lumbo-abdominal,  854 
mammary,  847 
metatarsal,  854 
nerve  section  for,  820 
stretching  for,  820 
neurectomy  for,  820 
occipital,  835 
pathology,  751 
plantar,  854 
reflex,  816 

removal  of  Gasserian  ganglion  for,  820,  978 
symptomatic,  750 
symptoms  of.  731 
tic  douloureux,  751 
treatment,  817 
trigeminal,  814 
Neurasthenia,  51 

aching  of  limbs  in,  59 
adventitious  auditory  symptoms  in,  63 
head  symptoms  in,  59 
limb-sensations  in,  59 
visual  symptoms  in,  62 
anomalies  of  visual  perception  in,  62 
appetite. in,  67 
apperception  in,  63 
auditory  hypersesthesia  in,  62 
backache  in,  58 
insomnia  in,  66 
cerebral  visual  centres  in,  61 
circulatory  disturbances  in,  68 
cutaneous  hypersesthesia  in,  69 
diagnosis  of,  77,  78 
digestive  disturbances  in,  67 
disorders  of  hearing  m,  62 
of  smell  in,  63 
of  taste  in,  63 
distraction  in,  63 
dreams  in,  66 
etiology,  52 

fatigue  sensations  in,  57,  58 
fear  in,  65 
forms  of,  73 
giddiness  in,  58 
handwriting  in,  66,  67 
headache  in,  58 
heart-murmur  in,  69 
hyperidrosis  in,  70 
hypochondria  in,  64 
ideas  in.  63 
inattention  in.  63 
intellectual  effort  in,  63 
introspection  in,  64 
irritability  in,  64 


Neurasthenia,  joints  in,  70 
masturbation  in,  72 
memory  in,  63 
mental  affections  in,  64 
mental  fatigue  in,  63 
miciurition  in,  71 
nerve  cells  in,  74,  75 
nosophobia  in,  64 
numbness  in,  60 
olfactory  hypersesthesia  in,  63 

parsesthesia  in,  63 
orgasm  in,  73 
oxalates  in,  71 
palpitation  of  heart  in,  68 
paresthesias  in,  60 

of  taste  in ,  63 
pathology  of,  73,  74,  75,  76,  77 
pelvic  disease  in,  73 
perspiration  in,  70 
phosphates  in,  72 
polyuria  in,  71 
prognosis  of,  78 
psychic  disturbances  in,  63 
pupillary  phenomena  in,  62 
rest  in,  79  ~ 
retina  in,  61 
saliva  in,  70 
secretions  In.  70 
senescence  in,  77 
sexual,  72 

disturbances  in,  72 

excess  in,  72 
simplex,  55 

adventitious,  symptoms  of,  56 

essential  symptoms  of,  56 

motor  symptoms  of,  56 

primary  symptoms  of,  56 

secondary  symptoms  of  56 

sensory  symptoms  of,  56 

symptomatology  of,  55 

tendon  reactions  in,  56 
sleep  in,  66 

somatic  disturbances  in,  67 
special  fears  in,  65 
speech  in,  66 
spinal  irritation  in,  69 

tenderness  in,  60 
spontaneous  fear  in,  65 
spurious  angina  in,  68 
symptomatica,  55 
tachycardia  in,  68,  69 
tinnitus  aurlum  in,  63 
tissue  changes  in,  76 
tongue  in,  67 
toxic  substances  in,  76 
terminalis,  77 
treatment  of,  79 

animal  extracts  in.  86 

antipyrin  in,  85,  86 

climate  in,  85 

diet  in,  80 

exercise  in,  85 

hydrotherapy  in,  84 

partial  rest,  79 

rest  cure.  79 

sea-voyages  in,  85 

surf-bathing  in,  85 
urates  in,  71 
uric  acid  in,  71 
urine  in,  70,  71 
vasomotor  symptoms  in,  70 
vertigo  in,  58 

visual  accommodation  in,  62 
visual  field  in .  61 
visual  disturbances  in,  61 
will  in,  64 
Neurectasy,  997 
Neurectomy,  998 
Neuritis,  721 

duration,  725 

etiology,  721 

from  carbonic  oxide,  730 

of  brachial  ydexus,  836 

of  circumflex  nerve,  725,  842 

of  facial  nerve,  723,  821 

of  median  nerve,  724,  844 

of  musculo-spiral  nerve,  723,  843 


1046 


INDEX. 


Neuritis  of  ulnar  nerve,  724,  845 

pathological  anatomy,  722 

of  sciatic  nerve.  849 

symptoms,  722,  730 

treatment,  725 

internal  medication,  725 
local  applications,  725 
rest,  725 
Neuro-electrotherapeutics,  1007 

mimesis.  111 

retinitis,  755 
Neuromata,  739 

amputation,  739 

false,  740 

true,  739 

surgical  treatment  of,  740 
Neurotic  vertigo,  948 
Neurotomy,  998 
Nightmare,  954 

palsy,  956 

terrors,  954 
Nocturnal  epilepsy,  298 
Nodding  spasm,  272 
Normal  electrical  reaction,  38,  39 

fundus,  754 
Nuclear  paralysis,  784 
acute,  785 
chronic,  786 
of  the  sixth  nerve,  789 
Numb  fingers,  721 
Nyctophobia,  66 
Nystagmus,  42,  793 

associated  with  other  movements,  794 

causes  of,  794 

congenital,  793 

extent  of  movements,  793 

frequency  of  movements,  793 

in  advanced  tabes,  793 

in  brain  tumor,  498 

in  cerebellar  tumors,  794 

in  diffuse  degenerations,  794 

in  disseminated  sclerosis,  793 

in  focal  brain  disease,  794 

in  Friedreich's  ataxia,  793 

lateral,  793 

rotary,  793 

unilateral,  793 

vertical,  793 


OBLIQUE  illumination,  45 
Object-blindness,  437,  439 
Obturator  nerve,  paralysis  of,  849 
Occipital  lobe  and  amblyopia,  421 
and  hemianopia,  421 
and  vision,  420,  421 
Occipitalis  major  nerve,  surgery  of,  1002 

minor  nerve,  surgery  of,  1002 
Occupation  spasms,  276 
Ocular  muscles,  associated  movements,  777 
convulsions  of,  793 
field  of  fixation,  777 
paralysis  of,  777 

general  symptoms,  777 

altered  carriage  of  the  head,  777 

diplopia,  777 

false   projection   of  the  field  of 

vision,  777 
primary  deviation,  777 
secondary  deviation,  777 
vertigo,  777 
strabismus,  777 
physiological  action  of,  776 
spasm  of,  792 
three  pairs  of,  776 
nerves,  diseases  of,  773 
palsies,  777 

from  contracted  pupil,  790 
from  diabetes,  782-791 
from  dilated  pupil,  790 
from  diphtheria,  782-791 
from  influenza,  782-791 
from  injuries,  782-791 
from  lesions  in  the  region  of  the  cavernous 
sinus,  790 
in  the  region  of  the  sphenoidal  fissure, 
782,  790 


Ocular  palsies,  from  ophthalmoplegia,  790 
from  poisons,  782-791 
in  disseminated  sclerosis,  791 
in  Friedreich's  ataxia,  791 
in  paretic  dementia,  791 
in  tabes,  791,  786 

differentiation  from  palsies  due  to  le- 
sions of  the  nerves  themselves,  791 
prognosis,  791 

in  nuclear  palsy,  792 
in  peripheral  and  basal  palsies,  792 
proptosis,  790 

from  rheumatism,  782-791 
their  significance,  788 
treatment,  792 
electrical,  792 
mechanical,  792 
medical,  792 
surgical,  792 
Oculo-facial  group,  776 
motor  nucleus,  773 

nerve,  anatomy  of,  773 

diseases  of,  773 
paralysis,  789 

as  a  distant  symptom,  789 
in  diphtheria,  790 
double,  790 

from  nuclear  disease,  790 
from  meningitis,  790 
in  non-syphilitic  tabes,  790 
in  syphilis,  790 
pseudo-ptosis,  790 
ptosis  as  a  distant  symptom,  789 
with  crossed  hemiplegia,  790 
from  disease  of  the  corpora  quad- 

rigemina,  789 
from  nuclear  disease,  789 
recurrent,  783 
CEsophageal  spasm,  275 
Olfactory  hallucinations,  805 
localization,  430 
nerves,  diseases  ot,  804 
Olivary  bodies,  defective  development  of,  338 
Operative  myxoedema,  916 
Operculum,  385 
Ophthalmoplegia,  40,  781,  784 
acute,  705 
chronic,  786 
externa,  784 
interna,  784,  802 
total,  40,  785 
universa,  785 
Ophthalmoscope,  45 
Opisthotonos,  212 
Optic  atrophy,  762 

diagnosis,  760 

of  primary  atrophy,  768 
of  secondary  atrophy,  768 
of  consecutive  atrophy,  768 
pathology  and  pathological  anatomy,  768 
prognosis,  768 
significance  of,  764 
symptomatology,  766 

appea  ranee  of  nerve,  766 
visual  changes,  766 
treatment,  769 
centres,  cortical,  420 

primary,  753 
chiasm,  752 
disk,  45 

normal,  45 
nerve,  752 

diseases  of,  752 
hyperajmia,  753 

intermediary  and  peripheral  fibres  ot,  753 
normal  relations,  752 
papiilo-macular  bundle  of,  753 
structure,  752 
vascular  supply,  752 
neuritis,  755.    See  Papillitis, 
appearance  of  nerve  In,  760 
choked  disk,  755 
course  and  prognosis,  760 
descending,  755 
diagnosis  of,  760 
etiology,  757 
Intra-ocular,  755 


INDEX. 


1047 


Optic  neuritis,  neuro-retinitis,  755 
orbital,  755 

pathologj'  and  patliological  anatomy,  761 
significance  of,  758 
symptomatology  of,  759 
theories  of,  755 
treatment,  761 
vision  in,  760 
oculomotor  reflex,  796 
path,  its  divisions,  422,  491 

termination  of,  in  corpora  geniculata  and 

optic  thalamus,  753 
visual  radiations,  753 
Orbital  optic  neuritis,  761 
Orthotonos,  212 

Oscillations  of  head  and  trunk  in  normal  walk,21 
of  normal  walk,  21 
of  foot  in  the  normal  walk,  22 
Osteoplastic  resection  of  skull,  961 
Othsematoma,  689 
Otitic  abscess,  376,  971 
Oxaluria,  72 
Oxyecoia,  808 


pACHYACRIE,  891 

JT     Pachymeningitis,  348 

counter-irritation  in,  349 
external,  348 

of  children,  350 
headache  in,  348 
hemorrhagic,  351 

diagnosis  of,  352 
hemorrhagic,  pathology  of,  351 
hemorrhagic,  spinal,  539 
surgical  treatment  of,  971 
hypertrophica  cervicalis,  538 

symptoms  of,  538 
internal  spinal,  539 
internal  cerebral,  350 
ossific,  348 
■  purulent  external,  348 
spinal,  533,  538,  539 
surgery  in,  350 
syphilitic,  352 
traumatic,  349 
treatment  of,  349 
tuberculous,  352 
Painful  tubercle,  surgical  treatment  of,  995 
Pain  sense,  34 

methods  of  testing,  35 
Palsy.  27 

general,  27 
local,  27 
multiple,  27 
Palmus,  261 
Pantomime,  436 
Pahtophobia,  66 
Papillitis,  4G,  755 

appearance  of  nerve  in,  760 
course  and  prognosis,  760 
diagnosis,  760 
etiology,  757 
significance  of,  758 
symptomatology  of,  759 
theories  of,  755 
treatment,  761 
vision  in,  760 
Paresthesia,  34 
Paresis,  27 
Parageusia,  806 
Paragraphia,  433,  440 
Paralexia,  436,  438,  440 
Paralysis,  27 
agitans,  288 

diagnosis,  293 
duration,  289 
etiology,  289 
morbid  changes  in,  291 
pathology,  290 
prognosis,  290 
symptoms,  288 
treatment,  294 
tremor  in,  288 
anterior  crural  nerve,  849 
auditory  nerve,  806 
brachial  plexus,  839 


Paralysis,  brachial  nlexus,  diagnosis,  841 
etiology",  839 
symptoms,  839 

in  ascending  neuritis,  839 
in  Klumpke's  paralysis,  840 
in  paralysis  from  fracture  or  dis- 
location of  the  humerus,  840 
in  paralvsis  of    the    lower   arm 

type,  840 
in  paralysis  from  morbid  processes 

in  the  neck,  840 
in  paralvsis  of  the   upper   arm 

type,  840 
in  primary  brachial  neuritis,  839 
treatment,  841 
in  cervical  myelitis,  562 
in  dorsal  myelitis,  562 
.  in  lumbar  myelitis,  562 
of  ciliary  muscle,  801 
of  circumflex  nerve,  842 
of  convergence,  40,  788 
of  external  cutaneous  nerve,  843 
ocular  muscles,  777 

general  symptoms,  777 

altered  carriage  of  head,  777 

diplopia,  777 

false    projection  of   field  of 

vision,  777 
primary  deviation,  777 
secondary  deviation,  777 
strabismus,  777 
vertigo,  777 
method  of  examination,  780 
special  symptoms,  777 

paralvsis  of  external  rectus, 
"778 
of  inferior  oblique,  779 
of  inferior  rectus,  779 
of  internal  rectus,  778 
of  oculomotor  nerve,  780 
of  superior  oblique,  780 
of  superior  rectus,  779 
varieties  of,  781 

of  basal  palsies,  782 
of  cerebral  palsies,  784 
of   orbital  'and     peripheral 
palsies,  782 
plantar  nerve,  854 
popliteal  nerve,  853 
of  facial  nerve,  821 
of  fifth  nerve,  811 

crossed  paralysis  of,  813 
diagnosis  of,  813 

differentiation   from   neural- 
gia, 813 
of  locality  of  lesion,  813 
etiolog}',  811 
symptoms,  812 
treatment,  813 
of  fourth  nerve,  789 

in  basilar  meningitis,  789 
in  cerebellar  disease,  789 
in  tumor  of  the  pineal  gland,  789     • 
isolated  paralysis,  789 
together  with  paralysis  of  the  third, 
789 
of  hypoglossal  nerve,  832 
diagnosis,  833 
etiology,  832 
prognosis.  834 
symptoms,  833 
treatment,  834 
of  the  internal  plantar  nerve,  854 

popliteal  nerve,  853 
of  larynx,  829 
of  median  nerve,  844 
of  musculo-cutaneous  nerve,  843 
of  musculo-spiral  nerve,  843 
of  obturator  nerve,  849 
of  pathetic  nerve,  789 
of  perforans  Casserii,  843 
of  peroneal  nerve,  853 
of  pharynx,  829 
of  phrenic  nerve.  836 
of  posterior  thoracic  nerve,  842 
of  sciatic  nerve,  853 
of  sixth  nerve,  789 


1048 


INDEX. 


Paralysis  of  sixth  nerve,  as  a  direct  symptom,  789 
as  a  distant  symptom,  789 
association    with    paralysis   of    the 

facial,  789 
basilar,  789 
nuclear,  789 

occurring  with  hemiplegia,  789 
of  small  sciatic  nerve,  854 
of  spinal  portion  of  spinal  accessory  nerve,832 
symptoms,  832 
treatment,  832 
of  superior  gluteal  nerve,  849 
of  supra-scapular  nerve,  S42 
of  third  nerve,  789 

as  a  distant  symptom,  789 
apparent  ptosis,  790 
ptosis  as  a  distant  symptom,  789 
with  crossed  hemiplegia,  790 
from  disease  of  the  corpora 

quadrigemina,  789 
from  nuclear  disease,  789 
in  diphtheria,  790 
double,  790 

from  nuclear  disease,  790 
from  meningitis,  790 
in  non-syphilitic  tabes,  790 
in  syphilis,  790 
of  tongue,  832 

from  infra-nuclear  disease,  833 
from  nuclear  disease,  833 
from  supra-nuclear  disease,  833 
of  trochlear  nerve,  789 
of  ulnar  nerve,  845 
spastic,  27 
Paralytic  convergent  squint,  40 

dementia,  667 
Parkinson's  disease,  288 
Paramimia,  436,  440 
Paramyoclonus,  268 
Paraphasia,  436,  438,  440 
Paraplegia,  27 

of  childhood,  511,  517 
Paresis,  667 
Paretic  dementia,  667 

ascending  form,  674,  694,  695 
circular  form  of,  680 
diagnosis,  695 

differential,  from  "syphilitic 
paresis,"  syphilitic  demen- 
tia, 696,  697 
diifereutiation  from  alcohol- 
ism, 697 
lead  encephalopathy,  697 
tumor,  697 

from  neurasthenia,  696 
duration,  690 

in  males  and  females,  691 
of  the  depressive  form,  691 
of  the  expansive  form,  691 
of  the  simple  demented  form, 
691 
etiology,  667 

general  symptoms  common  to  all 
forms    of   the    established 
disease,  680 
mental  phenomena,  680 
physical  phenomena,  680 
diplopia,  681 
gait,  681 

handwriting,  681 
knee-jerks,  681 
movements,  681 
muscular  weakness,  680 
myosis,  681 
ptosis,  681 
reaction  of  pupils  to  light, 

681 
spasmodic  twitching,  681 
speech,  681 
tremor,  680 
unequal  pupils,  681 
pathology  and  pathological  anatomy,  691 
autotoxin,  693 
brain  tissue,  692 
cells  of  Deiters,  692 
changes  in  bloodvessels,  692 
changes  in  the  calvarium,  691 


Paretic  dementia,  pathology  and  pathological 
anatomy,    changes   in   the 
dura,  691 
changes  in  lymphatic  supply, 

692 
changes  in  the  nerve  cells,  692 
changes   in    the    peripheral 

nerves,  695 
changes  in  vascular  supply, 

692 
convolutions,  692 
cord  changes,  693,  694 
descending  degeneration,  693 
ependymitis,  692 
fissures,  692 

frequency  of  disease  of  poste- 
rior columns  in  paresis,  695 
hemorrhagic    pachymeningi- 
tis, 691 
interstitial  processes,  693 
leptomeningitis,  691 
Mendel's  dog  expert ments,693 
meningo-encephalitis,  691 
oedema    of   membranes   and 

brain.  692 
parenchymatous  changes.  693, 

694 
pathology     of    the     tabetic 

form,  694 
proliferation  of  the  connec- 
tive-tissue elements,  692 
proliferation   of  the  neurog- 
lia, 692     . 
spider  cells,  692 
syphilis  and  paresis,  693 
theories  of  the  nature  of  the 

pathological  process,  693 
toxic  agents  and  paresis,  693 
toxine  of  syphilis  as  a  cause 

of  paresis,  693 
ventricles,  692 
weight  of  brain,  692 
prognosis,  695 
relation  of  the  lesions  to  the  symptoms, 

695 
remissions,  690 
causes  of,  690 
diurnal,  690 

legal  responsibility  during,  690 
of  long  duration,  690 
problems  presented  by,  690 
summary  of  symptoms,  683 

general  somatic,  trophic,  and  vis- 
ceral symptoms,  687 
bedsores,  689 
blebs,  689 
circulation,  687 
digestion,  688 
ecchymoses,  689 
epistaxis,  689 
hsematOma     of     the 

ear,  689 
hematemesis,  659 
hemorrhage  from  the 

bowel,  689 
herpetic  eruptions,689 
metrorrhagia,  689 
muscular  wasting,  689 
nutritive  changes,  688 
perforating  ulcer,  689 
purpuric  blotches,  689 
respiration,  688 
secretions,  688 

perspiration,  688 
saliva,  688 
urine,  688 
skin,  689 

tache  cerebrale,  689 
temperature,  688 
trophic  changes  in  the 

bones,  6b9 
trophic  changes  in  the 

joints,  689 
ulcers,  689 

vasomotor   weakness, 
689 
motor  symptoms,  685 


INDEX. 


1049 


Paretic  dementia,  motor  symptoms,  seizures,  685 
apoplectiform  attacks, 

685 
epileptiform   attacks, 

685 
hysteriform,  687 
sequelae  of,  686 
temperature     follow- 
ing, 686 
tetaniform,  687 
speech  disturbances,  685 
weakness,  tremor,  ataxia, 
685 
psychic  symptoms,  683 

anomalies  of  the  ccenses- 

thesis,  684 
anomalies   of    conscious- 
ness, 684 
anomalies  of  the  special 

senses,  684 
crimes  by  paretics,  684 
delusions,  684,  685 
hallucinations,  684 
illusions,  684 
loss  of  inhibitory  control, 

684 
losses,  683 

perversions  of  the  moral 
sense,  684 
quantitative      and      qualitative 

changes,  683 
sensory  symptoms,  687 
ataxic  pains,  687 
cutaneous  sensibility,  687 
general  and  special,  680 
headache,  687 
neuralgia,  687 
smell,  687 
taste,  687 
vision,  687 
surgical  treatment  of,  978 
symptoms  and  course  of,  671 

course  of  the  depressive  form,  680 
delusions  of  belittlement,  679 
delusions  of  physical  ills,  679 
delusions  of  spiritual  ills,  679 
depressive  delusions,  679 
hallucinations,  679 
hypochondriasis,  679 
melancholia,  679 
mental  depression,  679 
silent  excitement,  680 
first  stage  of  the  established  disease,  676 
symptoms  of  the  expansive  form,  676 
transition  from  initial  period,  679 
of  simple  or  uncomplicated  form, 

680 
loss  of  memory,  680 
quiet  dementia  in,  680 
initial  period  of,  672 

apoplectiform  attacks,  675 
appearance,  672 
delusions  of  grandeur,  677 

examples  of,  677 
dementia,  673 
destractiveness,  679 
diurnal  variation  of    symptoms, 

675 
duration  of  the  initial  period,  675 
eating  and  drinking,  673 
essential    features  of  the  initial 

period,  675 
epileptiform  attacks,  675 
emotions,  673 
excitement,  679 

expansive    state    without    well- 
marked  delusions,  678 
extravagant  enterprises,  674 
facial  expression,  678 
forgetfulness,  673 
headaches,  672 
hypochondriasis,  676 
judgment,  677 
knee-jerks,  674 
mania,  679 
melancholy,  676 
mental  condition,  672 


Paretic  dementia,  initial  period  of,  moral  nature, 
674 
motor  excitement,  679 
movements,  674 
neuralgic  pains,  672 
obscenity,  673 
physical  conditions,  672 
reflexes,  674 
restlessness,  679 
sensibilities,  673 
sexual  excess,  674 
silent  excitement,  679 
sleep  disturbances,  674 
speech,  673 
temporary  remissions  during  the 

initial  period,  675 
termination  of  the  initial  period, 
676 
prodromal  stage,  672 
period  of  fully  developed  disease,  676 
second  stage  of  established  disease,  682 
aphasia,  682 
bedsores,  683 
bladder  and  bowels,  682 
delusions,  682 
dementia,  682 
features,  682 
movements,  682 
speech,  682 

trophic  disturbances,  683 
stages  of  the  fully  developed  period,  676 
third  stage  of  the  estsblished  disease,  688 
bedsores,  683 
contractures,  683 
dementia,  683 
hematomata,  683 
treatment,  697 
antipyrine,  698 
baths,  698 
bedsores,  698 
feeding,  698 

feeding  of  bedsores,  698 
hypnotics,  697 
rest  cure,  697 
Parietal  lobe,  392,  395 
Parosmia,  805 
Partial  rest  cure,  79,  85 
Passive  chorea,  27 

tremor,  27 
Patellar  reflex,  28 
Pathetic  nerve,  anatomy  of,  774 
diseases  of,  773 
origin  of,  775 
paralysis  of,  789 
Peduncles  of  the  callosum,  384 
Percussion  note  in  brain  abscess,  379 
Perforans  Casserii,  paralysis  of,  843 
Perimeter,  47 
Peripheral  neuritis,  726 
in  the  aged,  733 
vision,  46 
Personal  history,  18 
i  Peroneal  nerve,  paralysis  of,  853 
!  Petit  vial,  297 
Phantom  tumor,  32,  127,  275 
Phenomena  of  nutrition,  36,  37 
Photophobia,  66 
Phosphaturia,  72 
Phrenic  nerve,  diseases  of,  836 
Physical  basis  of  words,  494 
Physiological  cup,  754 
Piano-player's  cramp,  279 
Pituitary  body,  tumor  of.  479 
gland,  function  of,  893 

role  of  its  secretion  in  nervous  nutrition, 

893 
structure  of,  893 
Plantar  neuralgia,  854 

reflex,  36 
Pli  courbc,  395 
Pleurosthotonos,  212 
Pneumogastric  nerve,  diseases  of,  828 
Poisoning  from  arsenic,  200 
from  lead,  196 
from  mercury,  201 
Poliencephalitis  corticalis,  372 
inferior,  372 


1050 


INDEX. 


Poliencephalitis  inferior  acuta,  660 
chronica,  657 
■     superior,  372 
acuta,  785 
chronica,  786 
Poliomvelltis,  620 
acute,  620 

course  of,  622 
diagnosis  of,  623 

from  cerebral  palsies,  623 
from  rickets,  623 
etiology,  620 
pathology,  622 
prognosis,  623 
symptomatology,  621 
treatment,  624 

of  acute  stage,  624 
of  chronic  stage,  624 

electricity  in,  624 
massage  In,  624 
anterior,  620 

subacute  and  chronic,  624 
of  adults,  624 

differentiation  from  multiple  neuri- 
tis, 624 
from  progressive  muscular  atro- 
phy, 624 
treatmeiit  of,  625 
Polyneuritis,  726 

Polymyositis,  subacute  progressive,  857 
Pons,  defective  development  of,  338 
Popliteal  nerves,  surgery  of,  1004 
PorencephaUa,  317,  319 
pathology  of.  319,  510 
symptoms  of.  322,  511 
Porencephalus,  319,  510 
Posterior  cervical  nerves,  resection  of,  1000 
sclerosis,  633 

thoracic  nerve,  paralysis  of,  842 
tibial  nerve,  surgery  of,  1004 
Postero-lateral  central  arteries,  446 

-mesial  central  arteries,  44o 
Posl-operculum,  385 

-hemiplegic  chorea.  263 
-paralytic  chorea,  263 
Posture,  19 

Pott's  disease,  laminectomy  for,  553,  990 
Prefrontal  region,  4-^2 
Preoperculum,  385 
Pressure  sense,  34 

methods  of  testing,  34 
Prevost's  symptom.  787 
Primary  lateral  sclerosis,  629 
optic  atrophy,  762 

etiology  of,  762 

paretic  dementia  of,  764 

spinal  lesions  of,  762 

Friedreich's  ataxia,  763 
injuries  of  the  cord,  764 
insular  sclerosis,  763 
lateral  sclerosis,  763 
locomotor  ataxia,  762 
centres,  753 
position  of  the  eyes,  776 
spastic  paraplegia,  629 
visual  ganglia,  753 
Procursive  epilepsy,  297 

Prognosis  of  paralyses  of  the  spinal  nerves,  855 
Progressive  facial  hemiatrophy,  904 
general  paresis,  667 
muscular  atrophy,  625 
diagnosis,  628 

from  amyotrophic   lateral  scler- 
osis, 628 
from  diffuse  myelitis,  628 
from  lead-poisoning,  628 
from  local  atrophy,  628 
from  neuritis,  628" 
from  pachvmeningitis  cervicalis, 

628 
from   the   progressive    muscular 

dystrophies,  628 
from  syringomyelia,  628 
etiology,  625 
pathology  and  pathological  anatomy 

of,  627 
prognosis  of,  62S 


Progressive  muscular  atrophv,  symptomatology 
of,  625 
termination  of,  627 
treatment  of,  62S 
type  of  Aran-Duchenne,  625 
dystrophies,  864 
neurotic  atrophy,  871 

diagnosis  of.  872 
etiology  of,  871 
pathological  anatomy  of,  873 
prognosis  and  treatment  of,  873 
symptoms  and  course  of,  871 
spastic  ataxia,  648 
Propositionizing  centre,  434 
Prosopalgia,  814 
Pseudo-bulbar  palsy,  657 

-general  paralysis  from  lead,  197 
-muscular  hyp'ertrophy,  864 
course  of,  866 
diagnosis  of,  870 
etiology  of,  868 
pathological  anatomy  of,  868 
prognosis  of.  871 
symptoms  of,  864 
treatment  of,  871 
-ptosis,  790 
Ptosis,  42 

as  a  distant  symptom,  789 

from  disease  of  the   corpora   quadrigemina, 

789 
from  nuclear  disease,  789 
matinal,  42 

with  crossed  hemiplegia.  790 
Pudic  nerve,  surgery  of,  1005 
Puerperal  tetanus,  213 
Puncture  of  the  lateral  ventricles,  968 

of  spinal  membranes  in  the  lumbar  region, 

969 
of  subarachnoid  space,  969 
Pupil,  43,  794 

reflex  arc,  796,  797 

centripetal  portion  of,  797 
centrifugal  portion  of,  798 
Mevnert's  fibres,  798 
Argyll-Robertson,  43.  800 
Pupil,  cerebral  cortex,  reflex  of,  803 
changes,  795.  797 

due  to  abeyance  of  brain  function,  797 
cerebral  irritation,  797 
disease  of  eye  or  optical  defects,  797 
drugs.  797 
localized  cerebral  lesion   in   special 

centres  or  tracts.  797 
spinal  or  sympathetic  lesion,  797 
consensual  reflex  action  of,  796 
contracted,  43 
contracting  centre  of,  796 
contraction  of,  796,  798 
dilated.  43 

dilating  centre  of,  797 
dilatation  of,  797,  798 
direct  reflex  action  of.  795 
in  cervical  myelitis,  562 
in  disease,  797 
in  epilepsy,  801 
inequality,  801 
latent  anisocoria,  801 
equilibrium  of,  43 
Hutchinson's,  364 
indirect  reflex  action  of,  796 
immobility  of,  and  trifacial  ansesthesia,  803 
inequality  of.  799 
in  locomotor  ataxia,  799 

Argyll-Robertson  symptom,  800 
converse  of  Argyll-Robertson  symp- 
tom, 800 
loss  of  accommodative  reaction,  801 
loss  of  light  reaction,  800 
loss  of  reaction  to  accommodation  in, 

800 
reflex  iridoplegia,  800 
unilateral  reflex  iridoplegia,  800 
measurement  of,  795 
normal,  795 

in  paralytic  dementia,  801 
inequality  of,  801 
interior  ophthalmoplegia,  801 


INDEX. 


1051 


Pupil,  in  paralytic  dementia,  irregular,  801 
pupillary  reactions,  801 
loss  of  accommodation,  801 

of  reflex  dilatation  to  cutaneous 
stimulation,  801 
reflex  iridoplegia,  801 
position  of,  795 
reactions  of,  795 
shape  of,  795 
size  of,  795 
skin  reflex  of,  797 
varying  inequality  of,  799 
Pupillary  reactions,  method  of  testing,  795 
Pupils,  associated  action  of,  797 

QUADRANT  anopsia,  771,  773 
hemianopsia,  771,  773 
Quadrate  lol)Ule,  419 
Qualitative  change,  37 
Quantitative  change,  37 
increase,  37 
decrease,  37 


RABIES,  215 
Rachischisis,  340 
Radial  nerve,  surgery  of,  1003 
"Railway  spine,"  135 
Ramon  y  Cajal  on  the  cortex,  398 
Raynaud's  disease,  880 
diagnosis  of,  884 
duration  of,  883 
etiology  of,  881 
history  of,  880 
pathology  of,  884 
prognosis  of,  885 
symptoms  of,  881 

constitutional,  883 
local,  881 
treatment  of,  885 
Reaction  of  degeneration,  38,  39 

diagnostic  value  of,  39 
Rectal  crises,  640 

spasm,  275 
Recurrent  oculomotor  paralysis,  783 
Red  softening,  469,  554,  557 
Re-enforcement,  electrical,  29 
motor,  28 
negative,  29 
sensory,  28 
Reflex  arc  of  pupil,  796,  797 

centripetal  portion  of,  797 
centrifugal  portion  of,  798 
Meynert's  fibres  of,  798 
iridoplegia,  800 
vertigo.  948 
Relative  frequency  of  paralysis  of   the  ocular 

muscles,  792 
Removal  of  Gasserian  ganglion,  978 

Meckel's  ganglion,  999 
Renal  crises,  640 
Risus  sardonicus,  212 
Rest-cure,  79-82 

body-weight  in,  83 
calisthenics  in,  84 
drugs  in,  82,  83 
electricity  in,  81 
isolation  in,  80 
massage  in,  81 
passive  movements  in,  84 
Swei'lish  movements  in,  84 
Retro-hulbar  neuritis,  761 
acute,  761 

etiology  of,  761 
chronic,  761 

etiology  of,  761 
tobacco,  762 
toxic  causes,  762 
pathology  of,  762 
treatment  of,  762 
-pharyngeal  abscess,  991 
Rheumatic  chorea,  1S4 
hemiplegia,  184 
insanity,  183 
meningitis,  184 
multiple  neuritis,  733 


Rheumatic  nervous  aflTections,  183 
diagnosis  of,  185 
etiology  of,  183 
pathology  of,  185 
prognosis  of,  185 
symptoms  of,  183 
treatment  of,  185 
neuralgia,  184 
Beuritis,  184 
spinal  cord  diseases,  184 
Right  temporal  lobe,  432 
Romberg  symptom,  20,  634 
Romberg's" spasm,  272 
Rongeur's  forceps,  959,  960 

Rose's  operation  for  removal  of  the  Gasserian 
ganglion,  978 
tetanus,  212 


SACRAL  plexus,  diseases  of,  848,  853 
Saltatoric  spasm,  261 
diagnosis  of,  263 
prognosis  of,  263 
symptoms  of,  261,  262 
Saturday-night  palsy,  723,  844 
Saturnine  pseudo-general  paralysis,  1 97 
Scapulo-humeral  form  of  muscular  atrophy,  866 
Scbmaus's  experiments  in  concussion,  142,  143 
Sciatic  nerve,  paralysis  of,  853 

neuritis,  849 
Sciatica,  849 

diagnosis  of,  851 
etiology  of,  849 
prognosis  of,  851 
symptoms  of,  850 
treatment  of,  852 

constitutional  measures,  852 
counter-irritation,  852 
drugs.  852 
electricity,  852 
immobility,  852 
local  measures,  852 
massage.  852 
nerve  stretching,  852 
Weir  Mitchell's  method,  852 
Scleral  ring,  754 
Scleroderma,  900 
course  of,  902 
diagnosis  of,  904 
etiology  of,  901 
pathology  of,  903 
symptoms  of,  901 
treatment  of,  904 
Scleroma  adultorum,  901 
Sclerosis  of  the  brain,  373 
Scrivener's  palsy,  276 
Seamstresses'  cramp,  279 
Secondary  atrophy  of  optic  nerve,  762 
etiology  of,  764 
degeneration,  457,  462 
positions  of  eyes,  776 
Senile  chorea,  257 

tremor,  283 
Sense  of  temperature,  35 
Sensori-motor  functions  of  motor  area,  417 
Sensory  aphasia,  433,  437 
localization,  415 

nerve  roots,  intra-spinal  division  of,  1002 
pathways  in  cord,  416 

in  flUet,  416 
re-enforcement,  28 
regions  of  cortex,  415 

pathways  to,  416 
representation  in  the  cortex,  417 
the  limbic  lobe,  417 
Septicsemic  multiple  neuritis,  733 
Shaking  palsy,  288 
Shingles,  848 
Short  ciliary  nerves,  794 
Sick  headache,  939 
Siderodromophobia,  66 
Sinus  thrombosis,  365 
Sinuses  of  the  dura  mater,  365 
Sixth  nerve,  diseases  of,  773 
Skin  reflex  of  pupil.  797,  803 

effect  of  section  of  fifth  nerve,  803 
path  for,  803 


1052 


INDEX. 


Sleep.  949,  953 

disorders  of,  953 

drunkenness,  955 

morbid,  955 

palsy,  956 
Small  sciatic  nerve,  paralysis  of,  854 
Smell,  affections  of,  804 
Smith's  cramp,  279 

Softening  of  brain,  467.    See  Acute  Softening  of 
Brain. 

of  spinal  cord,  554 
Somnambulism,  105,  955 
Soul-blindness,  437,  439 


clonic,  27 
of  larynx,  830 
of  levator  palpebrse,  793 
of  pharynx,  829 
of  ocular  muscles,  792,  793 
of  tongue,  275 
tonic,  27 
Spasms,  functional,  270 
Spasmodic  convergent  strabismus,  792 
strabismus,  792 
tabes  dorsalis,  629 
vrry-neck,  272 

etiology  of,  273 
morbid  anatomy  of,  274 
prognosis  of,  274 
symptoms  of,  273 
treatment  of,  274 
Spastic  diplegia  of  childhood,  510,  515 
pathology  of,  511 
symptoms  of,  515 
gait  in  hysteria,  24 

oscillations  of  the  foot  in,  24,  25 
hemiplegia  of  childhood,  509,  513 
age  of  acquired,  510 
atrophy  and  sclerosis  in,  510 
cysts  in,  510 
frequency  of,  509 
from  meningitis,  510 
from  tumor,  510 
from  vascular  disease,  510 
morbid  anatomy  of,  510 
porencephalus  in,  510 
symptoms  of,  513 
paralysis,  27 
paraplegia,  629 

of  childhood,  511,  517 
symptoms  of,  517 
spinal  paralysis,  629 
Specific  gravity  of  brain  and  spinal  cord,  382 
Speech,  mechanism  of,  432 
Sphincter  iridis,  794 
Sphincters,  centres  for,  651 
Special  fears,  65 
Spina  bifida,  523 

and  hydrocephalus,  531 
bladder  and  rectum  in,  531 
causes  of,  529 
clinical  history  of,  529 
diagnosis  of,  532 
morbid  anatomy  of,  524 
occulta,  528,  529 
paralysis  in,  531 
pelvic  cysts  from,  528,  531 
prognosis  of,  533 
sacral  forms  of,  528 
surgery  of,  988 
treatment  of,  533 
Spinal  abscess,  552,  991 

accessory  nerve,  diseases  of,  828,  832 
surgery  of,  1000 
spasm,  272 
arthropathies.  592,  639 
caries,  534,  537,  538.  539,  550 
diagnosis  of,  553 
etiology  of,  551 
laminectomy  for,  553,  990 
symptoms  of,  557 
treatment  of,  553 
centre  for  anal  sphincter,  651 
for  vesical  sphincter,  651 
cord,  612 

anaemia  of,  555 

anterior  columns  of,  612,  614 


Spinal  cord,  anterior  columns  of,  horns  of,  614 
motor  ganglion  cells  of,  614 
artefacts  of,  521 
blood-supply  of,  620 
cell  groups  in  anterior  horn  of,  614 
cervical  enlargement  of,  612 
Clarke's  column  of,  613 
columns  of,  612 

of  Goll  and  Burdach,  612,  614 

ofTiirck,  612,  614 
crossed  pyramidal  tracts  of,  613,  614 
crossing  of  sensory  fibres  in,  614 
direct  cerebellar  tract  of,  613,  614 

pyramidal  tract,  614 
distribution  of  motor,  sensory,  trophic, 

and  reflex  centres  through  the  cord, 

615,  616,  617 
embryology  of,  523 
focal  lesions  of,  615,  616,  617 
Gowers's  tract,  613,  614 
gray  matter  of,  612 
gunshot  wounds  of,  990 
hemorrhage  into,  541 
heterotopia  of,  521 
hypersemia  of,  555 
inflammation  of,  556.    See  Myelitis, 
knee-jerk,  618 
lateral  columns  of,  613,  614 
lesions  of  the  cauda  equina  and  of  the 
lumbo-sacral  enlargement,  618 

of  the  motor  tracts,  618 

anterior  horns,  618 

producing   anaesthesia   to   pain  and 
temperature,  618 
Lissauer's  tract,  613 
localization  of  system  diseases  of,  615 
lumbar  enlargement  of,  612 
malformations  of,  521 
membranes  of,  620 
posterior  columns  of,  612,  614 
reflex  centres  of,  613 

relations  to  spinal  canal  and  vertebrse,;612 
relative  proportion  of  the  gray  and  white 

matter  in  the  enlargements  of,  613 
segments  of,  612 

functions  of,  615,  616,  617 
softening,  554 
spurious  heterotopia,  512 
structure  of,  612 
surgery  of,  988 
system  diseases  of,  614 
trophic  centres,  613 

centres  for  muscles,  614 
tumors,  599 

types  of  spinal  paralysis,  618 
vasomotor  centres,  613 
drainage,  969,  990 
hemorrhage,  544,  990 
etiology  of,  543 
morbid  anatomy  of,  545 
non-traumatic,  542 
symptoms  of,  543 
traumatic,  542 
treatment  of,  545 
injuries,  546 

leptomeningitis,  533,  537,  539 
localization,  613-617 
myosis,  799 
nerves,  prognosis  of  paralysis  of,  855 

treatment  of  paralysis  of,  855 
pachymeningitis,  533,  534,  538 
and  leptomeningitis,  533 
caries  in,  534,  537 

causes  ol,  534 

cold  in,  534 

diagnosis  of,  539 

infection  in,  534 

morbid  anatomy  of,  535 

myelitis  in,  535 
.     pathology  of,  534 

prognosis  of,  540 

secondary  degenerations  in,  535 

stages  of,  539 

symptoms  of,  537 

syphilis  in,  534,  537 

trauma  in,  534 

treatment  of,  540 


INDEX. 


1053 


Spinal  spastic  paraplegia  in  children  from  in- 
herited syphilis,  714 
syphilis,  709 

cerebral  complications  in,  711 
cord  changes,  711 
Erb's  symptom-group,  711 
meningo-myelitis,  711 
pathology  of,  711 
precocious  spinal  syphilis,  711 
symptoms  of,  709,  710 
tumors,  599 

medical  treatment  of,  610 
surgical  treatment  of,  610,  993 
Spontaneous  fear,  65 
Stasophobia,  66 
Status  epilepticus,  298 
StilUcidium,  42 
Strabismus,  spasmodic,  792 
Structure  and  functions  of  the  spinal  cord,  612 
Struma  exophthalmica,  920 
Subacute  progressive  polymyositis,  857 
complications  of,  859 
course  of,  858 
diagnosis  of,  862 
duration  of,  860 
etiology  of,  857 
pathology  and  morbid   anatomy  of, 

860 

prognosis  of,  863 

symptoms  of,  858 

treatment  of,  863 

Subarachnoid  puncture,  969 

Subaural  galvanization,  1009 

Subdural  hemorrhage,  362,  364,  982 

treatment  of,  365,  983 
Suboperculum,  385 
Sulci,  384.    See  Fissures. 
Sulcus  extremis,  390 
Sulcus  paracentralis,  388 

medialis,  388 
Sunday-morning  paralysis,  723,  844 
Superior  gluteal  nerve,  para  lysis  of,  849 
Supra-orbital  nerve,  surgery  of,  998 
Supra-scapular  nerve,  paralysis  of,  842 
Surface  temperature,  36 
Surgery  of  brain,  957 

access  to  brain,  960 
appearance  of  the  brain,  962 
closure  of  the  dura,  964 

of  the  opening  in  the  skull,  964 
completion  of  the  operation,  964 
control  of  hemorrhage,  962 
drainage  in,  963 
marking  the  bone,  959 
osteoplastic  resection,  961 
position,  959 

recognition  of  the  motor  centres  by  fara- 
,  dization,  963 

removal  of  portions  of  the  brain,  963 
secondary  operations,  965 
technique  of  957 

disinfection  of,  958 
determination  of  the  fissures,  958 
trephining  in,  960 
of  nerves,  995 
of  peripheral  nerves,  996 
of  spinal  cord,  988 
Sv^ay,  19 

antero-dextral,  20 
backv?ard,  20 
forward,  20 

in  locomotor  ataxia,  20 
normal,  20 
Sydenham's  chorea,  227 
Symmetrical  gangrene,  880 
Sympathetic  ptosis,  790 
Symptomatic  disorders,  927 

neurasthenia,  55 
Syphilis  of  nervous  system,  699 
acquired,  700 

precocious  nervous  syphilis,  700 

frequency  of,  700 
time  of  appearance  of  symptoms 
700 
affections  arising  from  altered  nutri 
tion,  713 
arising  from  moral  shock,  713 


Syphilis  of  nervous  system,  cerebral,  702 
general  symptoms,  702 
special  symptoms,  702 

in  syphilis  of  the  base,  703 
in  syphilis  of  the  convexity, 

706 
in  syphiUtic  dementia,  707 
degenerative    changes    in   gum- 
mata,  699 
diagnosis,  714 

by  the  "  therapeutic  test,"  717 
difference  between  nervous  syph- 
ilis and  degenerative  diseases 
occurring  in  syphilitic  subjects, 
700 
differentiation  of  diffuse  syphilis 
of  the  cortex  from  paretic  de- 
mentia, 696,  715 
general  subacute  character  of  the 

affection,  715 
history  of  primary  sore,  714 
multiplicity  of  lesions,  714 
of  cerebral  syphilis,  715 
of  spinal  syphilis,  716 
of  syphilis  of  nerves,  717 
peculiar   progress  of  the  symp- 
toms, 715 
etiology,  701 

functional  nervous  diseases  in,  712 
inherited,  700,  714 

time  of  appearance  of  symptoms, 

701 
new  formations  of  syphilis,  699 
peculiarities  of  syphilitic  lesions,  699 
prognosis  of,  7 17 
spinal,  709 

Erb's  form  of  spinal  syphilis,  709 
sj'mptoms  of  7U9 
symptoms  of,  701 

forms  of  nervous  syphilis,  701 
multiplicity  of,  701 
symptom  groups,  701 
syphilis  of  the  nerves,  712 
of  the  cranial  nerves,  712 
of  the  spinal  nerves,  712 
angina  pectoris,  713 
chorea,  713 
hysteria,  713 
syphiUtic  neurasthenia,  713 
tissues  primarily  affected  by  syphilis, 

699 
treatment,  718 

duration  of,  719 
hypodermatic  injections,  719 
inunction,  717 
iodides,  717 
mercurials,  717 
Syphilitic  insanity,  708 
neuritis,  733 
spondylitis,  714 
Syphilophobia,  709 
Syringomyelia,  587 

absence  of  symptoms  in,  593,  596 
areas  of  sensory  loss  in,  589,  591 
ataxia  in,  593 

atrophy  of  muscles  in,  590,  591 
atypical  forms,  592,  593 
changes  of  skin  and  nails,  592 
course  of,  593 
diagnosis  of,  596 

from  cervical  pachymeningitis,  596 
from  focal  myelitis,  596 
from  leprosy,  596 
from  Morvan's  disease,  596 
from  neuritis,  596 

from  progressive  muscular  atrophy,  596 
from  tumors,  596 
dissociation  of  cutaneous  sensation  in,  589 
fibrillary  contractions  in,  592 
fragility  of  bones  in,  592 
joint  changes  in,  591,  592 
latent  form  of,  593 

loss  of  sense  of  pain  and  temperature  in,  589 
most  common  type  of,  588 
muscular  weakness  in,  592 
origin  of  cavity,  587 
painless  felon,  592 


1054 


INDEX. 


Syringomyelia,  pains  in,  591 

pathological  anatomy,  593 

prognosis  of,  597 

pupils  in,  593 

scoliosis  in,  590,  592 

spastic  paralysis  in,  593 

structure  of  the  cavities,  593,  594,  595 

symptoms  of.  588 

treatment  of,  597 

tremor  in,  592 

trophic  disturbances,  592 
System  diseases  of  spinal  cord,  614 


TABES  dorsalis,  633 
Tabetic  form  of  paretic  dementia,  694 
Tache  cerebrale,  354,  375 
Tachycardia,  68,  69 
Tactile  sense,  33 

table  of,  33,  34 
Taste,  affections  of,  885 

nerves  concerned  in,  805 
Technique  of  spinal  surgery,  993 
Telegrapher's  cramp,  279 
Temperature  sense,  35 

methods  of  testing,  35 
Tempero-sphenoidal  abscess,  377,  973 
Tendo-Achillis  jerk,  28 
Tendon  reactions,  27 

methods  of  el  citing,  29,  30 
notation  of,  32 
relations  to  cord  levels,  32 
theories  of,  28 
Terminal  neurasthenia,  77 
Test  letters,  46 
Tetanin,  211 
Tetano-toxine,  211 
Tetanus,  209 

bacillus  of,  210 
death  from,  212 
diagnosis  of,  213 
etiology  of.  209 
of  head,  212 
hydrophobicus,  212 
immunization,  214 
morbid  anatomy  of,  211 
mortality  in,  213 
neonatorum,  212 
puerperal,  213 
pulse  in,  212 
respirations  in,  212 
surgical  measures  in,  214 
symptoms  of,  211 
temperature  in,  212 
treatment  of,  214 
Tetany,  219 

course  of,  222 
diagnosis  of,  222 
etiology  of,  219 
pathology  of,  222 
symptoms  of,  220 
treatment  of,  222 
Thalamus  and  sensation,  419 
Thermal  sense,  35 

methods  of  testing,  35 
Thermo-aneesthesia  in  syringomyelia,  589 
Third-nerve  diseases  of,  773 
Thomsen's  disease,  873 
diagnosis  of,  876 
etiology  of,  873 
history  of,  873 
pathology  of,  876 
prognosis  of,  877 
symptoms  of,  874 
tonic  spasm,  874 
mechanical  excitability  of  muscles, 

874 
electrical  reactions,  875 
treatment  of,  877 
Thrombosis  of  brain,  467. 
sinuses,  365 

causes  of,  365 
chronic  otorrhcea  and,  366 
diagnosis  ot,  369 
general  symptoms  of,  366 
prognosis  of,  370 
septic,  366 


Thrombosis  of  brain,  special  symptoms  of,  366 
surgical  procedure  in,  370,  974 
treatment  of,  370,  974 
trephining  in,  370,  974 
Thyroid  extract  in  cretinism,  920 
in  myxcedema,  917 
gland,  trophic  affections  associated  with  dis- 
ease of,  913 
Tic  convulsif,  816 
douloureux,  814 
rotatoire,  272 
Tinnitus  aurium,  808 
causes  of,  808 
diagnosis  of,  810 
prognosis  of,  810 
symptoms  of,  .^09 
treatment  of,  810 
of  cause,  810 
of  symptoms,  810 
Tobacco  amblyopia,  761 
Tonic  spasm,  27 
Topophobia,  66 
Touch  squint,  34 
Toxic  affections,  183 
amblyopia,  761 
vertigo,  947 
Trajectories  of  the  normal  walk,  21 
Trance,  106 

Transverse  myelitis,  556.    See  Myelitis. 
Trauma  in  nervous  diseases,  135 
Traumatic  hysteria,  158 

achromatopsia  in,  163 
ansesthesia  in,  158-162   . 
circulatory  disturbances  in,  168 
contractions  in,  166 
digestive  disturbances  in,  168 
dyschromatopsia  in,  163 
gait  in,  165 

geometrical  anaesthesia  in,  162 
hemiansesthesia  in,  161 
hyperjesthesia  in,  165 
hypertesthetic  zones  in,  165 
hysterical  attack  in,  166 
hysterical  joint  in,  167 
hysterogenous  zones  in,  167 
motor  symptoms  in,  165 
peculiarities  of,  158 
reflexes  in,  168 

respiratory  disturbances  in,  168 
sensory  stigmata  of,  158 
spasm  in,  166 
tremor  in,  166 

trophic  disturbances  in,  168 

visual  disturbances  in,  163 

intra-cranial  hemorrhage,  363,  981 

surgical  treatment  of,  365,  981,  983- 
lumbago,  146 

attitude  in,  147 
knee-jerk  in,  147 
meningeal  hemorrhage,  363 
neurasthenia,  148 

aural  symptoms  in,  154 
circulatory  disturbances  in,  156 
digestive  disturbances  in,  156 
electrical  changes  in,  155 
gait  in,  154 
insomnia  in,  150 
menstruation  in,  157 
mental  symptoms  in,  150 
motor  symptoms  in,  154 
pupils  in,  154 
reflexes  in,  155 

respiratory  disturbances  in,  156 
sensory  symptoms,  151 
sexual  symptoms,  157 
symptoms  of,  149 
tremor  in,  155 

trophic  disturbances  in,  155 
urinary  symptoms,  157 
visual  disturbances  in,  151, 152, 153- 
neurosis,  169 

symptoms  of,  169, 170 
nervous  aflFections,  135 
diagnosis  of,  176 
pathologj'  of,  141,  142,  143 
prognosis  of,  79 
simulation  of,  176, 177 


INDEX. 


1055 


Traumatic  nervous  aflections,  symptoms  of,  145 
treatment  of,  188., 
sclerosis,  170 

diplopia  in,  172 
etiology  of,  171 
handwriting  in,  173 
mental  symptoms,  171 
motor  symptoms  in,  173 
nystagmus  in,  172 
pathology  of,  170 
reflexes  in,  173 
sensory  symptoms,  172 
special  senses  in,  172  „ 
symptoms  of,  171 
tremor  in,  173 
spinal  sclerosis,  174 

symptoms  of,  175  J 
diagnosis  of,  175 
Treatment  of  paralysis  ot  the  spinal  nerres,  855 
Tremor,  27 

alcoholic,  191 
classification  of,  282 
from  lead,  198 
functional,  280 

diagnosis  of,  284 
pathology  of,  283 
prognosis  of,  286 
treatment  of,  286 
hereditary,  283 
hysterical,  122 
intention,  27 
mercurial,  202 
neurasthenic,  57 
passive,  27 
senile,  283 
toxic,  282 
Trephining,  960 
Trigeminal  cough ,  276 
neuralgia,  814 
diagnosis,  817 
etiology  of,  814 
migratory  pains,  816 
of  inferior  maxillary  division,  816 
of  ophthalmic  division,  815 
of  superior  maxillary  division,  816 
ocular  neuralgia,  815 
prognosis  of,  817 
radiation  of  pain  in,  816 
removal  of  Gasserian  ganglion  for,  987 
symptoms,  815 
tender  points  In,  815,  816 
ticconvulsif,  816 
treatment  of,  817 
electricity,  819 
local  measures,  819 
medicinal,  817 
surgical  measures,  820 
trophic  disturbances,  816 
vasomotor  disturbances,  816 
nerve,  diseases  of,  811 
paralysis,  811 

crossed  paralysis  of  fifth  nerve,  813 
diagnosis  of  813 

diflferential  diagnosis  from  neuralgia, 

813 
of  locality  of  lesion,  813 
etiology  of,  811 
symptoms  of,  812 
treatment  of,  8 13 
Trismus,  212 

Trochlear  nerve,  diseases  of,  773 
Trochlearis  palsy,  789 
Trophic  diseases   associated   with    pathological 

changes  in  the  thyroid  gland,  913 
Trophoneuroses,  880 
Tubercular  multiple  neuritis,  733 
Tumors  of  cms,  498 
of  basal  ganglia,  497 
of  base  of  brain,  498 
of  brain,  470.    See  Brain  Tumor. 

surgical  treatment  of,  976 
of  Cauda  equina,  653,  654 
of  cerebellum,  499 
ataxia  in,  499 
gait  in,  500 
of  corpora  quadrigemina,  498 
of  corpus  callosmn,  493 


Tumors  of  frontal  lobe,  487 
of  gyrus  fornicatus,  493 
of  gyrus  margiualis,  493 
of  hippocampal  gyrus,  493 
ot  island  of  Reil,  493 
of  median  surface,  493 
of  medulla,  498 
of  motor  area,  489 
of  nerves,  739 

diagnosis  of  740 
etiology  of,  740 
multiple  neuromata,  739 
neuroma,  739 
false,  739 
structure  of  739 
neuroma,  true,  739 
surgical  treatment  of,  995 
symptoms  of  740 
treatment  of,  740 
of  occipital  region,  491 
of  operculum,  493 
of  parietal  region.  490 
of  pons,  498 

of  sacro-coccygeal  region,  congenital,  528 
of  spinal  envelopes  and  of  the  cord  itself,  599 
classification  of,  bOO 
course  and  duration  of,  607 
diagnosis  of,  609 
from  caries,  610 
from  chronic  myelitis,  610 
from  hvsterical  "neurasthenia, 

609 
from  neuralgia,  609 
from  neuritis,  609 
from  pachymeningitis,  610 
from  rheumatism,  609 
of  location,  609 
diflferentiaiion  of  tumors  of  the 
meninges  from  tumors  of   the 
cord, 608 
etiology  of,  599 
initial  stage  oi,  602 
pathology  of,  600 

relative  frequency  of   the  differ- 
ent forms  of,  601 
stages  of.  602 
symptoms  of,  601 
antt'Sthesia,  605 
auEesthesia  dolorosa,  606 
atrophy  of  muscles,  607 
bedsores,  606 

Brown-Sequard's  paralysis, 605 
cord-pains,  603 
electrical       excitability      of 

wasted  muscles,  607 
girdle  pain,  603 
headache,  607 
hypersesthesia,  605 
of  destruction  of  cord,  602 
of  irritation  of  cord,  602 
optic  neuritis,  607 
pain,  603 

pain  in  tubercle,  604 
parsesthesia,  604 
paralysis,  605 
priapism,  606 
pupils  in,  607 
radiations  of  pain,  604 
reflexes,  606 
root-pains,  603 
spasm,  604 
vomiting,  607 

when  in  the  cauda  equina,  609 
when     in    cervical   enlarge- 
ment, 605,  608 
when  in  dorsal  cord,  608 
when  in  lumbar  enlargement, 

606,  608 
when  in   lumbar  and  sacral 

segments,  609 
when  in  upper  cervical  seg- 
ment, 608 
treatment  of,  610 
medicinal,  610 
surgical,  610,  993 
of  Sylvian  fissure,  493 
temporal  region,  493 


1056 


INDEX. 


Tumors  of  thalamus,  497 
Typhoid  neuritis,  732 

symptoms  of,  732 

ULNAR  nerve,  paralysis  of,  845 
surgery  of,  1003 
Uncus,  393 
Unequal  pupil,  799 
Unilateral  reflex  iridoplegia,  800 
Uraemia,  188 

convulsions  in,  189 

diagnosis  of,  189 

etiology  of,  188 

hemiplegia  from,  189 

pathology  of,  188 

prognosis  of,  190 

symptoms  of,  188 

treatment  of,  190 
Urethral  crises,  640 
Utterance  centre,  434 

VARYING  inequality  of  pupils,  799 
Veins,  cerebral,  448 

inferior  cerebellar,  449 
middle  cerebral,  449 
of  Galen,  449 
supercerebral ,  449 
superior  cerebellar,  449 
Sylvian,  449 
Verbal  amnesia,  440 
Vertical  diplopia,  781 
crossed,  781 
homonymous,  781 
Vertigo.  943 

cUnical  considerations  of,  945 

diagnosis  of,  948 

etiology  of,  944 

from  cardiac  and  vascular  disturbances ,  947 

from  disease  of  the  ear,  945 

from  intra-cranial  disease,  948 

in  Meniere's  disease,  945 

of  mechanical  origin,  948 

etiology  and  symptoms  of,  946 
prognosis  of,  946 
theories  of,  946 
treatment  of,  946 
of  neurotic  origin,  948 

pathology  of,  944 
prognosis  of,  948 
of  reflex  origin,  948 


Vertigo,  of  toxic  origin,  947 
treatment  of,  949 
Vesical  crises,  640 
Vision  of  fixation,  46 
Visual  acuteness,  47 

centres  for  space,  light,  and  color,  422 

localization,  420 

path,  752 

radiation,  753 

tract,  491 
Von  Grsefe  sign,  42 


WAKING  numbness,  721 
Wasting  palsy,  625 
Water  on  the  brain,  343 
Watson's  experiments  in  concussion,  142 
Weir  Mitchell's  knee-jerk  metre,  30 
Wernicke's  symptom,  44,  802 

as  a  distant  symptom,  802 
in  basal  disease,  802 
lesions  producing  it,  802,  803 
method  of  eliciting,  802 
persistent,  802 
significance  of,  802 
transient,  802 
White  matter,  weight  of,  382 

softening,  554,  557 
Wilder  on  the  convolutions,  387,  388 
Word-blindness,  437,  496 
and  hemianopsia,  439 
concepts,  495 
deafness,  437,  440,  496 
pictures,  495 
Wounds  of  the  brain,  986 

of  nerves,  745,  996 
Wrist-drop  from  musculo-spiral  paralysis,  723,  843 

-jerk,  28,  619 
Writer's  cramp,  276 

diagnosis  of,  278 
etiology  of,  276 
pathology  of,  278 
prognosis  of,  278 
symptoms  of,  277 
treatment  of,  279 


yELLOW  softening,  469,  557 
yWICKELWINDUNG,  327 


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BALL  (CHARLES  B.).  THE,  RECTUM  AND  ANUS,  THEIR  DISEASES 
AND  TREATMENT.  New  (2d)  edition.  In  one  12mo.  volume  of  453  pages,  with 
60  engravings  and  4  colored  plates.  Cloth,  $2.25.  Just  ready.  See  Series  of  Clinical 
Manuals,  page  13. 


Philaaelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  {cor.  18ih  St.).' 


LEA    BROTHERS    &     CO.'S    PUBLICATIONS.  3 

BARNES  (ROBERT  AND  FANCOURT).  A  SYSTEM  OF  OBSTETRIC  MED- 
ICINE AND  SURGERY,  THEORETICAL  AND  CLINICAL.  The  Section  on 
Embryology  by  Pkof.  Milnes  Maeshajll.  In  one  large  octavo  volume  of  872  pages 
with  231  illustrations.     Cloth,  $5  ;  leather,  |6. 

BACON   (GORHAM)   AND  BLAKE   (CLARENCE  J. j.     ON  THE  EAR.    One 

12mo.  volume,  350  pages.     Fully  illustrated      In  press. 

BARTHOLO W  ( ROBERTS ) .  CHOLERA  ,-  ITS  CA  USA  TION,  PRE  VENTION 
AND  TREATMENT.  In  one  12mo.  volume  of  127  pages,  with  9  illustrations. 
Cloth,  $1.25. 

BARTHOLO W  (ROBERTS).  MEDICAL  ELECTRICITY.  A  PRACTICAL 
TREATISE  ON  THE  APPLICATIONS  OF  ELECTRICITY  TO  MEDICINE 
AND  SURGERY.  Third  edition.  In  one  octavo  volume  of  308  pages,  with  110  illus- 
trations. 

BELL   (F.  JEFFREY).     COMPARATIVE  ANATOMY  AND  PHYSIOLOGY. 

In  one  12mo.  volume  of  561  pages,  with  229  engravings.     Cloth,  $2.     See  Student^  Series 
of  Manuals,  p.  14. 

BERRY  ( GEORGE  A. ).  DISEASES  OF  THE  EYE;  A  PRACTICAL  TREAT- 
ISE FOR  STUDENTS  OF  OPHTHALMOLOGY.  Second  edition.  Very  hand- 
some octavo  volume  of  745  pages,  with  197  original  illustrations  in  the  text^  of  which  87 
are  exquisitely  colored.     Cloth,  |8. 

BILLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY.  Includ- 
ing in  one  alphabet  English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in 
Medicine  and  the  Collateral  Sciences.  In  two  very  handsome  imperial  octavo  volumes, 
containing  1574  pages  and  two  colored  plates.  Per  volume,  cloth,  $6 ;  leather,  $7  ;  half 
Morocco,  $8.50.     For  sale  by  subscription  only.     Specimen  pages  on  application. 

BLACK  (D.  CAMPBELL).  THE  URINE  IN  HEALTH  AND  DISEASE, 
AND  URINARY  ANALYSIS,  PHYSIOLOGICALLY  AND  PATHOLOGI- 
CALLY CONSIDERED.  In  one  12mo.  volume  of  256  pages,  with  73  engravings. 
Cloth,  $2.75. 

BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC.  With 
Experiments.  New  American  from  the  fifth  London  edition.  In  one  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2 ;  leather,  $3. 

BROADBENT  (W.  H.).  THE  PULSE.  In  one  12mo.  volume  of  317  pages,  with 
59  engravings.     Cloth,  $1.75.     See  Series  of  Clinical  Manuals,  page  13. 

BROWNE  ( LENNOX ) .  THE  THR  OA  T  AND  NOSE  AND  THEIR  DISEASES. 
New  (4th)  and  enlarged  edition.  In  one  imperial  octavo  volume  of  751  pages,  with  235 
engravings  and  120  illustrations  in  color.     Cloth,  $6.50. 

KOCH'S    REMEDY   IN   RELATION   ESPECIALLY    TO    THROAT 

CONSUMPTION.     In  one  octavo  volume  of   121  pages,  with   45  illustrations,  4  of 
which  are  colored,  and  17  charts.     Cloth,  $1.50. 

BRUCE    (J.    MITCHELL),     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

Fifth  edition.     In  one  12mo.  volume  of  591  pages.     Cloth,  $1.50.     See  Student^  Series  of 

Manuals,  page  14. 
PRINCIPLES  OF  TREATMENT.     In  one  octavo  volume.     Preparing. 

BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY,  THERA- 
PEUTICS AND  MATERIA  MEDIC  A  ;  including  the  Pharmacy,  the  Physiological 
Action  and  the  Therapeutical  Uses  of  Drugs.     In  one  octavo  volume. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
from  the  fourth  English  edition.  In  one  imperial  octavo  volume  of  1040  pages,  with  727 
illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  See  Taylor  on  Venereal  Diseases, 
page  15. 

BURCHARD  (HENRY  H.).  DENTAL  PATHOLOGY  AND  THERAPEUTICS, 
INCLUDING  PHARMACOLOGY.  Handsome  octavo,  575  pages,  with  40(1  ilhis- 
trations.     Just  ready.     Cloth,  $5  ;  leather,  $6.     {Net.) 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  {cor.  18th  St.). 


LEA    BROTHERS    &    CO:S    PUBLICATIONS. 


BURNETT  (CHARLES  H.).  THU  EAR:  ITS  ANATOMY,  PHYSIOLOGY 
AND  DISEASES.  A  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 
Second  edition.  In  one  8vo.  volume  of  580  pages,  with  107  illustrations.  Cloth,  $4 ; 
leather,  §5. 

BUTLIN  (HENRY  T.).  DISEASES  OF  THE  TONGUE.  In  one  pocket-size 
12mo.  volume  of  456  pages,  with  8  colored  plates  and  3  engravings.     Limp  cloth,  ^3.50. 

See  Series  of  Clinical  Manvxils,  page  13. 

CARTER  (R.  BRUDENELL)  AND  FROST  (W.  ADAMS).  OPHTHALMIC 

StfRGEBY.     In  one  pocket-size  12mo.  volume  of  559  pages,  with  91  engravings  and 
one  plate.     Cloth,  §2.25.     See  Series  of  Clinical  Manuals,  page  13. 

CASPARI  (CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  Students 
and  Pharmacists.  In  one  handsome  octavo  volume  of  680  pages,  with  288  illustrations. 
Cloth,  S4.50. 

CHAPMAN  (HENRY  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    In 

one  octavo  volume  of  925  pages,  with  605  illustrations.     Cloth,  §5.50 ;  leather,  §6.50. 

CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  §3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS,  ULCERS 
AND  ABSCESSES.     In  one  12mo.  volume  of  207  pages.     Cloth,  §1.25. 

CHURCHILL    (FLEETWOOD).     ESSAYS   ON  THE  PUERPERAL  FEVER. 

In  one  octavo  volume  of  464  pages.     Cloth,  §2.50. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).     THE  DISSECTOR'S  MANUAL. 

In  one  12mo.  volume  of  396  pages,  with  49  engravings.     Cloth,  §1.50.     See  Students'  Series 
of  Manuals,  page  14. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
HUMAN  BODY.     In  one  12mo.  volume  of  178  pages.     Cloth,  §1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manvxils,  page  13. 

CLOUSTON    (THOMAS    S.).     CLINICAL    LECTURES   ON   MENTAL    DIS- 
EASES.  New  (4th)  edition.     Octavo  of  736  pages,  with  15  colored  plates.     Cloth,  §4.75. 
g®""  Folsom's  Abstract  of  Laws  of  U.S.  on  Custody  of  Insane,  octavo,  §1.50,  is  sold  in 
conjunction  with  Clouston  on  Mental  Diseases  for  §5.50  for  the  two  works. 

CLOWES    (FRANK).  AN  ELEMENTARY   TREATISE    ON  PRACTICAL 

CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.    From  the 

fourth  English  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  55  engrav- 
ings.    Cloth,  §2.50. 

COAKLEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREATMENT  OF 
DISEASES  OF  THE  NOSE,  THROAT,  NASO-PHARYNX  A    D  TRACHEA. 

In  one  12mo.  volume  of  about  400  pages,  fully  illustrated.     Preparing. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
pages,  with  339  engravings.     Cloth,  §5.50 ;  leather,  §6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
OLOGY. With  Xotes  and  Additions  to  adapt  it  to  American  Practice.  By  Thos.  C. 
Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one  handsome  octavo  volume  of  412  pages,  with 
331  engravings.     Cloth,  §3.25. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In  one  large  8vo.  volume  of 
719  pages.     Cloth,  §5.25  ;  leather,  §6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
TREATMENT.  Translated,  with  Xotes  and  Additions,  by  J.  Henry  C.  Shies,  M.D., 
and  J.  William  White,  M.D.  In  one  8vo.  volume  of  461  pages,  with  84  illustrations. 
Cloth,  §3.75.  ■ 

CULBRETH  (DAVID  M.  R.).    MATERIA  MEDICA  AND  PHARMACOLOGY. 

In  one  handsome  octavo  volume  of  812  pages,  with  445  engravings.     Cloth,  §4.75. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  {cor.  18th  St.). 


LEA    BROTHERS    &    CO.'S    PUB  L/C  AT/0 /If  S. 


CULVER  (E.  M.)  AND  HAYDEN  fj.  R.).  MANUAL  OF  VENEREAL  DIS- 
EASES.    In  one  12mo.  volume  of  289  pages,  with  33  engravings.     Cloth,  $1.75. 

D ALTON   (JOHN   C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Seventh 

edition, thoroughly  revised.  Octavo  of  722  pages, with  252  engravings.  Cloth,  $5;  leather,$6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In  one  hand- 
some 12mo.  volume  of  293  pages.     Cloth,  $2. 

DAVENPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  of  Gynecology. 
For  the  use  of  Students  and  General  Practitioners.  New  (3dj  edition.  In  one  hand- 
some 12mo.  volume,  with  many  engravings.     Shortly. 

DAVIS  (F.H.).     LECTURES  ON  CLINICAL  MEDICINE.    Second  edition.     In 

one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  For  Students  and 
Practitioners.  In  one  very  handsome  octavo  volume  of  546  pages,  with  217  engravings, 
and  30  full-page  plates  in  colors  and  monochrome.     Cloth,  $5 ;  leather,  $6. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo  volume  of  700 
pages,  with  300  engravings.     Cloth,  $4. 

DENNIS  (FREDERIC  S.j  AND  BILLINGS  (JOHN  S.).  A  SYSTEM  OF 
SURGERY.  In  Contributions  by  American  Authors.  In  four  very  handsome  octavo 
volumes,  containing  3652  pages,  with  1585  engravings,  and  45  full-page  plates  in  colors 
and  monochrome.  Complete  work  just  ready.  Per  volume,  cloth,  $6 ;  leather,  $7 ;  half 
Morocco,  gilt  back  and  top,  $8.50.     For  sale  by  subscription  only.     Full  prospectus  free. 

DERCUM  (FRANCIS  X.),  Editor.  A  TEXT-BOOK  ON  NERVOUS  DIS- 
EASES. By  American  Authors.  In  one  handsome  octavo  volume  of  1054  pages,  with 
341  engravings  and  7  colored  plates.     Cloth,  $6;  leather,  $7.     {Net.) 

DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS ;  THEIR 
CLASSIFICATION,  HISTORY,  SYMPTOMS,  PATHOLOGY  AND  TREAT- 
MENT. Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page  plates  in 
colors.     Limited  edition,  de  luxe  binding,  S4.     {Net.) 

DRAPER  ( JOHN  C. ) .  MEDICAL  PHYSICS.  A  Text-book  for  Students  and  Prac- 
titioners of  Medicine.     Octavo  of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  A  new  American,  from  the  twelfth  London  edition,  edited  by  Stanley 
Boyd,  F.R.C.S.     Large  octavo,  965  pages,  with  373  engravings.     Cloth,  $4 ;  leather,  $5. 

DUANE  (ALEXANDER ) .  THE  STUDENT'S  DICTIONAR  Y  OF  MEDICINE 
AND  THE  ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Derivation  and 
Full  Explanation  of  Medical  Terms.  Together  with  much  Collateral  Descriptive  Matter, 
Numerous  Tables,  etc.  New  edition.  With  Appendix.  Square  octavo  volume  of  690  pages. 
Cloth,  S3 ;  half  leather,  $3.25  ;  full  sheep,  $3.75.     Thumb-letter  Index,  50  cents  extra. 

DUDLEY    (E.   C).     PRINCIPLES  AND   PRACTICE    OF   GYNECOLOGY. 

Octavo,  about  750  pages,  with  425  engravings  in  black  and  colors.     In  press. 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DISEASES 
OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital.  In  one  octavo  volume  of 
175  pages.     Cloth,  SI. 50. 

DUNGLISON  fROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics, 
Pathology,  Surgery,  Ophthalmology,  Otology,  Laryngolog}',  Dermatology,  Gynecology, 
Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc.  By  Kobley  Dungli- 
so>',  M.D.,  LL.D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia.  Edited  by  Richakd  J.  Dtjxglison,  A.M.,  M.D.  Twenty-first 
edition,  thoroughly  revised  and  gi*eatly  enlarged  and  improved,  with  the  Pronunciation, 
Accentuation  and  Derivation  of  the  Terms.  With  Appendix.  Imperial  octavo  of  1225 
pages.     Cloth,  $7  ;  leather,  $8.     Thumb-letter  Index,  75  cents  extra. 

DUNHAM  (EDWARD  K.).     MORBID  AND  NORMAL  HISTOLOGY.     Octavo, 

400  pages,  richly  illustrated.     Preparing. 


P/j//adelpf>ia.  706,  708  and  710  Sansom  St.— New  York,  111  Fift/i  Ave.  {cor.  18th  St.). 


6  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  $3.50 ;  leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for  Students  and 
Practitioners.  In  one  handsome  8vo,  volume  of  576  pages,  with  148  engravings. 
Cloth,  $3 ;  leather,  §4. 

EGBERT  (SENECA).     HYGIENE  AND  SANITATION.     In  one  12mo.  volume  of 

359  pages,  with  63  illustrations.     Just  ready.     Cloth,  $2.25,  net. 

ELLIS   (GEORGE  VINER).     DEMONSTRATIONS  IN  ANATOMY.     Being  a 

Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection.    From  the  eighth  and  revised 
English  edition.     Octavo,  716  pages,  with  249  engravings.     Cloth,  $4.25 ;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE  OF 
O  YNuECOL  OGY.  For  the  use  of  Students  and  Practitioners.  Third  edition,  enlarged 
and  revised.     8vo.  of  880  pages,  with  150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE^  AND  ART  OF  SURGERY.  A  new 
American  from  the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo 
volumes  containing  2316  pages,  with  984  engravings.     Cloth,  $9 ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American  Text-books 
of  Dentistry,  page  2. 

FARQUHARSON    (ROBERT).      A     GUIDE    TO    THERAPEUTICS.     Fourth 

American  from  fourth  English  edition,  revised  by  FEAi^rK  Woodbury,  M.D.     In  one 
12mo.  volume  of  581  pages.     Cloth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.     Octavo,  391  pages,  with  73  engravings  and  21  colored  plates.     Cloth,  $3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised  by  Frederick  P.  Henry, 
M.D.     In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  $5 ;  leather,  $6. 

■ A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION;  of  the  Physi- 
cal Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fifth 
edition,  revised  by  James  C.  Wilson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 

A   PRACTICAL    TREATISE   ON  THE  DIAGNOSIS  AND    TREAT- 


MENT OF  DISEASES  OF   THE  HEART.    Second  edition,  enlarged.     In  one 
octavo  volume  of  550  pages.     Cloth,  $4. 

A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING 
THE  RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  octavo  vol- 
ume of  591  pages.     Cloth,  $4.50. 

MEDICAL  ESSAYS.    In  one  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

ON  PHTHISIS :  ITS  MORBID  ANA TOMY,  ETIOL OGY,  ETC.    A  Series 


of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages.     Cloth,  $3.50. 

FOLSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
OF  THE  INSANE.  In  one  8vo.  volume  of  108  pages.  Cloth,  $1.50.  With  Gouston 
on  Mental  Diseases  (see  page  4),  at  $5.50  for  the  two  works. 

FORMULARY,  THE  NATIONAL.  See  Stille,  Maisch  &  Caspari's  National  Dispensa- 
tory, page  14. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  and 
revised  American  from  the  sixth  English  edition.  In  one  large  octavo  volume  of  923 
pages,  with  257  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND-BOOK  OF 
TREATMENT.  Third  edition.  In  one  handsome  octavo  volume  of  664  pages. 
Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  {IN- 
ORGANIC AND  ORGANIC),  twelfth  edition.  Embodying  Watts'  Physical  and 
Inorganic  Chemistry.  In  one  royal  12mo.  volume  of  1061  pages,  with  163  engravings,  and 
1  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Ave.  [cor.  18th  St. 


LEA    BROTHERS    &    CO:S    PUBLICATIONS. 


FRANKLAND  (E.)  AND  JAPP  (F.  R.).  INORGANIC  CHEMISTRY.  In  one 
handsome  octavo  volume  of  677  pages,  mth  51  engravings  and  2  plates.  Cloth,  $3.75 ; 
leather,  84.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 
MALE.  In  one  very  handsome  octavo  volume  of  238  pages,  with  25  engravings  and 
8  full-page  plates.     Cloth,  $2. 

FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR-PASSAGES. 
Their  Pathology,  Physical  Diagnosis,  Symptoms  and  Treatment.  From  second  English 
edition.     In  one  8vo.  volume  of  475  pages.     Cloth,  $3.50. 

GANT  ( FREDERICK  JAMES  ) .  THE  STUDENT'S  S UR GER  T.  A  Multum  in 
Parvo.     In  one  square  octavo  volume  of  845  pages,  with  159  engravings.     Cloth,  §3.75. 

GERRISH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY.  By  American 
Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.  In  one  imp.  octavo  volume,  richly 
illustrated.     Preparing. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
TOLOGY.   Octavo  of  314  pages,  with  60  illustrations,  mostly  photographic.   Cloth,  $2.75. 

GIBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practitioners  and 
Students.     In  one  8vo.  volume  profusely  illustrated.     Preparing. 

GOULD  (A.  PEARCEi.  SURGICAL  DIAGNOSIS.  In  one  12mo.  volume  of  589 
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GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL.  New- 
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DISEASES.  For  Students  and  Practitioners  of  Medicine.  Second  edition.  In  one 
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GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOB- 
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GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEMISTRY.  For 
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GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  revised  by 
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HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  comprising 
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HARDAWAY  fW.  A.).  MANUAL  OF  SKIN  DISEASES.  New  (2d)  edition. 
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HARE  f  HOB  ART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL  THERA- 
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HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
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LEISHMAN  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Including  the  Dis- 
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MATERIA  MEDIC  A,  CHEMISTRY,  PHARMACY  AND  THERAPEUTICS. 
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LYONS  (ROBERT  D.).     A  TREATISE  ON  FEVER.     In  one  octavo  volume  of  362 

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MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDIC  A. 
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MANUALS.  See  Students'  Quiz  Series,  page  14,  Students'  Series  of  Manuals,  page  14,  and 
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MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
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MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAG- 
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PAYNE  (JOSEPH  FRANK).  A  MANUAL  OF  GENERAL  PATHOLOGY. 
Designed  as  an  Introduction  to  the  Practice  of  Medicine.  In  one  octavo  volume  of  524 
pages,  with  153  engravings  and  1  colored  plate. 

PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).     FRACTURES  AND  DISLOCATIONS.     In  one  12mo. 

volume  of  530  pages,  with  93  engravings.    Cloth,  $2.     See  Series  of  Clinical  Manuals,  p.  13. 

PLAYFAIR  (W.  S.).  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MID  WIFER  Y.  Sixth  American  from  the  eighth  English  edition.  Edited,  with 
additions,  by  E.  P.  Harris,  M.D  In  one  octavo  volume  of  697  pages,  with  217  engrav- 
ings and  5  plates.     Cloth,  $4 ;  leather,  $5. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  AND 


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POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  edition. 
Translated  by  Oscar  Dodd,  M.D  ,  and  edited  by  Sm  William  Dalby,  F.E.C.S.  In 
one  octavo  volume  of  748  pages,  with  330  original  engravings.     Cloth,  $5.50. 

POWER   (HENRY).     HUMAN  PHYSIOLOGY.     Second  edition.     In  one  12mo. 

volume  of  396  pages,  with  47  engravings.     Cloth,  $1.50.     See  Student's  Series  of  Manuals, 
page  14. 

PURDY  (CHARLES  W.).  BRIGHT 'S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  $2. 

PYE-SMITH  (PHILIP  H.).     DISEASES  OF  THE  SKIN.    In  one  12mo.  volume 

of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  $2. 

QUIZ  SERIES.     See  Students'  Quiz  Series,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
314  pages,  with  16  engravings.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  14. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRACTICE  OF 
OBSTETRIC  MEDICINE  AND  SURGERY.  In  one  imperial  octavo  volume  of 
640  pages,  with  64  plates  and  numerous  engravings  in  the  text.  Strongly  bound  in 
leather,  $7. 

REICHERT  (EDWARD  T.).  A  TEXT-BOOK  ON  PHYSIOLOGY.  In  one 
handsome  octavo  volume  of  about  800  pages,  richly  illustrated.     Preparing. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
New  (5th)  edition,  thoroughly  revised.     In  one  12mo.  volume  of  326  pages.     Cloth,  $2 

RICHARDSON   (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  one 

octavo  volume  of  729  pages.     Cloth,  $4 ;  leather,  $5. 

ROBERTS  (JOHN  B.).     THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 

SURGERY.     In  one  octavo  volume  of  780  pages,  with  501  engi-avings.     Cloth,  $4.50; 
leather,  $5.50. 

• THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting  Eoom  and  in 

preparing  for  Examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 

ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES,  INCLUDING  URINARY  DEPOSITS.  Fourth 
American  from  the  fourth  London  edition.  In  one  very  handsome  8vo.  volume  of  609 
pages,  with  81  illustrations.     Cloth,  $3.50. 

ROBERTSON  (J.  McGREGOR).    PHYSIOLOGICAL  PHYSICS.    In  one  12mo. 

volume  of  537  pages,  with  219  engravings.     Cloth,  $2.     See  Students' .Series  of  Manuals, 
page  14. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE  NERVOUS 
SYSTEM.  In  one  handsome  octavo  volume  of  726  pages,  with  184  engravings.  Cloth, 
$4.50;  leather,  $5.50. 

SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES,  PRACTI- 
CAL AND  CLINICAL.  New  (2d)  and  enlarged  edition.  In  one  12mo.  volume  ol 
551  pages,  with  18  typical  engravings.  Cloth,  $2.    See  Series  of  Clinical  Manuals,  page  13. 

SCHAFER  ( EDWARD  A. ) .  THE  ESSENTIALS  OF  HISTOL OGY,  DESCRIP- 
TIVE AND  PRACTICAL.  For  the  use  of  Students.  Fourth  edition.  In  one 
handsome  octavo  volume  of  311  pages,  with  325  illustrations.     Cloth,  $3. 

A  COURSE  OF  PRACTICAL  HISTOLOGY.      New  (2d)  edition.     In  one 

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SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES. 

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SCHOFIELD  (ALFRED  T.).  ELEMENTARY  PHYSIOLOGY  FOR  STU- 
DENTS. Jn  one  12mo.  volume  of  380  pages,  with  227  engravings  and  2  colored  plates. 
Cloth,  12. 

SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MASSAGE 
AND  METHODICAL  MUSCLE  EXERCISE.  Translated  by  Walter  Mendel- 
son,  M.D.,  of  New  York.  In  one  handsome  octavo  volume  of  274  pages,  with  117  fine 
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SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
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For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  STUDENTS'  MANUALS.     See  next  page. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICROSCOPICAL 
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octavo  volume  of  530  pages,  with  135  engravings  and  14  full-page  plates  in  colors 
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SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures  and  Laboratory 
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SLADE  (D.  D. ) .  DIPHTHERIA  ;  ITS  NATURE  AND  TREA TMENT.  Second 
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SMITH  (EDWARD).  CONSUMPTION;  ITS  EARLY  AND  REMEDIABLE 
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SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  INFANCY 
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SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thoroughly  revised 
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SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMATOLOGY, 
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5  of  which  are  in  colors.     Cloth,  $4.00. 

STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUSATION, 
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volume  of  163  pages,  with  a  chart  showing  routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS  AND  MATERIA  MEDIC  A.     Fourth  and  revised  edition. 


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14  LEA    BROTHERS    &     CO.' S    PUB  L/ CAT/0  HS. 


STILLE   (ALFRED),  MAISCH   (JOHN   M.)   AND   CASPARI   (CHAS.   JR.). 

THE  NATIONAL  DISPENSATORY :  Containing  the  Natural  History,  Chemistry, 
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ready  reference  Thumb-letter  Index.     Cloth,  §7.75 ;  leather,  |8.50. 

STIMSON   (LEWIS  A.).     A  MANUAL   OF  OPERATIVE  SURGERY.     New 

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A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.     In  two  hand- 


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STUDENTS'  QUIZ  SERIES.  A  New  Series  of  Manuals  in  question  and  answer  for 
Students  and  Practitioners,  covering  the  essentials  of  medical  science.  Thirteen  volumes, 
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Full  specimen  circular  on  application  to  publishers. 

STUDENTS'  SERIES  OF  MANUALS.  A  Series  of  Fifteen  Manuals  by  Eminent 
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Surgical  Pathology,  $2;  Treves'  Surgical  Applied  Anatomy,  $2;  Power's  Human 
Physiology  (2d  edition i,  $1.50;  Ealfe's  Clinical  Chemistry,  $1.50;  and  Clarke  and 
Lockwogd's  Dissector's  Manual,  $1.50 

For  separate  notices,  see  under  various  authors'  names. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY  OF  CLIN- 
ICAL MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE  OVARIES 
AND  FALLOPIAN  TUBES.  _  Including  Abdominal  Pregnancy.  In  one  12mo.  vol- 
ume of  513  pages,  with  119  engravings  and  5  colored  plates.     Cloth,  $3. 

TUMORS,  INNOCENT  AND  MALIGNANT.     Their  CUnical  Features  and 

Appropriate  Treatment.     In  one  8vo.  volume  of  526  pages,  with  250  engravings  and 
9  full-page  plates.     Cloth,  $4.50. 

TAIT  (LAWSON).  DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGERY. 
In  two  handsome  octavo  volumes.  Vol.  I.  contains  554  pages,  62  engravings,  and  3 
plates.     Cloth,  $3.     Vol.  IL,  preparing. 

TANNER  (THOMAS  HAWKES).  ON  THE  SIGNS  AND  DISEASES  OF 
PREGNANCY.  From  the  second  English  edition.  In  one  octavo  volume  of  490  pages,, 
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TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  New  American 
from  the  twelfth  English  edition,  specially  revised  by  Clark  Bell,  Esq.,  of  the  N.  Y. 
Bar.  In  one  octavo  volume  of  831  pages,  with  54  engravings  and  8  full-page  plates^ 
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edition.  In  one  Svo.  volume  of  788  pages,  with  104  illustrations.  Cloth,  85.50; 
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TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREATMENT  OF 
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A  PRACTICAL  TREATISE  ON  SEXUAL  DISORDERS  IN  THE  MALE 

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A    CLINICAL    ATLAS    OF    VENEREAL    AND    SKIN    DISEASES. 


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TAYLOR  (SEYMOUR).    INDEX  OF  MEDICINE.    A  Manual  for  the  use  of  Senior 

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THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  F.).  ^  PRACTICAL 
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THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES  OF 
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203  pages,  mth  25  engravings.     Cloth,  82.25. 

THE  PATHOLOGY  AND   TREATMENT  OF  STRICTURE  OF  THE 

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$3.50. 

TODD  (ROBERT  BENTLEY).  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.     In  one  8vo.  volume  of  320  pages.    Cloth,  $2.50. 

TREVES  (FREDERICK).  OPERATIVE  SURGERY.  In  two  8vo.  volumes  con- 
taining 1550  pages,  with  422  illustrations.     Cloth,  §9 ;  leather,  $11. 


A  SYSTEM  OF  SURGERY.  In  Contributions  by  Twenty-five  English  Sur- 
geons. In  two  large  octavo  volumes,  containing  2298  pages,  with  950  engravings  and 
4  full-page  plates.     Per  volume,  cloth,  $8. 

A  MANUAL  OF  SURGERY.     In  Treatises  by  33  leading  surgeons.     Three 


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dents'  Series  of  Manuals,  page  14. 

THE  STUDENTS'  HANDBOOK  OF  SURGICAL  OPERATIONS.    In 


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SURGICAL  APPLIED  ANATOMY.    In  one  12mo.  volume  of  583  pages 


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INTESTINAL  OBSTRUCTION.    In  one  12mo.  volume  of  522  pages,  with  60 


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TUKE  (DANIEL  HACK).  THE  INFLUENCE  OF  THE  MIND  UPON  THE 
BODY  IN  HEALTH  AND  DISEASE.  Second  edition.  In  one  8vo.  volume  of 
467  pages,  with  2  colored  plates.     Cloth,  83. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  PTOMAINS^ 
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16  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

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WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND  PRAC- 
TICE OF  PHYSIC.  A  new  American  from  the  fifth  and  enlarged  English  edition, 
with  additions  by  H.  Hartshoene,  M.D.  In  two  large  8vo.  volumes  of  1840  pages,  with 
190  engravings.     Cloth,  $9 ;  leather,  |11. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR  TO 
WOMEN.  Third  American  from  the  third  English  edition.  In  one  octavo  volume  of 
543  pages.     Cloth,  §3.75;  leather,  |4.75. 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 


HOOD.    In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAGING-  Third 
edition.  In  one  12mo  volume  of  594  pages,  with  475  engravings,  many  of  which  are 
photographic.     Cloth,  §3. 

WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR  THERA- 
PEUTIC INDEX.  Including  Medical  and  Surgical  Therapeutics.  In  one  square 
octavo  volume  of  917  pages.     Cloth,  $4. 

WILSON  (ERASMUS).  A  SYSTEM  OF;  HUMAN  ANATOMY.  A  new  and 
revised  American  from  the  last  English  edition.  Illustrated  with  397  engravings.  In 
one  octavo  volume  of  616  pages.     Cloth,  $4;  leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE     In  one  12mo 


volume.     Cloth,  |3  50. 

WINOKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED.  Trans- 
lated by  James  E.  Chadwick,  A.M.,  M.D.  With  additions  by  the  Author.  In  one 
octavo  volume  of  484  pages.     Cloth,  |4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY  Translated  from  the 
eighth  German  edition,  bv  Ira  Remsen,  M.D.  In  one  12mo.  volume  of  550  pages. 
Cloth   $3. 

YEAR  BOOK  OF  TREATMENT  FOR  1898.  A  Ciitical  Eeview  for  Practitioners  of 
Medicine  and  Surgery.  In  contributions  by  24  well-known  medical  writers.  12mo.,  488 
pages.  Cloth,  $1  50.  Just  Ready.  In  combination  with  The  Medical,  News  and  The 
American  Journal  of  the  Medical  Sciences,  75  cents.    See  page  1. 

YEAR-BOOKS  OF  TREATMENT  for  1892, 1893,  and  1896,  similar  to  above.     Each, 

cloth,  g;i.50. 

YEO  (I.  BURNEY).  FOOD  IN  HEALTH  AND  DISEASE.  New  (2d)  edition. 
In  one  12mo.  volume  of  592  pages,  with  4  engravings.  Cloth,  §2.50.  See  Series  of 
Clinical  Manuals,  page  13. 

A  MANUAL  OF  MEDICAL  TREATMENT   OR  CLINICAL  THERA- 


PEUTICS.    Two  volumes  containing  1275  pages.     Cloth,  §5.50. 

YOUNG  (JAMES  K.).     ORTHOPEDIC  SURGERY.     In  one  8vo.  volume  of  475 
pages,  with  286  illustrations.     Cloth,  |4;  leather,  $5. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  III  iFifth  Ave.  {cor.  18th  St.). 


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